wmj201504

COUNTRY
vol. 61
MedicalWorld
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 4, December 2015
Contents
Clean Technologies Can Change the World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Valedictory speech. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Inaugural Address as WMA President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
WMA 2015 General Assembly Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
WMA Resolution to Stop Attacks against Healthcare Workers and Facilities in Turkey. . . . 140
WMA Resolution on Global Refugee Crisis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
WMA Resolution about the Bombing on the Hospital of MSF in Kunduz . . . . . . . . . . . . . . . 141
WMA Declaration on Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
WMA Statement on Physicians Well-Being. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
WMA Statement on Transgender People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
WMA Statement on Vitamin D Insufficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
WMA Guidelines on Promotional Mass Media Appearances by Physicians . . . . . . . . . . . . . . 147
WMA Resolution on the Inclusion of Medical Ethics and Human Rights in the
Curriculum of Medical Schools World-Wide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
WMA Statement on Non-Discrimination in Professional Membership and Activities
of Physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
WMA Statement on Ethical Issues Concerning Patients with Mental Illness. . . . . . . . . . . . . 150
WMA Declaration of Oslo on Social Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . 151
WMA Statement on Supporting Health Support to Street Children . . . . . . . . . . . . . . . . . . . . 152
WMA Statement on Mobile Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
WMA Statement on Nuclear Weapons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
WMA Statement on Riot Control Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Body Cavity Searches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
The Climate/Health Nexus at COP21 & Beyond. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
121
Editorial
As I reflect on the activities surrounding
COP 21 – the United Nations Climate
Change Conference,currently being held in
Paris – what disturbs me most is the man-
ner in which climate change is being pre-
sented and discussed.
We hear forceful declarations from stake-
holders in the debate that climate change
is a huge and expensive problem and that
we have to act for the sake of future genera-
tions.
How in the world can you motivate peo-
ple by asking them to pay to solve a huge
problem with no immediate benefit? Rath-
er than hearing about expensive problems,
people are looking to be inspired by solu-
tions that provide an immediate economic
reward. And this is exactly what fighting
climate change can offer today if we accept
to modify our understanding of the situation.
When I was trained as a medical Doctor, I learned that a ‘problem’
is called a ‘symptom’. Every symptom has an origin, and by studying
that origin, we can find a treatment. In the case of climate change,
CO2
is not the problem; it’s only the symptom – the symptom of our
crazy manner of using and wasting energy.
Nevertheless, we see people continuing to fight against the symp-
tom, citing CO2
emissions as the source of the problem. We have
the ecologists who are advocating that we decrease our mobility, our
comfort, our economic development and our growth.  But really,
who would want that?  Then, we have those who resist measures to
reduce CO2
emissions for the sake of employment and profit. Hav-
ing two camps fighting each other will not solve the climate change
issue. It will continue to polarize the debate and lead to paralysis. 
Looking at how we consume energy and in particular the resulting
waste will go a long way in helping us better understand the real
issues at stake. The technologies we use today are 100 years old!
They present a complete lack of efficiency compared to the clean
technologies available: our combustion engines are three times less
efficient than electrical ones; light bulbs create more heat than light
and in turn require cooling devices; poor insulation of buildings and
single glazed windows continue to run up our monthly electricity
bills; and, heating and cooling systems, as well as industrial process-
es produce more losses than efficiency. Why are we so demanding
about modern information technology and so relaxed about energy
efficiency? Could Paris be the first Climate Conference that looks at
energy efficiency as a solution for climate change?
When I initiated the Solar Impulse project
to fly a solar powered airplane around the
world without a drop of fuel,it was precisely
to demonstrate that clean technologies can
achieve the impossible. We can reach more
with renewable energy and energy efficiency
than with fossil fuel. And all the technolo-
gies we use in the sky could be used today to
run a cleaner society.
Unfortunately, our world continues to react
to the issue of wasted energy by trying to
produce more and more energy, either fossil
or renewable, instead of opting for efficien-
cy. Is this rational? Would you fix a leak in
your bathtub by turning up the water fau-
cets or would you call a plumber to try and
identify where the leak is coming from?
This means governments should start to fo-
cus on how to replace these old polluting
devices with clean technological solutions. Our society has regula-
tions for hygiene, health, taxes, justice and education, but nothing
prevents us from wasting energy with outdated technology.Can you
imagine how many jobs would be created, and how much profit
made, if everyone rallied behind this new market? Lets stand up
against those who say that solving climate change will jeopardize
our economic development. It›s precisely the opposite!
My fear for COP 21 in Paris is that climate change stakeholders will
look at taking measures,which will be unacceptable.Developed coun-
tries will be asked to pay for the pollution they have caused, while
poorer countries will be asked to renounce on economic development
to which they are entitled. The result will be wide-scale resistance!
Targets for CO2
reduction and minimum temperature increases
become wishful thinking if they are not addressed with profitable
solutions that will help reach them. That’s where the focus of the
debate is needed: discussing which clean technological solutions are
the most relevant and directly profitable for which region of the
world and what type of economy?
Can you imagine the motivation of every country that could then
trade a costly sacrifice for a profitable investment? Clean technologies
impact climate change while at the same time being profitable, creat-
ing employment and stimulating economic development and growth.
This is why we should choose the clean technology revolution, even
if we were not facing any climate change issue at all…
Dr. Bertrand Piccard, Initiator,
Chairman and Pilot of Solar Impulse, http://www.solarimpulse.com
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv, editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design and
cover design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
The Latvian Medical Association, “Latvijas Ārstu biedrība”,
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Sir Michael MARMOT
WMA President
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Donchun SHIN
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
46-gil Ichon-ro
Yongsan-gu, Seoul 140-721
Korea
Prof. Dr. Frank Ulrich
MONTGOMERY
WMA Vice-Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Xavier DEAU
WMA Immediate Past-President
Conseil National de l’Ordre des
Médecins (CNOM)
180, Blvd. Haussmann
75389 Paris Cedex 08
France
Dr. Joseph HEYMAN
WMA Chairperson
of the Associate Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. Masami ISHII
WMA Treasurer
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Heikki PÄLVE
WMA Chairperson of the Medical
Ethics Committee
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Finland
Dr. Miguel Roberto JORGE
WMA Chairperson of the Socio-
Medical Affairs Committee
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Ardis D. HOVEN
WMA Chairperson of Council
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chicago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
Clean Technologies Can Change the World
Bertrand Piccard
BACK TO CONTENTS
122 123
WMA News WMA News
Dear Presidents and Chairpersons,
Dear Colleagues,
Dear Friends,
I am particularly honoured and pleased to
welcome here in Moscow the 116 members of
our world medical association or their repre-
sentatives.
As it happens we are holding here in Moscow
not only our 2015 General Assembly but also
the 201st
WMA Council Session and the An-
nual meeting of junior doctors.
I wish to thank the Russian Medical Society
for their friendly welcome and efficient organ-
isation.
Thanks are also due to the Russian Government
and the Moscow City Council for their support.
As I open this General Assembly, I believe it
is appropriate to recall the goals of the World
Medical Association.
Our aim is to serve mankind by striving to
achieve the highest international standards in
terms of medical education, medical science,
medical art, medical ethics and medical care
for all the peoples of the world.
The world is currently undergoing major up-
heavals. More than ever the medical profes-
sion and our associations must be present and
play an active role on the global scene.
Climate change.
A very last chance of reaching a consensus on
global warming will come up at the COP21
meeting in December in Paris. Physicians are
called upon to deal with the consequences of
climate change on human health worldwide.
Geopolitical upheavals
Migrant populations requiring immediate
health care, irrespective of their language, cul-
ture, religion or skin colour.
Upheavals due to armed conflicts
Here again doctors should guarantee high
standards of medical care in safe conditions,
for both patients and medical staff, consistent
with the ethical standards of our World Medi-
cal Association and our Health Care in Dan-
ger programme.
Scientific upheavals
With a very rapid evolution of medical science
and new technologies requiring an urgent up-
dating of medical training.
Throughout our discussions at this General
Assembly, we must therefore insist on the
absolute necessity of enforcing strong ethical
values, particularly as regards the autonomy of
physicians.
Medical autonomy is without doubt an over-
arching ethical value inasmuch as it guaran-
tees patient trust, professional confidentiality
and the protection of personal data.
It also means a respect for human beings, for
their enlightened consent or acceptance, their
vulnerability and their rights as human be-
ings.
I am, we are all, concerned by these upheav-
als which result in social and political situa-
tions that impact negatively on human health,
mainly on the poorest.
The WMA, our National Associations, each
and every one of us individually, all must work
together, in a spirit of brotherhood, equity and
solidarity, with full respect for the basic values
of medical ethics.
We should avoid all forms of fundamentalism,
be it social, political, professional or religious,
whilst preserving our own personal profes-
sional freedom – such are the stakes if we are
to safeguard the physician’s autonomy.
Medical autonomy impacts directly on all our
patients as well as on our ability to care for
foreign or migrant patients.
A flood of migrants is fleeing violence and the
fundamentalism of certain ideologies, bring-
ing us back to the historical and ethical origins
of our World Medical Association.
Let us accept these people and give them the
medical care they require.
For such is our simple duty, our contribution
to the survival of peace in the world.
Amidst these upheavals the physician is at the
forefront of the quest for peace and equity, for
he is expected to provide an immediate med-
ico-social response to the social determinants
of health.
Let us help our medical associations, our phy-
sicians to provide quality medical care for all
human beings. In full independence, full con-
fidence, whilst such are the values I strove to
promote through my one-year mandate as
your President.
Before I conclude, I would like to express my
personal gratitude to WMA Council mem-
bers, Chaired by Dr. Mukesh Haikerwal and
subsequently by Dr. Ardis Hoven as well as
the secretariat as a whole under Dr. Kloiber’s
leadership. My thanks also go to our Past
President Margaret Mungherera for her brave
involvement in the African project. I also ex-
tend my best wishes to Sir Michael, who will
take over the Presidency with his well-known
dynamism, enthusiasm, and joie de vivre.
My warmest thanks also go to our devoted of-
fice staff, Sunny, Clarisse, Anne-Marie, Julia,
Roderic and Lamine.
Thank you all for the high standard of your
contributions. Let us continue to bear witness
to and actively enforce the ethical values of the
World Medical Association.
In view of the serious problems we face, we
should continue to provide leadership for all
our medical associations.
It is our duty to combat violence relentlessly
by providing quality medical care for all.
Let us be proud of being physicians.
Let us be proud of our World Medical As-
sociation.
Let us be proud of serving peace for the wel-
fare of mankind.
Valedictory speech
Dr. Xavier Deau,
WMA General Assembly,
Moscow 16 September 2015
Honoured Guests, Colleagues,
In May 2011 Mary hanged herself. She was
found in the yard of her grandparents’house
on a First Nations Reserve in the province
of British Columbia in Canada. She was
fourteen. She was a First Nations, aborigi-
nal, Canadian.
Her story has particulars. All suicides do.
She had been physically and emotionally
abused at home and in her community, and
possibly sexually abused. Her mother was
mentally unstable and heard voices telling
her to ‘snap’ her child’s head. Officials at-
tributed the suicide to a dysfunctional child
welfare system, and to the fact that no one
took her complaints of abuse seriously or
acted on them.
There is another way to look at Mary’s sadly
foreshortened life, and that is to realise that
though her personal tragedy was unique,
there are many young aboriginal Canadians
who experience similar tragedies. In fact,
the aboriginal youth suicide rate in British
Columbia is five times the average for all
young Canadians. One cannot understand
fully why Mary saw no way out without also
asking why so many other young aborigi-
nal people in British Columbia reached the
same desperate point.
The starting point is poverty, bone-grinding
poverty, low educational levels and high
unemployment. But there were about 200
bands of aborigines in British Columbia,
more or less all in poverty. Yet 90% of the
adolescent suicides occurred in 12% of the
bands. Why some and not others? The dif-
ference was empowerment of communities.
Empowered communities participated in
land claims; self-government, had control
over educational, police and fire, and health
services; and establishment of ‘cultural’facil-
ities. The results were clear: the greater the
cultural continuity and community control
over their destiny, the lower was the youth
suicide rate. Poverty is bad, but poverty is
not destiny. Empowerment of communities
can save lives. I draw similar lessons from
studying the health of New Zealand Mao-
ris, Indigenous Australians, Native Ameri-
cans or indeed that of excluded groups else-
where in the world.
In January 2010,Haiti’s earthquake wreaked
havoc and 200,000 people died. Less than
two months later a quake 500 times stron-
ger hit Chile and the death toll was in the
hundreds. Haiti was underprepared in every
way imaginable. Chile was well prepared,
with strict building codes, well-organised
emergency responses and a long history of
dealing with earthquakes. True, the epicen-
tre of the Haitian earthquake was closer to
population centres than that of the Chilean
quake, but that was only part of the expla-
nation for the different scale of devastation.
What turns a natural phenomenon into a
disaster is the nature of society. The num-
ber of people who died had more to do with
Haiti’s lack of societal readiness and re-
sponse than with the strength of the quake.
In 2011 the London borough of Tottenham
broke out in urban riots.The precipitant was
the killing of a black man by police.But,un-
acceptable as that is, it was not the underly-
ing cause. Inequality was the culprit. I had
been citing an area of Tottenham as having
the worst male life expectancy in London –
18 years fewer than in the best-off area. All
in one of the world’s premier global cities.
London now has more high-end properties,
a price tag more than $5million, than Man-
hattan, Hong Kong, Singapore or Sydney.
It is not surprising that the riots broke out
in the area with the worst health. Ill-health
does not cause riots. Nor do riots cause
ill-health  – at least not directly. Relative
deprivation causes both urban unrest and
ill–health. Ninety per cent of young people
arrested in the riots were not in employ-
ment, education or training.
Similarly, in Baltimore in the US. When a
black man was killed in police custody ri-
ots broke out. Not uniformly across the city,
but in the area with condemned houses,
low levels of education and income and a
twenty year disadvantage in life expectancy
compared to the area with leafy opulence.
Inequality strains the binds of a cohesive
society. In Baltimore, those binds snapped.
The immediate effect is civil unrest. The
longer term effecs is health inequity.
These examples illustrate that the way we
organise our affairs, at the community level
or, indeed at the whole societal level, are
matters of life and death. As doctors we
cannot stand idly by while our patients suf-
fer from the way our societies are organised.
Inequality of social and economic condi-
tions is at the heart of it.
There are three aspects of Mary’s tragedy
worth emphasising. The first is the vital is-
sue of violence to girls and to women. It
can be fatal, both because it drives women
to suicide and because they may be killed
by their partners. Second, I  emphasised
empowerment of communities. But em-
powerment of individuals is also of vital
importance. A key route to female empow-
erment, globally, is education. Evidence
shows clearly: the greater the education
of women the less the likelihood of being
subject to domestic violence. Third is the
importance of mental illness. Mental ill-
Inaugural Address as
WMA President
Sir Michael Marmot,
WMA General Assembly,
Moscow 16 September 2015
BACK TO CONTENTS
124 125
WMA News WMA News
ness and substance use disorders constitute
the number one cause of years spent with
disability, globally.We cannot be concerned
with health, globally and in our countries,
and not be concerned with mental illness
and substance use.
More generally we need to recognise the
importance of the mind to health equity.
The mind is the major gateway through
which social determinants exert their effect
on health. Recognizing the importance of
the mind takes us back to early child devel-
opment and what I have called: equity from
the start.
In Aldous Huxley’s dystopia, Brave New
World,there were five castes.The Alphas and
Betas were allowed to develop normally.The
Gammas, Deltas, and Epsilons were treated
with chemicals to arrest their development
intellectually and physically, progressively
more affected from Gamma to Epsilon.The
result: a neatly stratified society with intel-
lectual function, and physical development,
correlated with caste.
That was satire, wasn’t it? We would never,
surely, tolerate a state of affairs that strati-
fied people, then made it harder for the
lower orders, but helped the higher orders,
to reach their full potential.Were we to find
a chemical in the water, or in food, that was
damaging children’s growth and their brains
worldwide,and thus their intellectual devel-
opment and control of emotions, we would
clamour for immediate action. Remove the
chemical and allow all our children to flour-
ish, not only the Alphas and Betas. Stop the
injustice now4 Yet, unwittingly perhaps, we
do tolerate such an unjust state of affairs
with seemingly little clamour for change.
The pollutant is called social disadvantage
and it has profound effects on developing
brains and limits children’s intellectual and
social development. Note, the pollutant is
not only poverty, but also social disadvan-
tage.There is a clear social gradient in intel-
lectual, socia, and emotional development –
the higher the social position of families the
more do children flourish and the better
they score on all development measures.
This stratification in early child develop-
ment, from Alpha to Epsilon, arises from
inequality in social circumstances.
This social gradient in children’s possibil-
ity to fulfil their potential, in its turn, has a
profound effect on children’s subsequent life
chances. We see a social gradient in school
performance and adolescent health; a gradi-
ent in the likelihood of being a 20 year old
not in employment, education, or training;
a gradient in stressful working conditions
that damage mental and physical health;
a gradient in the quality of communities
where people live and work; in social condi-
tions that affect older people; and, central
to my concern, a social gradient in adult
health. A causal thread runs through these
stages of the life course from early child-
hood, through adulthood to older age and
to inequalities in health. The best time to
start addressing inequalities in health is
with equity from the start. But intervention
at any stage of the life course can make a
difference. Relieving adult poverty, pay-
ing a living wage, reduction in fuel poverty,
improving working conditions, improving
neighbourhoods, and taking steps to reduce
social isolation in older people can save lives.
The health gradient to which these life
course influences give rise is dramatic.There
is a cottage industry, taking subway rides in
various cities and showing how life expec-
tancy drops a year for each stop. I have re-
ferred to twenty year gaps in Baltimore and
London; but the health differences between
rich and poor, dramatic as they are, are only
part of the problem. Commonly, people say
to me: I  am neither rich nor poor; what
does any of this have to do with me? The
evidence shows that there is a social gradi-
ent in health that runs from top to bottom
of society. People in the middle have worse
health than those above them in the social
hierarchy, but better than those below. We
calculated for England that if everyone en-
joyed the same life expectancy as the top
10%, based on education, there would be
202,000 fewer deaths each year; over 500 a
day.
One problem, then, is poverty. Another is
inequality. Both damage health and lead to
an unjust distribution of health.I have spent
my research life showing that the key deter-
minants of health lie outside the health care
system in the conditions in which people
are born, grow, live, work and age; and in-
equities in power, money and resources that
give rise to these inequities in conditions
of daily life. Since the establishment of the
WHO Commission on Social Determi-
nants of Health in 2005, I have been using
research knowledge to argue for policies on
social determinants of health.
Yet here I am, humbled by assuming office
as President of the World Medical Associa-
tion.Is there not a contradiction?The World
Medical Association, WMA, upholds the
highest ethical standards of the practice of
medicine. It speaks out fearlessly when the
right of doctors to pursue their noble call-
ing is threatened. As President, I want the
WMA to use the same moral clarity to be
active against the causes of ill-health and
what I call the causes of the causes – the
social determinants of health.
The opening sentence of my recent book,
The Health Gap: The Challenge of an Unequal
World, was: why treat people and send them
back to the conditions that made them
sick? No one is as concerned about health
and disease as we in the medical and other
health professions. It has been and will be
my mission to encourage our concerns with
the conditions that make people sick.
I am hugely encouraged already. My friends
in the Canadian Medical Association con-
ducted Town Hall meetings across Canada
to engage the public in discussion on how
the conditions of their lives related to their
health. The Canadian Medical Association
then took the initiative to suggest a meet-
ing at BMA House in London. Twenty
countries and 200 people asked to come,
including our now-Chair of Council, Ardis
Hoven, and then-president, Xavier Deau,
and participated with enthusiasm. I apolo-
gise in advance: I already have more invita-
tions from medical colleagues, enthusiastic
for the health equity agenda, than I could
possibly meet. We need a global social
movement.
I have been arguing that we have the knowl-
edge of what to do to act on social determi-
nants and health equity; we have the means.
We need to ensure that we have the will.
Do we really have the means? Consider.
What do the following have in common?
• 48 million people of Tanzania
• 7 million people of Paraguay
• 2 million people of Latvia
• top 25 US hedge fund managers
In 2013 each of these four groups had a
total income of between $21 and 28 bil-
lion. Imagine with me something totally
fanciful: that the 25 hedge fund manag-
ers gave up their income for one year. It
would double the income of Tanzania. The
hedge fund managers wouldn’t feel it, be-
cause they will earn an average of $1bil-
lion each the next year. I am not suggesting
for a moment that we simply pass the cash
to individual Tanzanians. But think of the
clean water that could be piped,the schools
that could be built, the nurses trained and
employed.
There is a great deal of money sloshing
about. Great inequality between countries
stops the money being spent in ways that
would benefit the poor and the needy.
Suppose, though, that there was reluc-
tance to see ourselves as part of a global
community.We would still have to address
staggering levels of inequality of income
and wealth within countries. Here is an
even more fanciful thought. Suppose that
the hedge fund managers of New York
paid a third of their $24 billion income in
tax – unlikely I know – that money could
fund 80,000 New York schoolteachers.
80,000.
What has this to do with doctors? At the
meeting of National Medical Associations
that we held in London we heard inspir-
ing examples of how doctors are already
working with communities to deal with the
social causes of ill-health. In India I  was
taken by medical colleagues to a tribal area
in Gujarat where the doctors are not only
treating people who, hitherto, had no access
to health care, but are working with others
in community development and education
to improve the conditions of daily life for
marginalised people. In Brazil, the social
gradient in stunting of young children is be-
coming progressively flatter. In Bangladesh
and Peru inequalities in child mortality
are decreasing. I am excited by the interest
generated in social determinants of health
globally in every region of the world: South
Africa, Zambia, Morocco, Colombia, Cuba,
Costa Rica, Panama, Surinam, Taiwan,
Sweden, Norway, Finland, Iceland and …
I could go on.
Colleagues, we can make a difference to the
causes of the causes of health equity, as part
of the practice of medicine.There is another
way we can make a difference, too. I do not
go for long without quoting the great Ger-
man pathologist, Rudolf Virchow, who said
that “physicians are the natural attorneys of
the poor”. We can, we do, we should speak
up about inequity in social conditions that
damage the health of the populations that
we serve.
It means to,that we should recognise and be
vocal about any societal trends that are like-
ly to affect health equity: climate change,
trade, financial crises.
I hold a Bernard Lown visiting professor-
ship at Harvard. Bernard Lown, great car-
diologist and co-founder of International
Physicians for the Prevention of Nuclear
War, said: never whisper in the presence of
wrong. Already WMA speaks up in a loud
voice about the highest ethical standards of
our profession. We should not whisper at
the gross inequities in the world that give
rise to health inequities.
In fact, so close is the link between social
conditions and health that, I argue, health
equity is a good measure of social progress;
much better than income growth. Senator
Robert Kennedy in a famous speech criti-
cised Gross National Product as a measure
of social progress. He said:
the gross national product does not allow for
the health of our children, the quality of their
education or the joy of their play. It does not
include the beauty of our poetry or the strength
of our marriages, the intelligence of our public
debate or the integrity of our public officials. It
measures neither our wit nor our courage, nei-
ther our wisdom nor our learning, neither our
compassion nor our devotion to our country, it
measures everything in short, except that which
makes life worthwhile.
Health and health equity are not only
worthwhile in themselves but they reflect
much else that makes life worthwhile: the
freedom to lead lives we have reason to
value.
As doctors, at our best, we flourish in the
cause of social justice. There is a great deal
of injustice in the world. Can we really be
optimistic? Let me quote from Nobel Prize
winning poet Seamus Heaney:
History says, don’t hope
On this side of the grave.
But then, once in a lifetime
The longed-for tidal wave
Of justice can rise up,
And hope and history rhyme.
So hope for a great sea-change
On the far side of revenge.
Believe that further shore
Is reachable from here.
Believe in miracle
And cures and healing wells.
I have had much reason to praise our medi-
cal students at the IFMS, and our junior
doctors. In the spirit of Heaney I  say to
our younger colleagues: believe in miracle
and cures and healing wells not just for our
patients but for society, too. If this sounds
idealistic I remember the words of Halfdan
Mahler,former Director-General of WHO,
who said when we published the report of
the Commission on Social Determinants
of Health: remember, idealists are the real-
ists in human progress. I have another poet
who has been my companion. When we
launched the Commission on Social De-
terminants of Health in Santiago, Chile,
I quoted Pablo Neruda. I did again at each
report we have published and I do so again
now. I invite you to:
Rise up with me…
Against the organisation of misery.
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WMA News WMA News
Wednesday, October 14
At the invitation of the Russian Medical
Society, delegates from 58 National Medi-
cal Associations met at the World Trade
Center in Moscow, Russia, October 14–17,
for the WMA’s 2015 General Assembly.
Council
Dr. Ardis Hoven, Chair of the WMA,
opened the 201st
Council session.
The Secretary General, Dr. Otmar Kloi-
ber, welcomed delegates from the Russian
Medical Society and a new member of the
Council, Dr. Steve Hambleton (Australian
Medical Association).There were no formal
apologies of absence.
Secretary General’s report
Dr. Kloiber referred to the written Coun-
cil report that set out the secretariat’s work
over the past six months.
He highlighted three items. First was
the close co-operation with the World
Health Organisation on the prevention
and control of non communicable diseas-
es. A workgroup was being set up on the
strengthening of health care systems and
the WMA needed help from NMAs to en-
sure that physicians were included on the
workgroup.
The second was the WMA influenza
campaign and the need for the WMA to
learn from the activities and campaigns of
NMAs. He reminded delegates that the
two targets of the campaign were to get a
higher penetration of immunisation in the
general population and more importantly to
get health professionals and especially phy-
sicians immunised. The immunisation rate
of health professionals in many countries
was simply not high enough and they all
owed it to their patients and their families
to be vaccinated.
The third item was the United Nations new
sustainable development goals, a series of
objectives to improve the lives of people
through economic, social and environmen-
tal dimensions and the eradication of pov-
erty in all forms. The goals were adopted in
September to cover the period from 2016
to 2030 and they replaced the Millennium
Development Goals which had been aimed
mainly at developing countries with varied
success.The new goals were more ambitious
and holistic and were aimed to apply to
all countries. There were 17 goals and 169
targets and all were extremely ambitious.
It was important for the WMA to reflect
these goals and to co-operate.
Emergency Resolutions
The Council then heard arguments for three
items to be considered as matters of urgency.
Attacks in Turkey
The Turkish Medical Association proposed
a resolution calling for an end to recent at-
tacks on healthcare personnel, patients, and
health care facilities in Turkey. Delegates
heard that a physician, a nurse and an am-
bulance driver had been killed within the
last two months and there had been attacks
against health care facilities and ambulanc-
es. There were curfews and the wounded
were not able to access health care facilities.
Preventable deaths were occurring as a re-
sult. The emergency resolution called for all
parties involved to respect the professional
autonomy and impartiality of healthcare
staff, and to comply fully with international
human rights law and other relevant inter-
national regulations.
The Council agreed that this matter should
be accepted as an emergency resolution.
Global Refugee Crisis
The British Medical Association said it was
very difficult to overestimate the degree of
urgency of this matter. They had seen over
the past year the numbers of refugees in-
creasing significantly. Recently this had
worsened and every country was close to
breaking point. Politicians appeared not to
know how to handle the matter. The es-
sential issue was one of humanity and look-
ing after the interests of people who were
suffering. At the end of day this became a
health problem if they did not treat people
with humanity.
The Council agreed that this matter should
be accepted as an emergency resolution.
Afghan Hospital Bombing
The Spanish Medical Association intro-
duced a resolution about the recent bomb-
ing of a hospital in Kunduz, Afghanistan.
It argued that the WMA should condemn
this bombing which went against the Dec-
laration of Human Rights. The resolution
demanded an immediate investigation by
an independent organisation and investiga-
tion into those who had committed this act.
Dr. Kloiber reminded the meeting that
when the bombing occurred the WMA had
issued a press release joining in the con-
demnation and Dr. Xavier Deau, the Presi-
dent, had said: ‘This latest tragedy strength-
ens our determination to ensure the safety
of hospitals, health care facilities, patients
and healthcare personnel during armed
conflicts. It underlines the importance of
our work with the International Committee
of the Red Cross to urge all governments to
do more to ensure the safety of health care
in situations of violence. Tragedies such as
this shame us all.
The Council agreed that the proposed reso-
lution should be accepted as an emergency
resolution.
Chair’s Report
Dr. Ardis Hoven gave a brief oral report,
saying that the WMA had continued to
achieve significant global recognition for
the value it brought to world medicine and
to physicians and their patients throughout
the world. It was a highly recognised global
leader in health, particularly through the
work with the Declaration of Helsinki.
Socio-medical affairs committee
Dr. Miguel Roberto Jorge (Brazilian Medi-
cal Association) took the chair.
Dr. Kloiber brought the committee up to
date with three items.
There had been some movement on tobacco
control with a focus on the effect of tobacco
on children, especially banning smoking in
cars. This was being recognised more and
more by lawmakers. He urged national
medical associations to approach their gov-
ernments to work on legislation to better
protect children.
On alcohol, more and more governments
were considering minimum pricing and
again it would be good if as many NMAs
as possible could discuss this with their law-
makers.
Finally, the WHO was developing a new
Global Strategy on Human Resources for
Healt, which represented a strategic vision
towards universal health coverage within
the framework of the UN sustainable de-
velopment goals. More effort was needed
to involve physicians in the development of
health policies and he again urged NMAs
to stress this when meeting their govern-
ments.
Health and Environment
Dr. Dongchun Shin (Korea), Chair of the
Environmental Caucus, reported on the ac-
tivities of the caucus that had met the day
before. The meeting focused on the forth-
coming United Nations Climate Change
Conference in Paris in December 2015.
There was a fruitful exchange of informa-
tion on the activities planned by partici-
pants within the framework of the event.
They had been trying to put health at the
centre of the negotiations. It was also an
opportunity to present and discuss WMA
activities planned in connection with the
Paris conference.
Health Care in Danger
Prof. Vivienne Nathanson (British Medi-
cal Association), chair of the Workgroup
on Health Care in Danger, reported on the
activities of the group, which had met the
day before. Dr. Bruce Eshaya-Chauvin, co-
ordinator of the International Committee
of the Red Cross Health Care in Danger
Project (HCiD), had updated the group on
the activities taken over the past six months
and had emphasized that the ICRC was
now trying to promote a move from a com-
munity of concern on HCiD issues to a
community of action. From this perspec-
tive, the workgroup encouraged constituent
members to take up the initiative and would
invite them to report on their activities in
this area.
Ageing
Dr. Nivio Moreira (Brazilian Medical As-
sociation) reported on the activities of the
workgroup that had been set up with the
mandate to produce a proposed policy on
ageing.The members had worked on a pre-
liminary draft via email with the support
of an expert, Dr. Alexandre Kalache, and
was now suggesting that the draft should
be circulated to national medical associa-
tions.
The committee agreed with this proposal.
Role of Physicians in Preventing the Traffick-
ing with Minors and Illegal Adoptions
The Spanish Medical Association reported
that the workgroup had met the previous
day and discussed a preliminary draft which
it suggested should be finalized and submit-
ted to the Council for consideration in Bue-
nos Aires next April.
This was agreed by the committee.
Physicians’ Well-being
The committee considered the proposed
Statement on Physicians’ Well-being
which was introduced by Dr. Robert Wah
(American Medical Association), Chair of
the Workgroup. The committee considered
several proposed amendments. One was a
suggestion that because physicians suffer-
ing ill health often tried to treat themselves
they should get the right diagnosis from the
most experienced physician in their depart-
ment of practice. However, this suggestion
was voted down.
Another amendment was to change the
wording of the document to refer to ‘edu-
cation’ rather than ‘training’. It was argued
that physicians were under considerable
risk of losing their professional autonomy
and clinical independence. This was mainly
done with words and the medical profession
was in danger of being seen as a technical
service. It was important therefore to talk
about ‘educating’ physicians rather than
‘training’physicians. It was agreed to review
this point before the Council meeting on
Friday.
The committee agreed that the document
should be sent to the Council and then for-
warded to the Assembly for adoption.
WMA 2015 General Assembly Report
Moscow, Russian Federation, October 14–17
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WMA News WMA News
Smallpox Destructions
The committee considered a proposed
Statement on the Destruction of Smallpox
Virus Stockpiles from the Junior Doctors
Network. It was proposed that the docu-
ment be considered by a small workgroup.
But the document failed to win support and
it was decided that the document should
not be approved.
Transgender
The Committee considered a proposed
Statement on Transgender People intro-
duced by the German Medical Association.
The committee was told that the document
was intended to serve as a guideline for pa-
tient-physician relations and to foster better
training to enable physicians to increase their
knowledge and sensitivity toward transgen-
der people. It acknowledged the inequities
faced by the transgender community and the
crucial role played by physicians in advising
and consulting with transgender people and
their families about desired treatments. Al-
though the proposers of the document were
aware of the cultural sensitivities in some
parts of the world with regard to this issue,
it was important for the WMA to stress
that cultural, political or religious consid-
erations must not take precedence over the
rights, health and well-being of transgender
people, or any patient for that matter. The
German Medical Association argued that
although the paper provided context by
briefly addressing some of the broader so-
cial issues faced by transgender people, the
overall scope of the paper, and especially the
recommendations, was focused on the role
of the physician and the healthcare system
at large in providing equitable treatment to
transgender people. It was important for the
medical community to highlight the poten-
tial health effects of negative social attitudes,
stigmatisation and discrimination towards
the transgender community.
During the debate that followed it was
explained that the issue of intersexuality
should not be incorporated into this docu-
ment but should be the subject of a separate
paper, which the Royal Dutch Medical As-
sociation had volunteered to prepare.
The committee agreed to the document
being sent to the Council for forwarding
to the General Assembly for approval and
adoption.
Vitamin D Insufficiency
The committee considered the proposed
Statement on Vitamin D Insufficiency.This
urged national medical associations to sup-
port continued research into vitamin D de-
ficiency which affected about a third of the
population.
The committee agreed that the Statement
be sent to the Council for approval and
then forwarded to the General Assembly
for adoption.
Mass Media Appearances
The committee considered proposed guide-
lines on Mass Media Appearances by Phy-
sicians, introduced by the Korean Medi-
cal Association. It was explained that the
document arose from serious concern over
the increase of physicians’ appearing on
the mass media to recommend unproven
treatments or products.The guidelines were
aimed at preventing physicians from being
involved in commercial activities that might
compromise professional ethics.They would
also contribute to patient safety by ensuring
physicians provided accurate, timely, and
objective information.
During a debate, it was decided to amend
the document to include the phrase that
physicians should not introduce false fr ex-
aggerated statements regarding their quali-
fications.
Discussion also took place on the docu-
ment’s statement that ‘When appearing in
media, physicians shall provide objective
and evidence-based information and shall
not recommend medical procedures or
products that are not medically proven.’ It
was decided to leave in the words ‘evidence-
based information’ but add the words ‘or
justified’ at the end of the sentence.
The committee agreed to amend the docu-
ment to say that ‘Physicians should not
recommend specific products’ rather than
‘physicians should not recommend specific
foods or health supplements’. The commit-
tee also debated whether the wording that
‘Physicians shall not engage in the pro-
motion, sale or advertising of commercial
products’ should be changed to ‘Physicians
should take great care when engaging in the
promotion….’But on a close vote it was de-
cided to keep the wording unchanged.
It was also decided to change the title of the
document to ‘Guidelines on Promotional
Mass Media Appearances by Physicians’.
The committee agreed that the proposed
guidelines, as amended, be sent to the
Council for approval and forwarded to the
General Assembly for adoption.
Boxing
ThecCommittee considered a proposed
major revision of the WMA Statement on
Boxing submitted by the South African
Medical Association.
It was agreed that the document be circu-
lated among constituent members for com-
ment.
Tobacco
The committee considered a proposed revi-
sion of the WMA Resolution on the Imple-
mentation of the WHO Framework Con-
vention on Tobacco Control produced by
the Australian Medical Association aimed
at encouraging national medical associa-
tions to get their governments to imple-
ment the Framework and in particular to
introduce a ban on smoking in enclosed
public places and work places.
It was agreed that the document be circu-
lated among national medical associations
for comment.
Female Genital Mutilation
The committee considered a proposed revi-
sion of the WMA Resolution on Female
Genital Mutilation prepared by the British
Medical Association, encouraging national
medical associations around the world to
become more active in campaigning to end
the practice.
It was agreed that the document be circu-
lated among constituent members for com-
ment.
Body Searches of Prisoners
The committee considered a proposed re-
vision of the WMA Statement on Body
Searches of Prisoners, also prepared by the
British Medical Association.
The committee again agreed that the docu-
ment be circulated among constituent
members for comment.
Workers’ Health & Safety
The committee considered a proposed Res-
olution on Occupational Health & Safety
submitted by the Turkish Medical Asso-
ciation, as well as a proposed Declaration
on responsibility of employers for workers’
health protection and occupational safety
submitted by the Russian Medical Society.
A proposed Declaration on Protection of
Human Reproductive Health which ad-
dressed health reproductive issues in rela-
tion to challenging working condition, was
also considered.
The committee decided to recommend to
the Council that a workgroup on Occupa-
tional Health be set up with the mandate
to look at the three proposed policies with
the aim of preparing a single proposal,if ap-
propriate.
Armed Conflicts
The committee then considered three pro-
posed Declarations – two from the Rus-
sian Medical Society on Priority of Human
Life and Health in Resolution of Territo-
rial Disputes and Armed Conflicts and on
Children’s Rights to Prioritized Evacuation,
Medical & Humanitarian Aid in the Areas
of Local Armed Conflict. A third proposed
Declaration on Triggering and Carrying out
Armed Conflicts as a Measure of Achieving
Objectives of State Politics was submitted
by the Polish Medical Chamber.
It was agreed that a workgroup be set up
with the mandate to look at the three pro-
posals with the aim of preparing a single
proposal, if appropriate.
Life Environment
A proposed Declaration on Maintaining
Safety of Life Environment for Human
Health, submitted by the Russian Medical
Society, was briefly considered, but failed to
find support.
Physicians’ Right to Information
The committee considered a proposed Dec-
laration on Physicians’ Right to Information
about the World Medical Association and
its Policies submitted by the Russian Medi-
cal Society. Its aim was to increase awareness
about WMA policies among physicians.
The committee agreed that the document
be circulated to constituent members for
comments.
Professional Autonomy of Physicians
The committee considered a proposed Dec-
laration on Professional Autonomy of Phy-
sicians as the Main Condition for Imple-
mentation of the Human Right to Health
submitted by the Russian Medical Soci-
ety and it was agreed that it be circulated
among constituent members for comments.
Obesity in Children
The committee considered a proposed State-
ment on Obesity in Children proposed by
the Israeli Medical Association. It was ex-
plained that the document brought together
different aspects to combat childhood obe-
sity, such as education and economic incen-
tives through taxes on unhealthy foods.
It was agreed that the proposed Statement
be circulated among constituent members
for comments.
Advocacy
Dr. André Bernard (Canadian Medical As-
sociation), Chair of the Advocacy Advisory
Committee, reported on the activities of the
Committee that had met the day before.
The committee had discussed the issue of
social media and the use of twitter during
WMA meetings.
It had also considered the proposal for an
International World Day on Combatting
Violence and it was agreed to explore what
opportunities might be provided by the
World Humanitarian Summit in 2016 to
organise an event.
Finally the committee considered how to
build on the success of the advocacy session
held in Durban in 2014, and agreed to con-
tact the Taiwanese Medical Association to
discuss the possibility of holding an advoca-
cy training session during the next General
Assembly in Taiwan in 2016.
Attacks against Healthcare workers and facili-
ties in Turkey
The committee considered the proposed
urgent Resolution to stop attacks against
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WMA News WMA News
healthcare workers and facilities in Turkey.
Following an explanation from the Turkish
Medical Association and a brief debate, it
was agreed that the proposed Resolution be
sent to the Council for forwarding to the
General Assembly for approval and adop-
tion.
Global Refugee Crisis
The committee considered the proposed
urgent Resolution on the Global Refugee
Crisis submitted by the British Medical
Association. Delegates were told it was
important that the WMA made the
point that refugees were people and as
people they were suffering. Doctors un-
derstood the suffering that had caused
them to becoge refugees. The process of
being a refugee was worsening this suf-
fering. They needed to be treated with
humanity. Yet much of the international
debate had been very alienating. This was
an opportunity to switch the tenure of
the debate.
The committee agreed that the Resolution
as amended be sent to the Council and
forwarded to the General Assembly for ap-
proval and adoption.
Bombing of the hospital run by Médecins Sans
Frontières in Kunduz, Afghanistan
The committee considered the proposed
urgent resolution on the bombing of the
hospital of Médecins Sans Frontières in
Kunduz, Afghanistan submitted by the
Spanish and South African medical as-
sociations. The meeting heard of the con-
cern about continued attacks on health
care workers and facilities around the
world. The recent bombing of the hospi-
tal in Kunduz attested to this particular
concern. It was important that the WMA
Assembly was part of the cry around the
world to advocate for the setting up of an
independent body to investigate the cir-
cumstances of the bombing of this hos-
pital.
It was agreed that the proposed resolution
be approved and sent to the Council for for-
warding to the General Assembly for ap-
proval and adoption.
Medical ethics committee
Dr. Heikki Pälve (Finland Medical Asso-
ciation) took the chair.
The committee meeting opened with
Dr. Kloiber reporting on four items:
First,Hhe said that an international discus-
sion was taking place on end of life care,
euthanasia and physician assisted suicide
and the WMA had to enter the debate.The
WMA would organise a session on this
topic at the Bioethics, Medical Ethics and
Health Law Conference in Naples the fol-
lowing week.
Second, he said the revised Declaration of
Helsinki had been discussed at many in-
ternational conferences and very positively.
The University of Harvard had now invited
the WMA to speak about post-trial access
to care.
Next, the Olympic Committee had invited
the WMA to take part in the revision pro-
cess of the Olympic Medical Code of Eth-
ics and submit comments.
Finally, he said that the WMA was in-
volved in the discussion at the WHO on
the regulatory aspects of biosimilars, which
dealt with the classification, remunera-
tion systems and bioethics of biosimilars.
The European Union had also invited the
WMA to speak about the ethical aspects of
biosimilars.
Dr. Jeff Blackmer (Canadian Medical As-
sociation) reported that the CMA and the
Royal Dutch Medical Association were
working on a paper to address end of life
care and assisted dying. This would be pre-
sented in 2016.
Person Centered Medicine
The committee received an oral report
from the Chair of the Workgroup on
Person Centred Medicine, Dr. Andrew
Dearden (British Medical Association).
He said the workgroup would develop a
new policy to be presented at the Coun-
cil meeting in Buenos Aires in April
2016. This would be based on comments
previously submitted on the draft polics
presented to the committee in Tokyo in
201, and the workgroup’s background
paper.
Health Databases
The committee received an oral report
from Dr. Jon Snædal (Iceland Medical
Association), Chair of the Workgroup
on Health Databases and Biobanks. The
WMA had received 90 comments from
international experts in response to a pub-
lic consultation on the workgroup’s draft
paper this year. This was followed by a
series of meetings. The next meeting to
discuss the topic would take place during
the Bioethics, Medical Ethics and Health
Law Conference in Naples. A workgroup
expert meeting in Korea was planned for
February 2016, along with a satellite ses-
sion during the World Congress of the
International Association of Bioethics in
Edinburgh in June 2016. It was hoped to
have a draft version ready for discussion at
the next Council meeting in Buenos Aires
in April 2016.
Inclusion of Medical Ethics and
Human Rights in the Curriculum
of Medical Schools
The rapporteur, Prof. Vivienne Nathanson,
asked the committee to consider the revised
version of the WMA Resolution on Inclu-
sion of Medical Ethics and Human Rights
in the Curriculum of Medical Schools,
which had been sent out for comments to
WMA members as part of the annual poli-
cy review. During a debate, delegates made
several detailed amendments to the word-
ing.
The committee agreed that the proposed
Resolution, as amended, be sent to the
Council with the recommendation that it
be forwarded to the General Assembly for
adoption.
Declaration of Geneva
The proposed revision of the Declaration of
Geneva was introduced by Dr. Ramin Parsa-
Parsi (German Medical Association), Chair
of the workgroup. He asked the WMA’s
ethics adviser Prof. Urban Wiesing to report
on the issue. Prof. Wiesing reminded the
meeting that the Declaration was written
and adopted in 1948 as an answer to World
War Two and the atrocity of physicians dur-
ing the Nazi regime. It was intended as a
substitute to the Hippocratic Oath and was
one of the most important documents of the
WMA.The Declaration had undergone mi-
nor amendments on several occasions. The
decision to consider revising the document
was not a response to any controversy. It was
simply to investigate whether the document
was still up to date. He outlined a number of
areas that might be examined.
The workgroup recommended that the
committee start a careful revision process
and revise the policy only where there were
strong arguments for a change.
The committee agreed that the workgroup
should proceed with its review process.
Non-discrimination in Professional Member-
ship and Activities of Physicians
The committee considered a proposed
minor revision to the Statement on Non-
discrimination in Professional Membership
and Activities of Physicians.
The committee agreed that the revision of
the proposed Statement, as amended, be
sent to the Council for forwarding to the
General Assembly for adoption.
HCiD Toolkit for Doctors
The committee considered the WMA pro-
posal for a toolkit for doctors working in
situations of violence.
The committee agreed that this be approved,
and that its publication on the WMA web-
page as an educational tool be approved by
the Council.
Mental Illness
The committee considered the proposed
revision of the WMA Statement on Ethi-
cal Issues concerning Patients with Mental
Illness. The guidelines were revised to take
account of the progress in psychiatric treat-
ment which now allowed for better care of
patients with mental illness.
The committee decided that the document,
as amended, be approved by the Council
with the recommendation that it be for-
warded to the General Assembly for adop-
tion.
Statement on Conflict of Interest
The committee considered a proposal for
rewording the WMA Statement on Con-
flict of Interest to align the policy with the
Declaration of Helsinki. This was accepted
as an editorial amendment.
Protection of human reproductive health
The committee considered a proposed revi-
sion of the WMA Declaration on Protec-
tion of Human Reproductive Health to
further complement the existing WMA
policies on reproductive health.
It agreed that the proposed Declaration be
referred to the workgroup on occupational
health.
The Participation of Physicians in Pre-natal
Gender Selection
The committee considered the proposed
WMA Resolution on the Participation of
Physicians in Pre-natal Gender Selection
and it was agreed that the proposed Resolu-
tion be circulated to constituent members
for comment.
Human Rights
Clarisse Delorme, WMA Advocacy Ad-
visor, reported that the WMA had been
invited by the UN Special Rapporteur on
Torture to participate in an expert meet-
ing that would inform the drafting of a
new thematic report by the United Na-
tions Special Rapporteur on Torture and
Other Cruel, Inhuman and Degrading
Treatment or Punishment, Professor Juan
E. Méndez. The report would address
gender perspectives on torture and other
cruel, inhuman or degrading treatment or
punishment.
Finance and Planning Committee
Dr. Dongchun Shin (Korean Medical As-
sociation) took the chair
Financial Statement
The Audited Financial Statement for 2014
was agreed by the committee and sent to
the Council for forwarding to the General
Assembly for approval and adoption.
WMA Budget and Membership Dues Pay-
ments
The budget for 2016 was agreed and sent to
the Council for forwarding to the General
Assembly for approval and adoption.
The committee also received the Dues Cat-
egories 2016 and it was agreed to recom-
mend to the Council that this be forwarded
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to the General Assembly for its informa-
tion.
Strategic Plan
Dr. Shin referred to the fact that the cur-
rent WMA Strategic Plan was valid until
the end of 2015 and should then be re-
newed. The Secretary General suggested
developing the Strategic Plan for the period
2016-2020 in a way which would enable the
WMA to be recognized as global medical
leaders and to increase its capacity to act,
respond and lead. He said the strategic aims
had to be supported by stronger business
development, allowing the Association to
grow without limiting its independence.
The committee agreed that the Secretariat
should develop a Strategic Plan for 2016-
2020, coordinating with the Business De-
velopment Group, and should report back
to the Council in Buenos Aires in April
2016.
Business Development
The committee received an oral report and a
written report from Dr. Dearden, the Chair
of the Business Development Group. Dr.
Dearden said the paper was not final but
rather was intended to provide direction.
The committee recommended that the re-
port be approved by the Council.
WMA Statutory Meetings
The committee considered arrangements
for future WMA meetings. The Confeder-
ación Médica de la República Argentina re-
viewed plans for the 2016 Council Session
in Buenos Aires and the Taiwan Medical
Association welcomed delegates to attend
the 2016 General Assembly in Taipei.
The committee agreed to recommend the
Council to approve that the venue for the
209th
Council session in April 2018 be Riga,
Latvia.
WMA Special Meetings
The committee received an oral report
from the Secretary General concerning two
meetings. Firs aOne Health Conference
held in Madrid in May 2015 was successful.
It was planned to hold the next conference
in Japan in 2017. Secony, the H20+ Health
Summit in 2015, which was planned to be
held in Turkey, could not take place due to
planning constraints. There was a strong
common interest with the Turkish Medi-
cal Association (TMA) in the health of
refugees and the Secretary General said he
would look into the possibility of organiz-
ing a meeting on 4this issue together with
the TMA. He was also exploring the pos-
sibility of a H20+ Health Summit in 2016
in China.
The committee agreed to recommend to the
Council that planning for the One Health
Conference with the World Association of
Veterinarians in spring 2017 in Japan be
continued in cooperation with the Japan
Medical Association and the Japan Veteri-
narians Association and that the Council
authorizes the Secretariat to continue to
organize the H20+ Health Summit in 2016.
Membership
The committee considered an application
from the Panhellenic Medical Association
and agreed to recommend to the Coun-
cil that the Association be admitted into
WMA membership.
Governance Review
Dr. André Bernard, on behalf of the Ca-
nadian Medical Association, proposed that
a workgroup be established to review the
governance of the WMA. It should have a
broad membership representation, includ-
ing the Associate Membership, to examine
possibilities for a governance review.
The committee recommended that the
Council approve the proposal..
Thursday, October 15
Associate members
Dr. Joseph Heyman (American Medical
Association) took the chair.
The meeting received reports on the Junior
Doctors Network from Dr. Elizabeth Wi-
ley, JDN Deputy Chair, and on the Past
Presidents and Chairs of Council Network
from Dr. Jon Snaedal.
Global Medical Electives
A proposed Statement on Ethical Consid-
erations in Global Medical Electives was
presented by Dr. Xaviour Walker on behalf
of the JDN and the committee agreed that
the Statement be considered by the General
Assembly.
Fossil Fuel Development
The meeting considered a proposed State-
ment on Fossil Fuel Development pre-
sented by Dr. Peter Orris. A brief debate
took place on the recommendation that
NMAs and other health organisations
should begin a process of transferring
their investments from energy companies
whose primary business relied on fossil
fuels to those providing renewable energy
sources.
The committee agreed that the document as
amended should be sent to the General As-
sembly for consideration.
Scientific session
The theme of the session was ‘Medical Edu-
cation’, with speakers from all parts of the
globe addressing the meeting.
The morning session opened with a speech
from President elect Sir Michael Marmot,
who spoke about ‘Social determinants of
health in undergraduate and postgraduate
education’.
He talked about social justice, political em-
powerment and creating the conditions for
people to have control of their lives. He
identified six policy recommendations to
achieve this – giving every child the best
start in life, enabling all children, young
people and adults to maximise their capa-
bilities and have control over their lives,
creating fair employment and good work
for all, ensuring a healthy standard of liv-
ing for all, creating and developing healthy
and sustainable places and communities
and strengthening the role and impact of
ill health prevention. He illustrated his talk
with statistics on life expectancy, under five
mortality, global disability and obesity. And
he ended with the words ‘Health is a Hu-
man Right. Do Something. Do more. Do
better’.
Professor David Gordon, President of the
World Federation for Medical Education,
titled his speech ‘Trends in Medical Edu-
cation: sometimes getting better, sometimes
getting worse’. He described medical edu-
cation as sometimes well planned, some-
times chaotic. He said the Federation was
not primarily concerned with the detail of
education and how it was taught, but more
with the quality, management, organisation,
support and delivery of medical education.
And he spoke about the current growth of
medical schools which was often bad and
uncontrolled.
Professor Kenji Matsubara, Vice President
of the Japanese Medical Association, spoke
about the CME system in Japan and said
that continuing professional development
was not carried out at the behest of oth-
ers, but was rather pursued of one’s own
accord to provide patients with safe and
high quality health care. Physicians had a
responsibility to broaden their knowledge,
improve their skills and continuously de-
vote themselves to study throughout their
lives in order to practice constantly advanc-
ing medicine and health care. Physicians
should be motivated to pursue a lifelong
education on their own initiative. This was
why the Japanese Medical Association pro-
vided CME programmes to facilitate effec-
tive self-learning and training. Its purpose
was to further raise physicians’ desire for
training and to increase the public’s trust by
highlighting physicians’ efforts to study.
Dr. Robert Wah, Past President of the
American Medical Association, spoke
about accelerating change in medical edu-
cation and the medical school of the future
with programmes focused on team-based
care, population health and chronic disease
management. He referred to the impor-
tance of technology to enhance learning
and the use of big data to understand health
outcomes. Dr. Leonid Eidelman, President
of the Israel Medical Association, spoke on
Medical Education in a Post-Modern Era
and compared modernist theory with post-
modern theory. He said that each genera-
tion of medical students came with differ-
ent expectations, different learning needs
and different styles. Today’s Millennials,
born after 1982 did better when given
specific goals but needed constant stimula-
tion and direction. They wanted constant
feedback and were interested in balancing
personal and professional lives. He referred
to the extent of burnout among physicians
and said this was strongly associated with
medical errors, prescribing habits and pa-
tient compliance.
His conclusion was that the postmodern
era called for recognition of generational
differences and that adjustments to new
styles could lead to better working condi-
tions, better patient care, delayed burn out
and professional fulfilment.
Professor Lizo Mazwai, President of the
South African Medical Association, gave
a talk entitled ‘Transformation of Medi-
cal Education for the 21st
Century’. He
referred to the five star doctor as being a
care provider, a decision maker, communi-
cator, community leader and manager. He
said that the principles of medical educa-
tion or training would always evolve due to
influences of socio economic factors, disease
profiles and the expanding role of science
and technology. The challenge was to adapt
curricula to be relevant both locally,regional
and globally. Internationalisation of health
and globalisation of resources demanded
that medical schools should continue to
share knowledge and technology more for
better equipped doctors.
Professor Florentino Cardoso, President
of the Brazilian Medical Association,
spoke about the importance of continuing
medical education and the motivations for
learning, while Professor Gia Lobhanidze,
Chairman of the Georgian Medical Asso-
ciation spoke about medical education in
Georgia going back to 1919. He looked at
the problems today, following the privati-
zation of medical institutions. As a result
there were almost no university clinics,
poor mastering of clinical proficiency and
a low quality of undergraduate and post
graduate education.
Professor Steve Hambleton, Immediate
Past President of the Australian Medical
Association, spoke about medical education
in Australia and the way it was embracing
digital transformation. He referred to the
country’s workforce and said there was a
high reliance on international health pro-
fessionals. There was a growing trend to-
wards specialisation and the medical train-
ing pathway was poorly co-ordinated. The
Government was now investing in digital
health and this would enhance e-learning.
Professor Sun Baozhi, from the Research
Center for Medical Education and China
Medical University, spoke about his coun-
try’s handling of medical education, the
progress made over the past 100 years and
the challenges faced by the country over
the past three decades. These included skill
imbalances and the shortage of nurses and
an insufficiency of education resources for
students.
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Climate change
During a workshop session on climate change,
Dr. Todd Sack, editor of My Green Doctor
and a gastroenterologist in Jacksonville, Flor-
ida, talked about bringing environmental sus-
tainability to medical offices. He spoke about
creating a healthier office and community
with employee participation and team build-
ing.He described a practice management tool
for medical offices and said that My Green
Doctor showed offices how to create and
manage an office green team. The result was
a saving of money and a greener environment.
Friday, October 16
Adjourned council
The Council resumed under the Chair
Dr.  Hoven to consider reports from the
three committees.
Socio-medical affairs committee
Physicians’ Well-Being
Following on the debate in the committee
about using the word ‘education’rather than
‘training’, the Council approved amend-
ments to the document.
A proposal was also made to delete a para-
graph relating to physician autonomy that
read: ‘Physician autonomy is one of the
strongest predictors of physician satisfac-
tion. Increasing external regulatory pres-
sures such as undue emphasis on cost effi-
ciencies and concerns about consequences
of reporting medical errors may unduly
influence medical decision-making and di-
minish a physician’s autonomy.’ It was ar-
gued that it was reasonable for physicians
to be cost efficient and to look into adverse
events when they occurred.This was part of
their professional life. However, the propos-
al was defeated and the Council approved
the document as amended and agreed that
it should be forwarded to the General As-
sembly for adoption.
Mass Media Appearances
The Council approved the proposed Guide-
lines.
The remainder of the Socio-Medical Af-
fairs Committee report was approved by the
Council.
Medical ethics committee
The Medical Ethics Committee report was
approved by the Council.
Finance and planning committee
The Finance and Planning Committee re-
port was approved by the Council.
Associate members
The Chair,Dr.Joseph Heyman,said progress
had been made in making Associate mem-
bership more meaningful, including more
conference calls, an educational webinar and
a web forum for members. Calling for an in-
crease in membership, he repeated what he
had said before that no-one would be Coun-
cil membes for ever, but they could be Asso-
ciate members for the rest of their lives.
Junior Doctors Network
Dr. Ahmet Murt, Chair of the JDN, re-
ported that junior members were now at-
tending the World Health Assembly meet-
ings. The network had developed a close
working relationship with the World Fed-
eration of Medical Education. The juniors
had published three newsletters and were
considering other publications. They were
also organising more regional meetings and
activities and following the WHO regional
committee meetings.
World Medical Journal
Dr. Peteris Apinis, Editor in Chief of the
WMJ, said that this was the 61st
year of the
publication of the World Medical Journal.
It was the first year that the Journal has been
published digitally,although they continued
to print 50 hard copies of the Journal to
mail to the WMA office and leading librar-
ies. He said he intended to pursue the idea
of making a photo album featuring snap-
shots of various WMA events. The length
of the Journal remained unchanged  – 40
pages plus a cover page. The contents had,
however, changed with more focus on opin-
ion leaders and interviews.
Assembly ceremonial session
The President, Dr. Xavier Deau, called to
order the Ceremonial Session.
The Secretary General, Dr. Otmar Kloi-
ber, welcomed the Honourable Dr. Tatiana
Vladimirovna Yakovleva, Deputy Minister
of Health of the Russian Federation, Prof.
Mikhail Paltsev, Chief Academic Secre-
tary of the Russian Academy of Sciences,
Prof. Natalia Narotchnitskaya, Director of
the Institute of International Collabora-
tion, Mr. Igor Khalevinskiy, President of the
Russian Association of Diplomats, Mr. An-
dre Mankowskiy, Chairman of the Guard-
ianship Board of the Russian Medical So-
ciety, Mr. Timofey Nizhegorodtsev, Head
of Department of the Social Sphere of the
Anti-Monopoly Service, Mr. Sergey Mura-
vyov, Head of Department of International
Collaboration of the Ministry of Health of
Russia,The Honorable Sir Tim Barrow, UK
Ambassador to the Russian Federation and
the Honourable Mr. Kamil Mohamed Ali,
Ambassador of the Republic of Djibouti.
He went on to introduce the official delega-
tions from each of the Constituent Mem-
bers present, as well as the observers from
non-member medical associations and in-
ternational organizations.
The Honourable Dr. Tatiana Vladimirovna
Yakovleva, Deputy Minister of Health of
the Russian Federation, officially welcomed
delegates to the 66th
General Assembly, say-
ing that it was an opportunity for a valuable
exchange of views and professional discus-
sion. She went on to stress that universal
access to healthcare and improvements in
the quality of medical services were the
responsibility of the State, society and the
medical community, and the importance of
cooperation between governmental bodies
and the medical community. She stated that
the Russian Ministry of Health cooperated
closely with medical professional bodies in
the development of regulation, the develop-
ment and approval of clinical recommenda-
tions on health issues, CPD, licensing and
registration, policy development, health in-
surance and medical ethics. She described
recent developments in Russia leading to-
wards autonomous regulation of the medi-
cal profession, the representative organisa-
tion being the Russian Medical Chamber.
Prof. Vladimir Dmitrievich Parshin, Presi-
dent of the Russian Medical Society, then
addressed the Assembly. He spoke about
the importance of physicians being able
to travel abroad to meet their colleagues.
The medical profession in Russia had long
retained the idea from the Soviet era that
their activities must be regulated by state
administrative bodies, with professional
bodies playing a secondary role. However,
new attitudes were developing with a grow-
ing recognition of the principle of profes-
sional freedom and autonomy. This was the
cornerstone principle of the WMA and
was connected with professional responsi-
bility and the right to health. He said that
the Russian Medical Society was the only
medical organisation in Russia which had
been pursuing the ideals of the WMA for
the past 20 years, despite resistance from
some powers. He stated that holding the
WMA Assembly in Moscow would help to
raise awareness of the importance of profes-
sional autonomy and expedite this process.
He closed by inviting delegates to return to
Moscow, emphasising traditional Russian
hospitality derived from the many nations
which make up the vast federation, and
wished them every success at the meeting.
The WMA Chair Dr. Ardis Hoven then
paid tribute to the retiring WMA Presi-
dent, Dr. Xavier Deau. She said he had
presided with great distinction over the af-
fairs of the Association. He was a highly re-
spected physician exemplifying the highest
ethical standards of the profession and he
had guided the WMA and the profession
over the past year, travelling exhaustively.
He was a gentle man in manner, strong in
opinion,highly competent and wise in deci-
sions,commanding by his presence and pas-
sionate about his patients.
Dr. Deau delivered his valedictory speech
(see box) and was given a standing ovation.
Sir Michael Marmot, Professor of Epidemi-
ology and Public Health at University Col-
lege London, was then installed as the 66th
President of the WMA to serve in 2015/16.
He took the oath of office as President and
delivered his inaugural speech (box).
Saturday, October 17
General assembly plenary session
The Credentials committee reported that 58
WMA constituent members had been reg-
istered and recognised at the meeting and
57 were in good standing.The total number
of votes was 136.
General report
Dr. Kloiber introduced the written report
that had been tabled, detailing the work of
the WMA secretariat and the Council over
the past year. He highlighted several items,
mentioning the advocacy work that had
been carried out in publicising the revised
Declaration of Helsinki.A similar approach
was now being taken in seeking public in-
put for the new WMA policy project on
databases and biobanks. The WMA had
received up to 90 well written and thought-
ful comments on how stakeholders and in-
terested groups thought it should proceed
with this policy.This had led to new insights
about the policy.
In addition to the work of developing policy,
the secretariat had been involved more and
more in human rights issues. It had been
very active with the United Nation organ-
isations and with members in addressing
both individual issues as well as more gen-
eral political issues. The spread of activity
had been extremely broad and reflected the
issues member organisations faced, ranging
from strictly medical problems such as vi-
tamin D to theoretical issues such as trade
agreements. However, the WMA secretari-
at at Ferney Voltaire was very small and it
had to be highly selective and set priorities.
He was disappointed not to be able to help
all the requests received.
Committee Reports
The Assembly adopted the following policy
documents without debate:
• Resolution on the Inclusion of Medical
Ethics and Human Rights in the Cur-
riculum of Medical Schools World-Wide
(see p.148)
• Revised Statement on Non-Discrimi-
nation in Professional Membership and
Activities of Physicians (see p.149)
• Statement on Ethical Issues concerning
Patients with Mental Illness (see p.150)
• Declaration on Alcohol (see p.141)
• Statement on Providing Health Support
to Street Children (see p.152)
• Statement on Riot Control Agents (see
p.155)
• Statement on Mobile Health (see p.153)
• Revised Statement on Nuclear Weapons
(see p.154)
• Statement on Physicians’Well-being (see
p.143)
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• Statement on Vitamin D Insufficiency
(see p.147)
• Guidelines on Promotional Mass Media
Appearances by Physicians (see p.147)
• Declaration of Oslo on Social Determi-
nants of Health (retitled) (see p.151)
• Attacks against Healthcare workers and
facilities in Turkey (see p.140)
• Global Refugee Crisis (see p.145)
Statement on Transgender People
Professor Monsignor Pablo Requena (Vati-
can Medical Association) said he would be
abstaining on the vote on this Statement.
He explained that the Vatican delegation
condemned absolutely any unfair discrimi-
nation and would resist any discrimination
against transgender people. However, in
some parts of this document a number of
matters that were not strictly medical were
discussed and the Statement proposed some
solutions that they did not all share.
The Assembly agreed to adopt the Statement.
Bombing of the hospital run by Médecins Sans
Frontières in Kunduz, Afghanistan (see p.141)
The Japanese Medical Association referred
to the demand in the emergency Resolu-
tion for an immediate enquiry by an in-
dependent body into the attack. It asked
whether it was possible for a third party to
investigate the bombing and suggested that
this point be deleted. However, the Span-
ish Medical Association argued that only
an independent investigation would shed
light on what had occurred. If there was no
independent investigation and no attempt
at trying to find a plausible explanation it
would be disastrous. It urged that this point
be maintained in the resolution. This was
supported by speakers from Cote d’Ivoire,
South Africa and India. Dr. Ved Prakash
Mishra (Indian Medical Association) said
the call for an independent investigation
must be maintained. On such a human
tragedy which had shaken the feet of civil-
ity and humanism if they deleted this they
would just be bystanders and onlookers to
human devastation. If they did not call for
an independent investigation they would be
losing relevance, consequence and impact.
But Dr. Frank Ulrich Montgomery (Ger-
man Medical Association) said that the
American President had already apologised
for the bombing and therefore an indepen-
dent investigation was not necessary.
On a vote, the proposal to delete the call for
an investigation was supported by 55 votes
to 45 with three abstentions and the emer-
gency Resolution as amended was support-
ed by 76 votes to 13, with 26 abstentions.
Treasurer’s Report
Dr. Masami Ishii, the Treasurer, reported on
the Financial Statement for 2014 and the
Budget for 2016. He referred to the positive
financial developments due to thrifty use
of budget means, efficient cost controlling,
a risk-free investment policy and the full
commitment of the Secretary General. Mr
Adi Hällmayer, the financial adviser, pro-
vided additional information on the 2014
statement, drawing particular attention
to the savings made by the South African
Medical Association in their organization
of the General Assembly in Durban.
Dr. Ishii reported on the dues increases
that would be necessary to maintain the
financial stability of the Association, and
reminded the delegates that investment
was necessary to maintain the important
activities of the WMA. He said the budget
represented investment in the future of the
profession, summarizing the ways in which
the WMA was supporting physicians and
promoting the highest standards of medical
ethics across the world. The money would
be used to establish further communica-
tions and educational missions.
The Audited Financial Statement for 2014
and the proposed Budget for 2016 were ap-
proved and adopted.
Membership
The Assembly agreed to the admission of
the Panhellenic Medical Association as a
WMA Constituent Member.
Social Determinants of Health
The Secretary General said that in view of
the importance of this topic,the Council had
suggested that the WMA Statement on the
Social Determinants of Health be changed
to a Declaration entitled The Declaration of
Oslo on the Social Determinants of Health.
This was approved by the Assembly.
Associate Members
The Assembly received two proposed policy
documents from the Associate Members,
the proposed Statement on Ethical Con-
siderations in Global Medical Electives and
the proposed Statement on Fossil Fuel De-
velopment. It was agreed that these should
be sent to the Council for consideration.
World Veterinary Association
Dr. Zoran Katrinka, from the World Vet-
erinary Association, spoke about the WVA,
saying that it was a global organisation and
a federation of national and regional asso-
ciations. It had member associations from
more than 60 countries with 500,000 indi-
vidual members. Its mission was ‘to ensure
and promote animal health and welfare and
public health globally, through develop-
ing and advancing veterinary medicine, the
veterinary profession as well as public and
private veterinary services’.The three pillars
of veterinary medicine were animal health,
public health and animal welfare. When
it came to animal health, prevention was
better than cure, through monitoring, sur-
veillance, early diagnosis and reporting of
animal diseases. Animal welfare was a mat-
ter of respecting freedoms and promoting
sustainable, high welfare agriculture. Pub-
lic Health related to the role veterinarians
played in food safety. He said veterinarians
did much to maintain control of zoonotic
diseases. Some 60 per cent of infections and
transmissible human diseases were zoonotic
in their nature and some 70 per cent of the
new emerging transmissible diseases were of
a zoonotic nature or had a zoonotic poten-
tial. And up to 75 per cent of the potential
or actual bioterrorism agents were zoonotic
in nature. He also spoke about education
and lifelong learning and ways being devel-
oped to strengthen the veterinary profes-
sion in the light of stress and the number
of suicides among veterinarians. He spoke
of the common challenges facing physicians
and veterinarians and for these reasons it
was all the more important for the profes-
sions to work in unison, as exemplified by
the success of the One Health conference
in Madrid this year.
Medical Women’s International Association
Professor Kyung Ah Park, President of the
Medical Women’s International Association
and Professor of Anatomy at Yonsei Uni-
versity College of Medicine in Seoul, Korea,
then addressed the Assembly. She said the
MWIA had around 20,000 members from
46 member countries. She gave the history
and structure of the organization. It was
founded in 1919 with the aims of offering
medical women the opportunity to meet,
to promote the general interest of medical
women by developing cooperation, friend-
ship and understanding without regard to
race, religion or political views, to overcome
gender-related differences in health and
healthcare between women and men, girls
and boys throughout the world, to overcome
gender related inequalities in the medical
profession and to promote Health for All
throughout the world with particular interest
in women, health and development.
As the current president, Dr. Park said her
theme was the prevention and elimina-
tion of domestic and sexual violence and
she mentioned the various projects she hsd
overseen in this area, as well as cooperation
on a Canadian project to distribute birthing
kits in order to lower maternal and infant
mortality. She had also overseen a survey on
violenc, to which 32 countries had respond-
ed.Her aim was also to expand membership
of the organisation to include more coun-
tries, especially in central Asia.
CPME
Dr. Katrín Fjeldsted, President of the
CPME (Standing Committee of European
Doctors), said her organization represented
34 countries in Europe.They were the voice
of the medical profession towards the Eu-
ropean Commission where they were stake-
holders. They were consulted on matters
concerning the medical profession, patients,
health in Europe, although matters of
health and health services belonged to the
member states. She spoke about CPME’s
work and the joint activities with the WMA
and other organisations. She expressed her
gratitude to Dr. Deau for the close coop-
eration he had facilitated over the past year
with the WMA, highlighting the WMA
policies CPME has endorsed and the areas
in which they shared similar policies, such
as professional autonomy, the TTIP agree-
ment, alcohol and tobacco, patient safety,
healthy aging, and eHealth.
International Trade Agreements
Dr. Andrew Deardon (British Medical As-
sociation) opened a debate on current in-
ternational trade agreements, designed to
allow NMAs to report on their activities in
this area.
He said the BMA was not anti-trade but
it was pro-health. A lot of work had been
done by the WMA and a number of coun-
tries. The BMA wanted to get an idea of
what other countries felt about these agree-
ments. The question was what more they
could do.It was not that they should oppose
trade, but that they should safeguard health.
Dr. Kloiber reiterated that the WMA had
no fundamental opposition against trade
and trade agreements. Trade, if it was fair,
could help to ease the burden of many
countries. However, with some trade agree-
ments there could be detrimental effects on
health, such as the attempts of the Mexican
Government to reduce the sugar intake by
children which had been stalled by some
countries in north America. The Mexican
Government had to give up and yet Mexico
was suffering a real obesity epidemic. The
same thing had happened with tobacco
legislation. Regulations against tobacco in
many countries had been attacked on the
basis of trade agreements and were being
dealt with in secret courts. They were a real
threat to many countries. Trade agreements
could have detrimental effects on social
conditions and could inhibit domestic legis-
lation on health issues.The WMA’s concern
was that these agreements were being made
in secret.
Leah Wapner (Israel Medical Association)
reminded the Assembly that this was not
the first time the WMA had taken a stand
on an issue of trade and health that was not
very popular at the beginning. Its position a
few years ago on patenting genes was simi-
lar. The WMA had said then it was against
patenting and everyone said this opposition
was against trade. Since then the US and
Australia had come out with a conclusion
that genes could not be patented. At the
moment the WMA had a very serious issue
of public relations and making its stand-
point understandable. What it was doing
here was a very important first step getting
information from the regions. The need
now was to turn this into something more
practical by developing an advocacy strate-
gy.They could then advocate for this around
the world.This would enable NMAs to have
an advocacy strategy within their country,to
approach their Parliamentarians to say why
it was so important to put safeguards for
health within these trade agreements.
Dr. Sergio Isaza Villa (Columbia Medical
Federation) said it was vital that the WMA
made known its stand with regard to high
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WMA News WMA News
cost treatments and the rights of physicians
to voice opinions regarding treatment.They
should try to control exorbitant costs based
on patents. Secondly, on physician autono-
my, in Columbia a law had been passed to
defend and protect the decisions of physi-
cians regarding treatment decisions. He
believed this was directly related to the is-
sue of physician autonomy and world trade
agreements.
Dr. Steve Child (New Zealand Medical
Association) said that New Zealand had
signed four free trade agreements in the last
20 years and many of the things being dis-
cussed had been present in these negotia-
tions throughout that time. He said it was
important that the WMA approached this
issue from a principled point of view rather
than on individual issues. In the Trans-
Pacific Partnership Agreement (TPPA)
signed two weeks ago,tobacco was excluded
and public health policy provisions were
protected. Countries were allowed to still
mandate their own public health policy pro-
visions.nMoreover, biosimilars and biologic
patents had remained the same. Referring
to the issue of transparency with these ne-
gotiations, he said that all countries needed
to take the agreements back to their Parlia-
ments for enabling legislation to be passed.
Other speakers reported on the approaches
they had made to their governments and
called on the WMA to stand firm on this
issue. Dr. Juan Rodriguez Sendin from the
Spanish Medical Associatio, spoke about
the difficulty in getting information about
these trade agreements from their Parlia-
mentarians. So many issues were at stake
and unless the situation changed radically
and they got to know the content of these
treaties the WMA should warn public opin-
ion about the danger of these negotiations.
Speakers from Malaysia, Argentina, India
and Nigeria added their voices in opposi-
tion to these agreements. Many speakers
called on the WMA to publicly state their
opposition to these agreements. Dr. Eliza-
beth Wiley, deputy chair of the JDN, spoke
about the threats to public health from these
negotiations, whether it was to professional
regulations, access to medical education or
climate change mitigation strategy,access to
medicines and tobacco regulation.
At the end of the debate Dr.Hoven said she
recognised the many challenges facing the
WMA from these trade agreements and she
would be asking the advocacy group to put
this matter on its agenda.
Open session
WMA Influenza Campaign
Dr. Julia Tainijoki-Seyer, medical advisor
with the WMA, gave an overview of the
WMA’s influenza prevention campaign. In
addition to the global mortality, flu caused
3.5 million cases of illness. This presented
an economic burden with indirect and direct
costs.Up to 60 per cent of health profession-
als had the virus, but 30 per cent were not
aware they had the flu, yet they still saw pa-
tients.The aims of the campaign were to in-
spire health professionals to get immunised,
to be a role model for their patients and to
focus on vulnerable groups. She stated that
the focus of this year’s campaign had been
children, due to their lack of prior immunity
and more frequent exposure to the virus. She
presented the materials developed for the
website, including the motto “let kids be
kids”,and encouraged NMAs to use the ma-
terial, which were free of charg,or to link the
webpages on their own websites. She closed
by presenting a video of Sophia,an animated
ambassador for the WMA and she asked
NMAs to share information about their own
activities on influenza with her.
Tree of Hippocrates
Dr. Yoshitake Yokokura (Japan Medi-
cal Association) described the legend that
Hippocrates taught medicine underneath
an old plane tree which still stood on the
Greek island of Kos. The tree was almost
dead. However, tree doctors commissioned
by the Greek government and the Japanese
Embassy had concluded that the tree could
be saved. He said that Hippocrates was the
Father of Medicine and it was their duty
to save the life of this tree. He urged the
WMA to collect donations to regenerate
the Tree of Hippocrates.
Turkey
Dr. Ilhan Bayazit (Turkish Medical Asso-
ciation) spoke about attacks on health care
personnel and facilities in Turkey. Several
health care staff had been killed. He also
spoke about the previous week’s bombing
in Ankara during a peace rally march. Po-
lice had used tear gas immediately after the
explosion.
Israel
Dr. Leonid Eidelman (Israel Medical As-
sociation) reported on the issue of force
feeding of hunger strikers in Israel. He said
that over the last few years detainees held
in Israeli prisons had used hunger strikes as
a tool for having their demands met. More
than a thousand hunger strikes had taken
place in recent years, lasting from several
days to weeks and months. In June 2014
around 100 strikers were simultaneously
hospitalized.This prompted proposed legis-
lation in the Israeli Parliament allowing for
the force feeding of hunger strikers in hos-
pital with court permission and despite ac-
tive opposition from prisoners. Against this
background the Israeli Medical Association
had convened a consensus conference with
all interested parties and the conference
had reached several conclusions relating
to physicians’ treatment of hunger strikers.
These included emphasising that doctors
must respect the free will of hunger strik-
ers as people and patients while doing all
they could to help the hunger striker to stay
alive, that forced medical treatment includ-
ing force feeding was forbidden, and that
physicians must maintain medical confi-
dentiality when treating patients. Following
the conference the Israeli Medical Associa-
tion had prepared guidelines for physicians
and had set up a 24-hour emergency hotline
to provide advice to physicians.
Dr. Eidelman said that the Israel Medical
Association could not support the proposed
legislation on this issue which was in con-
tradiction with physicians’ ethical obliga-
tions as set out in the WMA Declaration of
Malta, which said that force feeding was a
form of inhuman and degrading treatment.
Cote d’Ivoire
Dr. Kroo Florent Aka (Ordre National Des
Medicines De La Côte D’Ivoire) said that
the buruli ulcer was one of about 15 tropical
diseases which the WHO officially consid-
ered as orphan or neglected illnesses due to
a lack of a budget to treat them. It affected
tropical, sub-Saharan countries, including
China and Australia.There were 2,197 cases
in 2014, 38per cent of which were in the
Ivory Coast. He explained that the disease
was caused by a micro bacteria from the same
family as TB and leprosy, with fresh water
bugs found in lakes and rivers as carriers. It
produced blisters on the bodies of adults and
children which evolved into extensive ne-
crosis of soft skin tissue and abscesses, with
some resulting in the development of skin
cancer. Successful treatment was possible if
the disease was caught in its early stages, but
that access to treatment in many areas was
very limited, meaning that by the time many
patients get to hospital the effects were ir-
reversible. He asked the WMA to raise this
topic at the next WHO Assembly and re-
quested the development of a strategic plan
and sufficient funding to fight the disease.
Any other business
Junior Doctors Network
Dr. Ahmet Murt, Chair of the Junior Doc-
tors Network (JDN), reported that the
Network had been growing continually and
expanding the scope of its work, covering a
broad range of issues,not only those directly
associated with junior doctors. He com-
mented on the collaboration with medical
students and mentioned the recent regional
meeting in Macedonia and forthcoming
meetings in Istanbul and Malta. He went
on to thank the Russian Medical Society
for enabling the JDN to hold their meeting
in Moscow, which had enjoyed the high-
est participation ever. He congratulated his
Japanese colleagues, who had won the JDN
champions award at this meeting.
Bombing of the hospital run by Médecins Sans
Frontières in Kunduz, Afghanistan
At the suggestion from the Spanish Medi-
cal Association, the debate on the emer-
gency motion on the bombing of the MSF
hospital was reopened. Dr. Fernando Rivas
urged the Assembly to reconsider its earlier
decision to delete the call for an indepen-
dent investigation. He said MSF were col-
leagues and allies of the WMA and they
had requested an independent investigation
into the bombing. Despite having received
a message from the US president, MSF
continued to request that an international
humanitarian fact-finding commission be
brought in to conduct an independent in-
vestigation. He called for the WMA to take
the side of physicians not governments.
Dr. Mzukisi Grootboom (South Africa
Medical Association) said he was extremely
disappointed at the outcome of the earlier
debate to strike out the call for an indepen-
dent investigation. This was not just an at-
tack on a hospital. It was an attack on the
Geneva Convention. The WMA needed
to show leadership and support those doc-
tors who were at the hospital taking all the
risks to save people’s lives. Dr. Rutger Jan
Van der Gaag (Royal Dutch Medical As-
sociation) supported the call to reconsider,
saying that they should not be put off by the
fact that the President of the United States
had apologized. It was extremely important
to go further. Dr. Jeff Blackmer (Canadian
Medical Association) said that if the WMA
decided not to call for an independent en-
quiry the Canadian Medical Association
would be releasing a strongly worded press
statement the following week urging an in-
dependent investigation and he encouraged
other NMAs to do likewise.
Dr. Frank Ulrich Montgomery (German
Medical Association) said that detailed ac-
counts of the bombing had already been
published. An investigation committee had
also been set up and he asked what an ad-
ditional inquiry would add. It was not nec-
essary.
However, other speakers from India, Ar-
gentina and Nigeria supported the call for
an enquiry.
Delegates voted for the emergency resolu-
tion to be reconsidered. And they went on
to vote by 62 votes to 43 with nine absten-
tions in favour of the original resolution,
including the call for an independent inves-
tigation.
Junior Doctors
Dr. Georgiana Luisa Baca (United King-
dom) spoke about government plans in
England to remove the regulation of the
working hours of junior doctors, introduce
a seven day working pattern and not recog-
nise university degrees or part-time work
as work experience. She thanked the BMA
and Royal Colleges for their strong support
of the junior doctors,holding it up as a posi-
tive example of collegial support.
The Taiwan Medical Association presented
a short video of Taiwan, inviting all dele-
gates to attend the next year’s General As-
sembl, which will be held in Taipei.
The Chair thanked the delegates for their
efforts, time, thoughtfulness and commit-
ment to the WMA and the health of their
patients and concluded the meeting.
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WMA Resolution to Stop
Attacks against Healthcare
Workers and Facilities in Turkey
Adopted by the 66th
General Assembly, Moscow, Russia, October 2015
Preamble
Several media report that over the last two months of conflict in
Turkey, healthcare workers have been killed, wounded or threatened
with guns. Some physicians have been taken out of ambulances and
beaten. Access to wounded people is prevented by security forces,
and ambulances as well as health facilities are regularly targeted.
A rather comprehensive study conducted by the Turkish Medical
Association confirms these facts.
There are indications that attacks on healthcare workers and the
obstructions of service delivery are used as a deliberate political in-
strument to intimidate people, depriving them of their democratic
rights.
Parties in armed conflict have the obligation to protect health care
provision to wounded and sick and to prevent attack on or threat
to medical activities, healthcare workers and facilities. Physicians and
other healthcare workers should not be impeded to perform their du-
ties. Such attacks constitute blatant violation of international human
rights law, in particular the inherent right to life that shall be pro-
tected by law, and the right to enjoy the highest attainable standard
of health [1].
These attacks undermine gravely as well fundamental medical ethics
principles, in particular WMA international Code of Medical Eth-
ics and the Ethical Principles of Health Care in Times of Armed
Conflict and Other Emergencies endorsed by civilian and military
health-care organisations [2], stating that: “Health-care personnel,
as well as health-care facilities and medical transports, whether mil-
itary or civilian, must be respected by all. They are protected while
performing their duties and the safest possible working environ-
ment shall be provided to them” (article 10).
Recommendations
The WMA urges all parties to:
1. Stop attacks on healthcare workers and patients, health care fa-
cilities, and ambulances and ensure their safety,
2. Respect the professional autonomy and impartiality of health-
care workers,
3. Comply fully with international human rights law as well as
other relevant international regulations that Turkey is a State
Party to, and
4. Document and record all violations and duly prosecute their
perpetrators.
[1] International Covenant on Economic, Social and Cultural Rights, article
12 – December 1966
[2] Adopted by the ICRC, the WMA, the International Committee of Military
Medicine (ICMM), the International Council of Nurses (ICN) and the In-
ternational Pharmaceutical Federation (FIP) – June 2015
WMA Resolution on Global
Refugee Crisis
Adopted by the 66th
General Assembly, Moscow, Russia,
October 2015
The WMA recognises that mass movement of people often fol-
lows disasters that flow from armed conflict or natural phenomena
as populations seek to escape danger and deprivation. The current
mass movement of the populations, to escape the effects of armed
conflict including bombing, lack of access to utilities, clean water,
and the destruction of homes, schools and hospitals, has been nu-
merically larger than any mass movement of populations in over
70 years.
While the WMA recognises that countries may have concerns
about their ability to absorb significant numbers of new migrants,
we recognise that people fleeing warfare or natural phenomena are
doing so because they are desperate and often face life-threatening
conditions. They are afraid for their health, safety and welfare, and
that of the family members who accompany them.
Most countries have signed international treaties giving them bind-
ing obligations to offer aid and assistance to refugees and asylum
seekers. The WMA believes that when there are events, including
on-going events, such as conflict which generate refugee crises gov-
ernments must increase their efforts to provide assistance to those
in need.
This should include ensuring safe passage for refugees and appro-
priate support after they enter countries offering refuge. Recognis-
ing that the disaster from which they have fled and the vicissitudes
of the journey may have led to health problems it is essential that
receiving countries establish systems to provide health care to refu-
gees.
Governments should seek to ensure that refugees and asylum seek-
ers are able to live in dignity within their country of refuge and
make all efforts to enable their integration into their new society.
The international community should seek to obtain a peaceful solu-
tion in Syria under which the population can either stay at home
safely or, if they have already left, safely return home.
The WMA recognises that mass population movement causes
significant stress on the existing populations of countries as well
on those who become refugees. We believe that governments and
international agencies including the United Nations must make
more concerted efforts to reduce the pressures that lead to such
movements, including rapidly providing extensive relief after
natural phenomena, and making more efforts to avert or stop
armed conflict. Re-establishing security of food, water, hous-
ing, sewerage, education and health care, and improving public
safety should make a significant impact and reduce the numbers
of refugees.
The WMA:
• Recognises that the process of becoming a refugee is damaging to
physical and mental health;
• Commends those countries that have welcomed and cared for
refugees, especially those currently fleeing Syria;
• Calls on other countries to improve their willingness to receive
refugees and asylum seekers;
• Calls on national governments to ensure that refugees and asylum
seekers are enabled to live in dignity by providing access to es-
sential services;
• Calls on all governments to work together to seek to end local,
regional, and international conflicts, and to protect the health,
safety and welfare of populations;
• Calls on all governments to cooperate in providing immediate
help to countries facing the effects of natural phenomena, re-
membering that those already the most socio-economically dis-
advantaged will face the most challenges;
• Calls upon global media to report on the refugee crisis in a man-
ner that respects the dignity of refugees and displaced persons,
and to avoid bigotry and racial or other bias in reporting.
WMA Resolution about the
Bombing on the Hospital of MSF
in Kunduz
Adopted by the 66th
General Assembly, Moscow, Russia, October 2015
After the events of October 3 in Kunduz (Afghanistan), the WMA:
1. Extends its deepest condolences to families, colleagues and
friends of doctors, healthcare workers and patients killed in the
bombing.
2. Deeply regrets and condemns the bombing of the Hospital of
MSF, considering it a violation of human rights.
3. Reaffirms its positional statements on “Healthcare in Danger”
and calls on all countries to respect healthcare personnel in con-
flict situations.
4. Demands an immediate enquiry into the attack by an indepen-
dent body and the assumption of responsibilities.
WMA Declaration on Alcohol
Adopted by the 66th
WMA General Assembly, Moscow, Russia,
October 2015
Preamble
1. The burden of disease and injury associated with alcohol con-
sumption is a critical challenge to global public health and de-
velopment. The World Medical Association offers this declara-
tion on alcohol as its commitment to reducing excessive alcohol
consumption and as a means to support its members to assist
them in promulgating harm-reduction policies and other mea-
sures.
2. There are significant health, social and economic problems as-
sociated with excessive alcohol use. The harmful use of alcohol
kills approximately 2.5 million people every year (almost 4% of
all deaths worldwide), and is the third leading risk factor for
poor health globally, accounting for 5.5% of disability-adjusted
life years lost. The WMA Statement on Reducing the Global
Impact of Alcohol on Health and Society addresses these prob-
lems in more detail.
3. Effective alcohol harm-reduction policies and measures will in-
clude legal and regulatory measures that target overall alcohol
consumption in the populatio, as well as health and social policy
interventions that specifically target high-risk drinkers, vulner-
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WMA News WMA News
able groups and harms to people affected by those who consume
alcohol.
4. There are many evidence-based alcohol policies and preven-
tion programmes that are effective in reducing the health,
safety and socioeconomic problems attributable to harm-
ful use of alcohol. However, many countries have rela-
tively weak alcohol policies and prevention programmes
that are ineffective at protecting health and safet, and pre-
venting harm. International public health advocacy and
partnerships are needed to strengthen and support the
ability of governments and civil society worldwide to com-
mit to, and deliver on, reducing the harmful use of alcohol.
Health professionals have an important role to play in pre-
venting, treating and mitigating alcohol-related harm, using
effective preventive and therapeutic interventions.
5. The World Medical Association has a leadership role to en-
courage and support the development and implementation of
evidence-based national alcohol policies by promoting and fa-
cilitating partnerships, information exchange and health policy
capacity building.
Objectives
In developing policy, the WMA recommends focusing on the fol-
lowing broad objectives:
• Strengthen health systems to identify and improve a country’s
capacity to develop policy and lead actions that target excessive
alcohol consumption.
• Promote the development and evaluation in all countries of na-
tional alcohol strategies which are comprehensive, evidence-
based and include measures to address the supply, distribution,
sale, advertising and promotion of alcohol.
• Through government health departments,accurately measure the
health burden associated with alcohol consumption through the
collection of sales data, epidemiological dat, and per capita con-
sumption figures.
• Support and promote the role of health and medical profession-
als in early identification, screening and treatment of harmful
alcohol use.
• Dispel myths and dispute alcohol control strategies that are not
evidence-based.
• Reduce the impact of harmful alcohol consumption in at risk
populations.
• Foster multi-disciplinary collaboration and coordinated inter-
sectoral action.
• Raise awareness of alcohol-related harm through public educa-
tion and information campaigns.
Priorities
The following priorities are suggested for WMA members, national
medical associations and governments in the development of inte-
grated and comprehensive policy and legislative responses.
Regulate affordability, accessibility and availability
Pricing policies
Increase alcohol prices, through volumetric taxation of products
based on their alcohol strengt,and other proven pricing mechanism,
to reduce alcohol consumption at the population level, particularly
in heavy drinkers and high risk groups.
Accessibility and availability
Regulate access to, and availability of, alcohol by limiting the hours
and days of sale, the number and location of alcohol outlets and
licensed premises, and the imposition of a minimum legal drinking
age. Governments should tax and control the production and con-
sumption of alcohol, with licensing that emphasises public health
and safety and empowers licensing authorities to control the total
availability of alcohol in their jurisdictions.
Public authorities must strengthen the prohibition of selling to mi-
nors and must systematically request proof of age before alcohol can
be purchased in shops or bars.
Regulation of non-commercial alcohol
The production and consumption of non-commercial forms of al-
cohol, such as home brewing, illicit distillatio, and illegal diversion
alcohol to avoid taxes, should be curtailed.
Reduce harmful alcohol use
Regulation of alcohol marketing
Alcohol marketing should be restricted to prevent the early adop-
tion of drinking by young people and to minimise their alcohol
consumption. Regulatory measures range from wholesale bans and
restrictions on measures that promote excessive consumptio, to re-
strictions on the placement and content of alcohol advertising that
is attractive to young people. There is no evidence that industry
self-regulation and voluntary codes are successful at protecting vul-
nerable populations from exposure to alcohol marketing and pro-
motion
Increase public awareness of harmful alcohol consumption through prod-
uct labelling and public awareness campaigns.
In conjunction with other measures, social marketing campaigns
should be implemented to educate the public about harmful alcohol
use, to support drink driving policie, and to target the behaviour of
specific populations at high risks of harm. Public awareness mea-
sures can also include health warning labels on alcohol products,
mandated by an independent regulatory body.
The role of health and medical services in prevention
Health,medical and social services professionals should be provided
with the training, resources and support necessary to prevent harm-
ful use of alcohol and treat people with alcohol dependence, includ-
ing routinely providing brief advice to motivate high-risk drinkers
to moderate their consumption. Health professionals also play a key
role in education, advocacy and research. Specialised treatment and
rehabilitation services should be available and affordable for alcohol
dependent individuals and their families.
Drink driving measures
Key drink-driving deterrents should be implemente, which include
a strictly enforced legal maximum blood alcohol concentration for
drivers of no more than 50mg/100ml, supported by social market-
ing campaigns and the power of authorities to impose immediate
sanctions.
Respond to the alcohol industry
Limiting the role of the alcohol industry in alcohol policy development
The commercial priorities of the alcohol industry are in direct conflict
with the public health objective of reducing overall alcohol consump-
tion. Internationally, the alcohol industry is frequently included in al-
cohol policy development by national authorities, but the industry is
often active in opposing and weakening effective alcohol policies. In-
effective and non-evidence-based alcohol control strategies promoted
by the alcohol industry and the social organisations that the industry
sponsors should be countered.The role of the alcohol industry in the
reduction of alcohol-related harm should be confined to their roles
as producers, distributors and marketers of alcoho, and not include
alcohol policy development or health promotion.
WMA Statement on Physicians
Well-Being
Adopted by the 66th
WMA General Assembly, Moscow, Russia,
October 2015
Preamble
Physician well-being refers to the optimization of all factors af-
fecting biological, psychological and social health and preventing
or treating acute or chronic diseases experienced by physicians in-
cluding mental illness, disabilities and injuries resulting from work
hazards, occupational stress and burnout.
Physician well-being could have positive impact on patient care,
but more research is needed. The profession should therefore
encourage and support on-going research on physician’s health.
Evidence that already exists should be implemented in policy and
practice. While physicians tend to have healthy habits, it is es-
sential to enhance their health as a way to improve health for the
whole population.
Physicians and medical students at all career stages are exposed
to both positive experiences as well as a variety of stressors and
work injuries. The medical profession should seek to identify and
revise policies and practices that contribute to these stressors and
collaborate with NMAs in order to develop policies and practices
that have protective effects. Like all human beings, physicians ex-
perience illness, and they also have family obligations and other
commitments outside their professional lives that should be taken
into account.
One reason physicians delay seeking help is their concern about
confidentiality and feeling ill at ease in the patient role.They experi-
ence feelings of responsibility towards their patients and are sensi-
tive to external expectations on their health. Therefore, physicians
must be assured of the same right of confidentiality as any other
patient when seeking and undergoing treatment. The health care
system may need to provide special arrangements for the care of
physician-patients in order to uphold its duty to provide privacy and
confidentiality. Prevention, early assistance and intervention should
be available separately from any disciplinary process.
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Threats, Barriers and Opportunities
for Physician Well-Being
Professional Roles and Expectations
The medical profession often attracts highly driven individuals with
a strong sense of duty. Successfully completing the long and intense
educational requirements often confers upon physicians a high de-
gree of respect and responsibility in their communities.
With these high levels of respect and responsibility, physicians are
subject to high expectations from patients and the public.These ex-
pectations can contribute to prioritizing the care of others over care
of self and feelings of guilt and selfishness for managing their own
well-being.
There is a direct relationship between physicians’ and patients’ pre-
ventive health practices.This relationship should encourage health-
care systems to better support and evaluate the effects on patients of
improving physician and medical student health.
Work Environment
Working conditions, including workload and working hours, affect
physicians’motivation,job satisfaction,personal life and psychologi-
cal health during their careers.
Physicians are often perceived as being immune to injury and
diseases as they care for their patients, and workplace health and
safety programs may be overlooked. Physicians who are employed
by small organizations or who are self-employed may be at even a
higher risk for occupational diseases and may not have access to
health and safety programs provided by large health care establish-
ments.
As a consequence of their professional duties, physicians and physi-
cians in postgraduate education often confront emotionally chal-
lenging and traumatic situations including patients’suffering, injury
and death. Physicians may also be exposed to physical hazards like
radiation, noise, poor ergonomics, and biological hazards like HIV,
TB and hepatitis.
Some healthcare systems may exacerbate stress because of the hier-
archies and competition inherent in them. Physicians in postgradu-
ate education and medical students can be victims of harassment
and discrimination during their medical education. Due to their
position within the medical hierarchy, they may feel powerless to
confront these behaviours.
Physician autonomy is one of the strongest predictors of physician
satisfaction. Increasing external regulatory pressures such as undue
emphasis on cost efficiencies and concerns about consequences of
reporting medical errors may unduly influence medical decision-
making and diminish a physician’s autonomy.
Illness
Even though medical professionals recognize that it is preferable
to identify and treat illness early, physicians are often adept at
hiding their own illnesses and may continue to function without
seeking help until they become incapable of carrying out their du-
ties.There are many potential obstacles to an ill physician seeking
care including: denial, confidentiality issues, aversion to the pa-
tient role, practice coverage, fear of disciplinary action, potential
loss of practice privileges, loss of performance based payment and
the efficiencies of self-care. Because of these obstacles doctors are
often reluctant to refer themselves or their colleagues for treat-
ment.
Illnesses can include mental and behavioural health problems,
burnout, communication and interpersonal issues, physical and
cognitive problems and substance use disorders. These illnesses
and problems can overlap and can occur throughout the profes-
sional life cycle from basic medical education to retirement. It is
important to acknowledge the continuum of physician well-being,
ranging from optimal health, to minor illness, to debilitating ill-
ness.
Substance abuse may disrupt a physician’s personal life and may also
significantly affect his or her ability to care for patients. Easy ac-
cess to medications may contribute to physicians’ risk for abuse of
recreational drugs and prescription medications. Assistance prior to
impairment in the workplace is protective for physicians, their pro-
fessional credentials and their patients.
Improved wellness promotion, prevention strategies and earlier in-
tervention can help mitigate the severity of mental and physical ill-
nesses and help reduce incidence of suicide in physicians, physicians
in postgraduate education and medical students.
Recommendations
The World Medical Association recommends that National Medi-
cal Associations (NMAs) recognize and, where possible, actively
address the following:
1. In partnership with medical schools and workplaces, NMAs
recognize their obligation to provide education at all levels
about physician well-being. NMAs should collaboratively pro-
mote research to establish best practices that promote physician
health and to determine the impact of physician well-being on
patient care.
2. Physician well-being should be supported and provided
within and outside the workplace. Support may include but
is not limited to referral to medical treatment, counselling,
support networks, recognized physician health programs, oc-
cupational rehabilitation and primary prevention programs
including resiliency training, healthy lifestyles and case man-
agement.
3. NMAs should recognize the strong and consistent link between
physicians’ and patients’ personal health practices, providing yet
another critically important reason for health systems to pro-
mote physician health.
4. Physician health programs can help all physicians to proac-
tively help themselves via prevention strategies and can assist
physicians who are ill via assessment, referral to treatment
and follow-up. Programs and resources to help promote posi-
tive psychological health should be available to all physicians.
Early identification, intervention and special arrangements
for the care of physician-patients should be available to pro-
tect the health of physicians. Fostering a supportive and ac-
cepting culture is critical to successful early referral and in-
tervention.
5. Physicians at risk for abuse of alcohol or drugs should have ac-
cess to appropriate confidential medical treatment and compre-
hensive professional support. NMAs should promote programs
that help physicians re-enter medical practice with appropriate
ongoing supervision at the completion of their treatment pro-
grams. More research should be conducted to determine best
practices in preventing substance abuse among physicians and
physicians in postgraduate education.
6. Physicians have the right to working conditions that help limit
the risk of burnout and empower them to care for their per-
sonal health by balancing their professional medical commit-
ments and their private lives and responsibilities.Optimal work-
ing conditions include a safe and reasonable maximum number
of consecutive and total working hours, adequate rest between
shifts and appropriate number of non-working days. Relevant
organizations should constructively address professional au-
tonomy and work-life balance problems and involve physicians
in making decisions about their work lives. Working conditions
must not put the safety of patients or physicians at risk, and
ultimately physicians should be engaged in establishing optimal
workplace conditions.
7. Workplaces should promote conditions conducive to healthy
lifestyles, including access to healthy food choices, exercise, nu-
trition counselling and support for smoking cessation.
8. Physicians, physicians in postgraduate education and medical
students have the right to work in a harassment and violence-
free workplace. This includes freedom from verbal, sexual and
physical abuse.
9. Physicians, physicians in postgraduate education and medical
students have the right to a collaborative safe workplace. Work-
places should promote interdisciplinary teamwork, and commu-
nication between physicians and all other professionals in the
workplace should be offered in a spirit of cooperation and re-
spect. Education on communications skills, self-awareness and
team-work should be considered.
10. Medical staff should undergo training in recognizing, handling
and communicating with potentially violent persons. Health
care facilities should safeguard against violence including rou-
tine violence risk audits, especially in mental health treatment
facilities and emergency departments. Staff members who are
victims of violence or who report violence should be supported
by management and offered medical, psychological and legal
counselling.
11. Medical schools and teaching hospitals should develop and
maintain confidential services for physicians in postgraduate
education and medical students and to raise awareness of and
access to such programs. Workplaces should consider offering
medical consultations to physicians in postgraduate education
in order to identify any health issues at the outset of medical
education.
12. Workplace support for all physicians should be easily accessible
and confidential. Physicians evaluating and treating their medi-
cal colleagues should not be required to report any aspects of
their physician-patients’ care in any manner not required for
their non-physician patients.
WMA Statement on Transgender
People
Adopted by the 66th
WMA General Assembly, Moscow, Russia,
October 2015
Preamble
In most cultures, an individual’s sex is assigned at birth according
to primary physical sex characteristics. Individuals are expected to
identify with their assigned sex (gender identity) and behave ac-
cording to specific cultural norms strongly associated with this
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(gender expression). Gender identity and gender expression make
up the concept of “gender” itself.
There are individuals who experience different manifestations of
gender that do not conform to those typically associated with their
sex assigned at birth. The term “transgender” refers to people who
experience gender incongruence, which is defined as a marked mis-
match between one’s gender and the sex assigned at birth.
While conceding that this is a complex ethical issue, the WMA
would like to acknowledge the crucial role played by physicians in
advising and consulting with transgender people and their families
about desired treatments.The WMA intends this statement to serve
as a guideline for patient-physician relations and to foster better
training to enable physicians to increase their knowledge and sensi-
tivity toward transgender people and the unique health issues they
face.
Along the transgender spectrum, there are people who, despite hav-
ing a distinct anatomically identifiable sex, seek to change their pri-
mary and secondary sex characteristics and gender role completely
in order to live as a member of the opposite sex (transsexual). Oth-
ers choose to identify their gender as falling outside the sex/gender
binary of either male or female (genderqueer). The generic term
“transgender” represents an attempt to describe these groups with-
out stigmatisation or pathological characterisation. It is also used
as a term of positive self-identification.This statement does not ex-
plicitly address individuals who solely dress in a style or manner
traditionally associated with the opposite sex (e.g. transvestites) or
individuals who are born with physical aspects of both sexes, with
many variations (intersex). However, there are transvestites and in-
tersex individuals who identify as transgender. Being transvestite or
intersex does not exclude an individual from being transgender. Fi-
nally, it is important to point out that transgender relates to gender
identity, and must be considered independently from an individual’s
sexual orientation.
Although being transgender does not in itself imply any mental im-
pairment, transgender people may require counseling to help them
understand their gender and to address the complex social and re-
lational issues that are affected by it. The Diagnostic and Statistical
Manual of Mental Disorders of the American Psychiatric Associa-
tion (DSM-5) uses the term “gender dysphoria” to classify people
who experience clinically significant distress resulting from gender
incongruence.
Evidence suggests that treatment with sex hormones or surgi-
cal interventions can be beneficial to people with pronounced and
long-lasting gender dysphoria who seek gender transition.However,
transgender people are often denied access to appropriate and af-
fordable transgender healthcare (e.g. sex hormones, surgeries, men-
tal healthcare) due to, among other things, the policies of health
insurers and national social security benefit schemes, or to a lack of
relevant clinical and cultural competence among healthcare provid-
ers. Transgender persons may be more likely to forego healthcare
due to fear of discrimination.
Transgender people are often professionally and socially disadvan-
taged, and experience direct and indirect discrimination, as well as
physical violence. In addition to being denied equal civil rights, an-
ti-discrimination legislation which protects other minority groups
may not extend to transgender people. Experiencing disadvantage
and discrimination may have a negative impact upon physical and
mental health.
Recommendations
1. The WMA emphasises that everyone has the right to deter-
mine one’s own gender and recognises the diversity of pos-
sibilities in this respect. The WMA calls for physicians to up-
hold each individual’s right to self-identification with regards
to gender.
2. The WMA asserts that gender incongruence is not in itself a
mental disorder; however, it can lead to discomfort or distress,
which is referred to as gender dysphoria (DSM-5).
3. The WMA affirms that, in general, any health-related proce-
dure or treatment related to an individual’s transgender status,
e.g. surgical interventions, hormone therapy or psychotherapy,
requires the freely given informed and explicit consent of the
patient.
4. The WMA urges that every effort be made to make individual-
ised, multi-professional, interdisciplinary and affordable trans-
gender healthcare (including speech therapy, hormonal treat-
ment, surgical interventions and mental healthcare) available
to all people who experience gender incongruence in order to
reduce or to prevent pronounced gender dysphoria.
5. The WMA explicitly rejects any form of coercive treatment or
forced behaviour modification. Transgender healthcare aims to
enable transgender people to have the best possible quality of
life. National Medical Associations should take action to iden-
tify and combat barriers to care.
6. The WMA calls for the provision of appropriate expert train-
ing for physicians at all stages of their career to enable them
to recognise and avoid discriminatory practises, and to provide
appropriate and sensitive transgender healthcare.
7. The WMA condemns all forms of discrimination, stigmatisa-
tion and violence against transgender people and calls for ap-
propriate legal measures to protect their equal civil rights. As
role models, individual physicians should use their medical
knowledge to combat prejudice in this respect.
8. The WMA reaffirms its position that no person, regardless of
gender, ethnicity, socio-economic status, medical condition or
disability, should be subjected to forced or coerced permanent
sterilisation (WMA Statement on Forced and Coerced Sterili-
sation). This also includes sterilisation as a condition for recti-
fying the recorded sex on official documents following gender
reassignment.
9. The WMA recommends that national governments maintain
continued interest in the healthcare rights of transgender people
by conducting health services research at the national level and
using these results in the development of health and medical
policies. The objective should be a responsive healthcare system
that works with each transgender person to identify the best
treatment options for that individual.
WMA Statement on Vitamin D
Insufficiency
Adopted by the 66th
WMA General Assembly, Moscow, Russia,
October 2015
Preamble
Vitamin D has major role in calcium and bone metabolism. Normal
values are 75-100 nmol/L (30-40 ng/ml). Vitamin D deficiency is
defined if serum hydroxyvitamin D levels are less than 50 nmol/L
(20 ng/ml), insufficiency as 50-75 nmol/L (20-30 ng/ml).
Studies demonstrate that vitamin D is essential also for overall
health and well-being. In the body vitamin D is produced during
exposure to sunlight and in lesser degree by food intake.
Vitamin D exists in two forms: vitamin D3
(cholecalciferol in hu-
mans and other mammals) and vitamin D2
(ergocalciferol in plants),
but both are similarly metabolized. Vitamin D3
is more active than
vitamin D2.
The serum concentration of the hepatic metabolite of vitamin D3,
the 25-hydroxyvitamin D, is considered as the best biomarker of
vitamin D status.
Vitamin D deficiency is an important health issue globally. About
one third of the population is estimated to have lower serum con-
centration of vitamin D.
Many studies have shown that vitamin D deficiency is linked to
impaired growth and development. Because vitamin D receptors
are broadly distributed in tissues, vitamin D deficiency is associated
with musculoskeletal disorders (osteoporosis), falls, fractures, auto-
immune disorders, chronic inflammatory diseases, type 2 diabetes
mellitus, and cardiovascular, neurologic and psychiatric disorders.
High risk groups are young children,the elderly and pregnant wom-
en. Primary factors, contributing to vitamin D deficiency, include
reduced sunshine exposure, poor quality diet, availability of fortified
foods and supplement use.
Recommendations
Because of widespread occurrence of vitamin D deficiency/insuf-
ficiency it is desirable to focus attention on adequate preventive ac-
tions in populations at risk. Determining vitamin D levels requires
only a blood test, and oral supplementation is a simple treatment
method. Sun exposure is not generally recommended because it can
increase the risk of skin cancer.
The World Medical Association recommends that national medical
associations:
1. Support continued research in vitamin D and its metabolites.
2. Educate physicians about the evolving science of vitamin D and
its impact on health (documents, brochures, posters).
3. Encourage physicians to consider measuring the serum con-
centrations of 25-hydroxyvitamin D in the patients at risk of
vitamin D deficiency.
4. Monitor development of dietary recommendations for vita-
min D.
WMA Guidelines on
Promotional Mass Media
Appearances by Physicians
Adopted by the 66th
WMA General Assembly, Moscow, Russia,
October 2015
Preamble
Mass media can effectively play diverse roles in medical commu-
nication. Physicians, as professionals and experts, can contribute to
improved public health by providing the public with accurate health
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related information. Mass media provides a channel through which
physicians may contribute to society by leveraging mass media ap-
pearances in positive ways.
However, the increase in instances of physicians’ frequent appear-
ances on mass media to recommend unproven treatments or prod-
ucts and to use such appearances for marketing purposes is posing
a serious concern. The public may readily accept groundless recom-
mendations by physicians and may develop unrealistic expectations.
The subsequent confusion and disappointment can damage the
patient-physician-relationship.
This issue is more serious in some countries where there are differ-
ent systems of medicine, including alternative medicine.
Recommendations
The WMA recommends the following guidelines regarding mass
media appearances by physicians to prevent them from being in-
volved in commercial activities that may compromise professional
ethics and to contribute to patient safety by ensuring physicians
providing accurate, timely, and objective information.
Accurate and Objective Delivery of Scientifically
Proven Medical Information
When appearing in media, physicians shall provide objective and
evidence-based information and shall not recommend medical pro-
cedures or products that are not medically proven or justified.
A physician shall not use expressions that may promote unrealistic
patient expectations or mislead viewers about the function and ef-
fect of medical procedures, drugs or other products.
Physicians shall include important information including possible
adverse effects and risks when explaining medical procedures,drugs,
or other products.
Not Abusing Mass Media as a Means of Advertisement
Physicians should not recommend specific products by either spe-
cifically introducing or intentionally highlighting the name or
trademark of a product.
Physicians shall practice prudence regarding personal appearances
on home shopping program..The physician should have no financial
stake in the products being sold.
Physicians shall not be a part of mass media advertisement on any
produc, which is harmful to huma, and/or environment.
Maintaining Professional Integrity
Physicians shall not require or receive economic benefits for mass
media appearances other than a customary appearance fee.
Physicians shall not provide economic benefits to broadcasting per-
sonnel in order to secure mass media appearances.
Physicians shall not engage in the promotion, sale or advertising of
commercial products and shall not introduce false or exaggerated
statements regarding their qualifications such as academic back-
ground, professional experience, medical specialty and licensure as
a specialist, for the benefit of the economic interests of any com-
mercial entity.
WMA Resolution on the
Inclusion of Medical Ethics and
Human Rights in the Curriculum
of Medical Schools World-Wide
Adopted by the 51st
World Medical Assembly, Tel Aviv, Israel,
October 1999
and revised by the 66th
WMA General Assembly, Moscow, Russia,
October 2015
Preamble
Medical School curricula are designed to prepare medical stu-
dents to enter the profession of medicine. Increasingly, in addi-
tion to core biomedical and clinical knowledge, they teach skills
including critical appraisal and reflective practice.These additional
skills help to enable future doctors to understand and assess the
importance of published research evidence, and how to evaluate
their own practice against norms and standards set nationally and
internationally.
In much the same way that anatomy, physiology and biochemistry
are a solid base for understanding the human body, how it works,
how it can fail or otherwise go wrong, and how different mecha-
nisms can be used to repair damaged structure and functions, there
is a clear need for physicians in training to understand the social,
cultural and environmental contexts within which they will practice.
This includes a solid understanding of the social determinants of
health.
Medical ethics includes the social contract made between the
health care professions and the societies they serve, based upon
established principles, on the limits that apply to medical practice.
It also establishes a system or set of principles through which new
treatments or other clinical interventions will be sieved before de-
cisions are made on whether elements are acceptable within medi-
cal practice. There is a complex intermingling of medical ethics
and the duties of physicians to patients, and the rights patients
enjoy as citizens.
At the same time physicians face challenges and opportunities in
relation to the human rights of their patients and of populations,for
example, occasions for imposing treatments without consent, and
will also often be the first to observe and to itemize the infringe-
ment of these rights by others, including the state. This places very
specific responsibilities upon the observing physician.
Physicians have a duty to use their knowledge to improve the well-
being and health of patients and the population.This will mean con-
sidering social and societal change, including legislation and regula-
tion, and can only be done well if doctors can take a holistic view
within clinical and ethical parameters.
Physicians should press government to ensure legislation supports
principled medical practice.
Given the core nature of health care ethics in establishing medical
practice in a manner that is acceptable to society and that does not
violate civil, political and other human rights, it is essential that all
physicians are trained to perform an ethics evaluation of every clini-
cal scenario they may encounter, while simultaneously understand-
ing their role in protecting the rights of individuals.
Physicians’ability to act and communicate in a way that respects the
values of the individual patient is a prerequisite for successful treat-
ment. Physicians must also be able to work effectively in teams with
other health c are professionals including other physicians.
Failures of individual physicians to recognize the ethical obliga-
tions they owe patients and communities can damage the reputa-
tion of doctors both locally and globally. Therefore it is essential
that all doctors are taught to understand and respect medical eth-
ics and human rights from the beginning of their medical school
careers.
In many countries ethics and human rights are an integral part of
the medical curriculum, but this is not universal. Too often teach-
ing is undertaken by volunteers, and can fail if those volunteers are
unable or unavailable to teach, or if that teaching is unduly idiosyn-
cratic or inadequately based upon clinical scenarios.
The teaching of medical ethics should become an obligatory and
examined part of the medical curriculum within every medical
school.
Recommendations
1. The WMA urges that medical ethics and human rights be taught
at every medical school as obligatory and examined parts of the
curriculum, and should continue at all stages of post graduate
medical education and continuing professional development.
2. The WMA believes that medical schools should seek to ensure
that they have sufficient faculty skilled at teaching ethical en-
quiry and human rights to make these courses sustainable.
3. The WMA commends the inclusion of medical ethics and hu-
man rights within post graduate and continuing medical educa-
tion.
WMA Statement on
Non-Discrimination in
Professional Membership
and Activities of Physicians
Adopted by the 37th
World Medical Assembly, Brussels, Belgium, October
1985
and editorially revised by the 170th
WMA Council Session,
Divonne-les-Bains, France, May 2005
and revised by the 66th
WMA General Assembly, Moscow, Russia,
October 2015
The World Medical Association is in favour of equality of opportu-
nity in medical association activities, medical education and train-
ing, employment, and all other medical professional endeavours
regardless of any factors of discrimination.
The World Medical Association is unalterably opposed to the denial
of membership privileges and responsibilities in National Medical
Associations to any duly registered physician because of any factors
of discrimination.
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The World Medical Association calls upon the medical profession
and all individual members of National Medical Associations to ex-
ert every effort to prevent any instance in which such equal rights,
privileges or responsibilities are denied.
WMA Statement on Ethical
Issues Concerning Patients with
Mental Illness
Adopted by the 47th
WMA General Assembly, Bali, Indonesia, September
1995
and revised by the 57th
WMA General Assembly, Pilanesberg, South Af-
rica, October 2006
and by the 66th
WMA General Assembly, Moscow, Russia, October 2015
Preamble
Historically, many societies have regarded patients with mental ill-
ness as a threat to those around them rather than as people in need
of support and care. In the absence of effective treatment, to prevent
self-destructive behaviour or harm to others, many persons with
mental illness were confined to asylums for all or part of their lives.
Today, progress in psychiatric treatment allows for better care of
patients with mental illness. Efficacious drugs and psychosocial in-
terventions offer outcomes ranging from complete recovery to re-
mission for varying lengths of time.
The adoption in 2006 of the United Nations Convention on the
Rights of Persons with Disabilities constituted a major step towards
viewing them as full members of society with the same rights as ev-
eryone else. It is the first comprehensive human rights treaty of the
21st
century. It aims to promote, protect and reinforce the human
rights and dignity of all persons with disabilities, including those
with mental impairments.
Persons with major mental illnesses and those with learning dis-
ability have the same right to preventive services and interventions
to promote health as others members of the community, for which
they often have greater need because they are more likely to live
unhealthy lifestyles.
Patients with psychiatric morbidity may also experience non- psy-
chiatric illness. Persons with mental illness have the same right to
health care as any other patient. Psychiatrists and health care pro-
fessionals who provide mental health services should refer patients
to other appropriate professionals when patients need medical care.
Health care professionals should never decline to provide needed
medical care solely because the patient has a mental illness.
Physicians have the same obligations to all patients, including pa-
tients with mental illness.Psychiatrists or other physicians who treat
patients with mental illness must adhere to the same ethical stan-
dards as any physician.
The physician’s primary obligation is to the patient and not to serve
as agents of society, except in circumstances when a patient presents
clear danger to himself/ herself or others due to mental illness.
Physicians’ Ethical Responsibilities
The stigma and discrimination associated with psychiatry and the
mentally ill should be eliminated. Stigma and discrimination may
discourage people in need from seeking medical care, thereby ag-
gravating their situation and placing them at risk of emotional or
physical harm.
Physicians have a responsibility to respect the autonomy of all pa-
tients. When patients who are being treated for mental illness have
decision-making capacity, they have the same right to make deci-
sions about their care as any other patient.Because decision-making
capacity is specific to the decision to be made and can vary over
time, including as a result of treatment, physicians must continually
evaluate the patient’s capacity. When a patient lacks decision-mak-
ing capacity, physicians should seek consent from an appropriate
surrogate in accordance with applicable law.
The therapeutic relationship between physician and patient is
founded on mutual trust, and physicians have a responsibility to
seek patients’ informed consent to treatment, including patients
who are being treated for mental illness. Physicians should inform
all patients of the nature of the psychiatric or other medical con-
dition, and the expected benefits, outcomes and risks of treatment
alternatives.
Physicians should always base treatment recommendations on their
best professional judgment and treat all patients with solicitude and
respect, regardless of the setting of care. Physicians who practice
in mental health facilities, military or correctional institutions may
have concurrent responsibilities to society that create conflicts with
the physician’s primary obligation to the patient. In such situations,
physicians should disclose the conflict of interest to minimize pos-
sible feelings of betrayal on the patient’s part.
Involuntary treatment or hospitalization of persons with mental
illness is ethically controversial. While laws regarding involuntary
hospitalization and treatment vary worldwide, it is generally ac-
knowledged that this treatment decision without the patient’s in-
formed consent or against the patient’s will is ethically justifiable
only when: (a) a severe mental disorder prevents the individual from
making autonomous treatment decisions; and/or (b) there is signifi-
cant likelihood that the patient may harm him/her self or others.
Involuntary treatment or hospitalization should be exceptional and
physicians should utilize it only when there is good evidence that it
is medically appropriate and necessary and should ensure that the
individual is hospitalized for the shortest duration feasible under
the circumstances. Wherever possible and in accordance with local
laws, physicians should include an advocate for the rights of that
patient in the decision process.
Physicians must protect the confidentiality and privacy of all patients.
When legally required to disclose patient information, the physician
should disclose only the minimum relevant information necessary
and only to an entity legally authorized to request or require the in-
formation.When databanks allow access to or transfer of information
from one authority to another, confidentiality must be respected and
such access or transfer must comply fully with applicable law.
The participation of individuals with psychiatric illness in research
needs to be in full accordance with the Recommendations of the
Declaration of Helsinki.
Physicians must never use their professional position to violate the
dignity or human rights of any individual or group, and should nev-
er allow their personal desires, needs, feelings, prejudices or beliefs
to interfere with a patient treatment. Physicians must never abuse
their authority or take advantage of a patient’s vulnerability.
Recommendations
The World Medical Association and National Medical Associations
are encouraged to:
1. Publicize this Statement and affirm the ethical foundations for
treatment of patients with mental illness.
2. While doing so,call for full respect – at all times – of the dignity
and human rights of patients with mental illness.
3. Raise awareness of physicians’ responsibilities to support the
well-being and rights of patients with mental illness.
4. Promote recognition of the privileged relationship between pa-
tient and physician based on trust, professionalism and confi-
dentiality.
5. Advocate for appropriate resources to meet the needs of persons
with mental illness.
WMA Declaration of Oslo on
Social Determinants of Health
Adopted by the 62nd
WMA General Assembly, Montevideo, Uruguay,
October 2011
and the title (Statement to Declaration) changed by the 66th
WMA Gen-
eral Assembly, Moscow, Russia, October 2015
The social determinants of health are: the conditions in which peo-
ple are born, grow, live, work and age; and the societal influences
on these conditions. The social determinants of health are major
influences on both quality of life, including good health, and length
of disability-free life expectancy. While health care will attempt to
pick up the pieces and repair the damage caused by premature ill
health,it is these social,cultural,environmental,economic and other
factors that are the major causes of rates of illness and, in particular,
the magnitude of health inequalities.
Historically, the primary role of doctors and other health care pro-
fessionals has been to treat the sick – a vital and much cherished
role in all societies.To a lesser extent, health care professionals have
dealt with individual exposures to the causes of disease – smoking,
obesity, and alcohol in chronic disease, for example. These familiar
aspects of life style can be thought of as ‘proximate’causes of disease.
The work on social determinants goes far beyond this focus on proxi-
mate causes and considers the “causes of the causes”. For example,
smoking, obesity, alcohol, sedentary life style are all causes of illness.
A social determinants approach addresses the causes of these causes;
and in particular how they contribute to social inequalities in health.
It focuses not only on individual behaviours but seeks to address the
social and economic circumstances that give rise to premature ill
health,throughout the life course: early child development,education,
work and living conditions, and the structural causes that give rise
to these living and working conditions. In many societies, unhealthy
behaviours follow the social gradient: the lower people are in the so-
cioeconomic hierarchy,the more they smoke,the worse their diet,and
the less physical activity they engage in. A major, but not the only,
cause of the social distribution of these causes is level of education.
Other specific examples of addressing the causes of the causes: price
and availability which are key drivers of alcohol consumption; taxa-
tion, package labelling, bans on advertising, and smoking in public
places which have had demonstrable effects on tobacco consumption.
The voice of the medical profession has been most important in these
examples of tackling the causes of the causes.
There is a growing movement, globally, that seeks to address gross
inequalities in health and length of life through action on the so-
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cial determinants of health.This movement has involved the World
Health Organisation, several national governments, civil society or-
ganization, and academics. Solutions are being sought and learning
shared. Doctors should be well informed participants in this debate.
There is much that can happen within the practice of medicine that
can contribute directly and through working with other sectors.The
medical profession can be advocates for action on those social con-
ditions that have important effects on health.
The WMA could add significant value to the global efforts to ad-
dress these social determinants by helping doctors, other health
professionals and National Medical Associations understand what
the emerging evidence shows and what works, in different circum-
stances. It could help doctors to lobby more effectively within their
countries and across international borders, and ensure that medical
knowledge and skills are shared.
The WMA should help to gather data of examples that are working,
and help to engage doctors and other health professionals in trying
new and innovative solutions. It should work with national associa-
tions to educate and inform their members and put pressure on na-
tional governments to take the appropriate steps to try to minimise
these root causes of premature ill health. In Britain, for example,
the national government has issued a public health white paper that
has at its heart reduction of health inequalities through action on
the social determinants of health; several local areas have drawn up
plans of action; there are good examples of general practice that
work across sectors improve the quality of people’s lives and hence
reduce health inequalities. The WMA should gather examples of
good practice from its members and promote further work in this
area.
WMA Statement on Supporting
Health Support to Street
Children
Adopted by the 66th
WMA General Assembly, Moscow, Russia, October
2015
Preamble
The WMA recognises that having children living on the streets is
unacceptable in society even though this phenomenon is difficult to
avoid in many communities around the world.
The WMA intends to raise awareness within civil and medical so-
ciety about the fundamental role played by medical contact in im-
proving the situation of street children. In this regard, it is impor-
tant that the initial contact with street children be based on trust.
Therefore, together with other healthcare professionals and social
workers, medical contact should be viewed as the first step towards
resocialising street children by building trust between the physician
and the street child. Once achieved, a more global multidisciplinary
and multidimensional approach can follow to improve the well-
being of street children.
• Childhood and adolescence are the beginnings of a long physical,
mental, cultural and social growth process;
• The health of young people shapes the health of tomorrow’s pop-
ulation;
• Young people play a part in social cohesion and they are an asset
to any country;
• Addressing the social determinants of health is essential to
achieving equity in healthcare.The social determinants leading to
the appearance and growth of the phenomenon of street children
are varied and complex;
• The negative health impact of living on the streets for children,both
in terms of the additional health risks to which these children are
exposed and their lack of access to healthcare and prevention; street
children are, in particular, more vulnerable to acute illnesses and
traumatic injuries. In addition, preventive care and continuity of
care are non-existent for street children due to frequent relocation;
• The health of street children remains critical and has been ex-
acerbated by the global financial and economic crisis which has
contributed to family break-ups, social upheaval and disruptions
in healthcare and education;
• Children may be victims of discrimination arising from their gen-
der, ethnic origin, language, religion, political opinion, handicap,
social status or population migration;
• Street children are especially vulnerable to abuse,violence, exploi-
tation and manipulation, including trafficking;
• Child homelessness often goes unrecognised at a national and
international level since it is difficult to quantify and assess.
Recommendations
1. The WMA strongly condemns any violations of the rights of
children living on the streets and any infringements of these
rights, in particular discrimination and stigmatisation and their
exposure to abuse, violence, exploitation and manipulation, in-
cluding trafficking.
2. The WMA calls upon governments to address the factors which
lead to children living on the streets and to take action to im-
plement all applicable legislation and systems of protection to
reduce the health implications for street children. National au-
thorities have an obligation to provide care for all children and,
where necessary, to support their return to a living environment
appropriate for a child.
3. Reducing health implications includes not only direct treatment
of health issues but also protection of Street Children from
health risks such as exposure to drugs, HIV infection, smoking
and drinking.
4. The WMA calls upon governments, national medical associa-
tions and healthcare professionals to acknowledge the scale of
this phenomenon and to instigate prevention and awareness
campaigns. These children must be able to access the full range
of necessary health and social protection.
5. The WMA urges all national medical associations to work with
legal counterparts, governments, health care professionals and
public authorities to ensure the fundamental rights of children,
who are a particularly vulnerable population in need of protec-
tion, particularly access to healthcare and education. The right
to food and housing should be guaranteed, and any form of dis-
crimination or exploitation should be forbidden.
6. The WMA condemns any improper age-assessment practices
that make use of insufficiently reliable clinical or paraclinical
investigations. Until they reach adulthood, adolescents must be
able to enjoy their status as minors, as recognised by the UN
International Convention on the Rights of the Child.
7. The WMA urges physicians to remain vigilant in terms of de-
livering all the support required to provide suitable and compre-
hensive care for street children. Physicians should be aware that
homelessness is a pervasive problem. They should be knowl-
edgeable about the existence of homelessness in their own com-
munities and are encouraged to establish a relationship of trust
between the physician and the street child to become involved
in local relief and advocacy programs.
8. The WMA maintains that every effort should be made to pro-
vide all children, and particularly those that are homeless, with
access to a suitable and balanced psycho-social environment, in
which their rights, including the right to health, are respected.
WMA Statement on Mobile
Health
Adoptedbythe66th
WMAGeneralAssembly,Moscow,Russia,October2015
Preamble
Mobile health (mHealth) is a form of electronic health (eHealth)
for which there is no fixed definition. It has been described as medi-
cal and public health practice supported by mobile devices such as
mobile phones, patient monitoring devices, personal digital assis-
tants (PDAs), and other devices intended to be used in connection
with mobile devices. It includes voice and short messaging services
(SMS), applications (apps), and the use of the global positioning
system (GPS).
Sufficient policies and safeguards to regulate and secure the collec-
tion, storage, protection and processing of data of mHealth users,
especially health data, must be implemented. Users of mHealth ser-
vices must be informed about how their personal data are collected,
stored, protected and processed and their consent must be obtained
prior to any disclosure of data to third parties, e.g. researchers, gov-
ernments or insurance companies.
The monitoring and evaluation of mHealth should be imple-
mented carefully to avoid inequity of access to these technologies.
Where appropriate, social or healthcare services should facilitate
access to mHealth technologies as part of basic benefit packages,
while taking all the required precautions to guarantee data security
and privacy. Access to mHealth technologies should not be denied
to anyone on the basis of financial status or a lack of technical
expertise.
mHealth technologies cover a wide spectrum of functions. They
may be used for:
• Health promotional (lifestyle) purposes, such as apps into which
users input their calorie intake or motion sensors which track ex-
ercise.
• Services which require the medical expertise of physicians such
as SMS services providing advice to pregnant women or wearable
sensors to monitor chronic conditions such as diabetes. mHealth
technologies of this nature frequently meet the definition of a
medical device and should be subject to risk-based oversight and
regulation with all its implications.
mHealth may also be used to expedite the transfer of information
between health professionals, e.g. providing physicians with free,
cross network mobile phone access in resource poor settings.
Technological developments and the increasing prevalence and af-
fordability of mobile devices have led to an exponential increase in
the number and variety of mHealth services in use in both devel-
oped and developing countries.At the same time,this relatively new
and rapidly evolving sector remains largely unregulated,a fact which
could have potential patient safety implications.
mHealth has the potential to supplement and further develop exist-
ing healthcare services by leveraging the increasing prevalence of
mobile devices to facilitate access to healthcare, improve patient
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154 155
WMA News WMA News
self-management, enable electronic interactions between patients
and their physicians and potentially reduce healthcare costs. There
are significant regional and demographic variations in the potential
use and benefits of mHealth. The use of certain mHealth services
may be more appropriate in some settings than others.
mHealth technologies generally involve the measurement or
manual input of medical, physiological, lifestyle, activity and envi-
ronmental data in order to fulfil their primary purpose. The large
amount of data generated in this way also offers huge scope for
research into effective healthcare delivery and disease prevention.
However, this secondary use of personal data also has great poten-
tial for misuse and abuse, of which many users of mHealth services
are unaware.
The expansion of mHealth services has been largely market driven
and many technologies have been developed in an uncoordinated,
experimental fashion and without appropriate consideration of data
protection and security or patient safety aspects. It is often im-
possible for users to know whether the information provided via
mHealth stems from a reliable medical source. Major challenges
faced by the mHealth market are the quality of mHealth technolo-
gies and whether their use ultimately helps patients or physicians
achieve the intended purpose.
Comprehensive regulation and evaluation of the effectiveness, qual-
ity and cost effectiveness of mHealth technologies and services is
currently lacking, which has implications for patient safety. These
factors are crucial to the integration of mHealth services into regu-
lar healthcare provision.
Recommendations
1. The WMA recognises the potential of mHealth to supplement
traditional ways of managing health and delivering healthcare.
While mHealth may offer advantages to patients otherwise un-
able to access services from physicians, it is neither universally
appropriate nor always an ideal form of diagnosis and treatment
option. Where face-to-face treatment is available this is almost
always advantageous to the patient.
2. The driving force behind mHealth must be the need to elimi-
nate deficiencies in the provision of care or to improve the qual-
ity of care.
3. The WMA urges patients and physicians to be extremely dis-
cerning in their use of mHealth and to be mindful of potential
risks and implications.
4. A clear distinction must be made between mHealth technol-
ogies used for lifestyle purposes and those which require the
medical expertise of physicians and meet the definition of medi-
cal devices.The latter must be appropriately regulated and users
must be able to verify the source of information provided. The
information provided must be clear, reliable and non-technical,
and therefore comprehensible to lay people.
5. Concerted work must go into improving the interoperability,
reliability, functionality and safety of mHealth technologies,
e.g. through the development of standards and certification
schemes.
6. Comprehensive and independent evaluations must be carried
out by competent authorities with appropriate medical expertise
on a regular basis in order to assess the functionality, limitations,
data integrity, security and privacy of mHealth technologies.
This information must be made publicly available.
7. mHealth can only make a positive contribution towards im-
provements in care if services are based on sound medical ra-
tionale. As evidence of clinical usefulness is developed, findings
should be published in peer reviewed journals and be reproduc-
ible.
8. Suitable reimbursement models must be set up in consultation
with national medical associations and healthcare providers to
ensure that physicians receive appropriate reimbursement for
their involvement in mHealth activities.
9. A clear legal framework must be drawn up to address the issue
of identifying potential liability arising from the use of mHealth
technologies.
10. Physicians who use mHealth technologies to deliver healthcare
services should heed the ethical guidelines set out in the WMA
Statement on Guiding Principles for the Use of Telehealth for
the Provision of Health Care.
11. It is important to take into account the risks of excessive or in-
appropriate use of mHealth technologies and the potential psy-
chological impact this can have on patients.
WMA Statement on Nuclear
Weapons
Adopted by the 50th
World Medical Assembly, Ottawa, Canada,
October 1998
and amended by the 59th
WMA General Assembly, Seoul, Korea, Octo-
ber 2008
and by the 66th
WMA General Assembly, Moscow, Russia, October 2015
The WMA Declarations of Geneva, of Helsinki and of Tokyo make
clear the duties and responsibilities of the medical profession to pre-
serve and safeguard the health of the patient and to consecrate itself
to the service of humanity.The WMA considers that it has a duty to
work for the elimination of nuclear weapons.
Therefore the WMA:
• Condemns the development, testing, production, stockpiling,
transfer, deployment, threat and use of nuclear weapons;
• Requests all governments to refrain from the development, test-
ing, production, stockpiling, transfer, deployment, threat and use
of nuclear weapons and to work in good faith towards the elimi-
nation of nuclear weapons;
• Advises all governments that even a limited nuclear war would
bring about immense human suffering and substantial death toll
together with catastrophic effects on the earth’s ecosyste, which
could subsequently decrease the worlds food supply and would
put a significant portion of the world’s population at risk of fam-
ine; and
• Requests that all National Medical Associations join the WMA
in supporting this Declaration, use available educational re-
sources to educate the general public and urge their respective
governments to work towards the elimination of nuclear weap-
ons.
• Requests all National Medical Associations to join the WMA in
supporting this Declaration and to urge their respective govern-
ments to work to ban and eliminate nuclear weapons.
WMA Statement on Riot
Control Agents
Adopted by the 66th
WMA General Assembly, Moscow, Russia,
October 2015
Preamble
There has been a long-standing concern regarding the use of chemi-
cal weapons. Despite this concern, poison gas was used fairly exten-
sively during World War I, leading to a call from the International
Committee of the Red Cross (ICRC) in February 1918 for cessa-
tion of its use.
This led to the Geneva Protocol of 1925, the Biological and Toxin
Weapons Convention of 1972 (BTWC) and the Chemical Weap-
ons Convention of 1993 (CWC).
All but six countries in the world have signed and ratified the
CWC; two more have signed but not yet ratified, making it a nearly
universally accepted Convention.
The conventions prohibit the development, production and stock-
piling of chemical weapons in addition to their usage in warfare
and call for measures to decommission or destroy existing stores.
However,the CWC allows the use of specific chemicals in domestic
law enforcement including riot control situations, which means that
governments might hold stockpiles of certain agents. Even so, riot
control agents cannot be used in warfare; the exclusion has reached
the status of customary law which allows their use only in domestic
or national jurisdictions.
Although there is academic and military interest in what is often
called non-lethal weapons, the incidence of morbidity and mortal-
ity caused by weapons are not criteria used in prohibition. A tiered
approach based upon degrees of lethality of specific weapons is con-
trary to the ethos of both conventions.
In situations of widespread public unrest and political or other up-
risings governments unfortunately may choose to deploy riot con-
trol agents in a domestic setting. Although this is not in conflict
with the principles of the CWC their use may still give rise to spe-
cific medical, legal and ethical challenges.
While riot control agents are designed to make remaining within
the riot unpleasant and impractical,they are not expected to directly
cause any injuries or deaths. As with all other agents, how they are
used determines the concentration to which individuals are exposed.
The ability to take evasive actions, such as leaving the area, to reduce
exposure may also have an impact. It is recognised that individual
determinants including general health and age will affect an indi-
vidual’s response to chemical agent.
Release of chemical agents such as tear gas in a small enclosed space
exposes individuals to concentrations far higher than those expected
in normal deployment in riot situations, causing higher levels of
serious morbidity and potentially death.
Misuse of riot control agents, leading to serious harms or deaths
of demonstrators, exposing individuals excessively or using them
for oppressing non-violent peaceful demonstrations, may lead to a
breach of the human rights of the individuals concerned, in par-
ticular the right to life (article 3), the right to freedom of expression
(article 19) and of peaceful assembly (article 20) of the Universal
Declaration of Human Rights.
Governments, who authorize the stockpiling and use of such agents
by their police and security forces, are urged to consider that there
might be fatal results of their usage. Governments are required to
ensure that they are used in a manner which minimise their likeli-
hood of causing serious morbidity and mortality.
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156 157
UNITED KINGDOMUNITED KINGDOM Body Cavity SearchesBody Cavity Searches
Recommendations
1. The WMA recognises that the inappropriate use of riot con-
trol agents risks the lives of those targeted and exposes peo-
ple around, amounting to a potential breach of human rights
standards, in particular the right to life, the right to freedom of
expression and of peaceful assembly as stated in the Universal
Declaration of Human Rights.
2. In case of use of riot control agents, the WMA urges States
to do so in a manner designed to minimise the risk of serious
harm to individuals, and to prohibit its use in the presence of
vulnerable populations, such as children, older people or preg-
nant women;
3. The WMA insists that riot control agents should never be used
in enclosed spaces where chemical concentrations may reach
dangerous levels, and where people cannot move away from ar-
eas with high concentrations of the agent;
4. The WMA insists that governments train police and other secu-
rity forces in the safe and legal use of riot control agents,in order
to minimise the risk of harm when they are deployed.This must
include the rapid evacuation of any individual who is apparently
suffering from a high level of exposure, not aiming people, and
not using the agent excessively;
5. The WMA insists that States penalise individuals who misuse
riot control agents and who deliberately endanger human life
and safety by using the agents. Such misuse leading to serious
physical harms or death of individuals should be investigated by
independent experts.
6. The WMA calls for unimpeded and protected access of
healthcare personnel to allow them to fulfil their duty of at-
tending to the injured as set forth in the “WMA Declara-
tion on the protection of healthcare workers in situations of
violence”.
7. The WMA recommends that because of the significant difficul-
ties and risks to health and life associated with the use of such
riot control agents States should refrain from using them in any
circumstances.
The BMA prepared a revised version of
an old WMA policy for consideration
at the Committee Meetings in Moscow.
Earlier consideration had made it clear
that revision was necessary; the BMA
agreed to undertake the work. Hernan
Reyes, lately of the ICRC worked with
the author, to ensure that the version
submitted was in accordance with inter-
national norms.
Why does this matter?
Body cavity searches are a reality of life with-
in detention settings worldwide. At their
least harmful they are rarely performed, but
done when it is considered that a detainee
might have concealed within a body cavity
drugs, weapons or other contraband items.
These items might pose a risk of immedi-
ate harm to the detainee him/herself, to
those around the detainee including prison
guards, or might post a future threat within
the detention environment.
There are a number of simple ethical prin-
ciples that need to be observed during the
search, regardless of who carries it out.
Where doctors are asked to become in-
volved, the ethical principles are added to
by consideration of the patient-doctor rela-
tionship.
Before any search
All body cavity searches are, at least, poten-
tially demeaning, generating psychosocial
harm at some level. They can also result
in actual physical harm to the detainee, es-
pecially if carried out by someone without
training, or by someone not using appropri-
ate care and attention.
The fact that there is a potential risk is not
a reason to insist that doctors carry out all
such searches; but it is an imperative to re-
quire that those performing searches are
properly trained and carry out their search-
ing in a safe manner.
Why not a doctor
performing the search?
In most cases the searches are carried out
for non-medical reasons. Although the
detainee could suffer harm from some
concealed items in most cases the harm
would be caused by their later use on the
Body Cavity Searches
Vivienne Nathanson
detainee him/herself or on their use by
the detainee against others. The search is
therefore performed for reasons associ-
ated with the good order of the place of
detention, for reduction in the presence of
weapons, drugs or other contraband and
other associated reasons. If doctors per-
form the search they are becoming simple
arms of the institution, rather than the dis-
passionate medical professional. This risks
undermining the separation of the role of
the doctor and thus the patient (detainee)-
doctor relationship. If the detainee sees
the doctor as just another part of the
prison system s/he is unlikely to trust the
doctor, and ultimately that breakdown in
trust raises significant risks to both patient
and doctor, and to public health within the
prison community.
Wherever a search is carried out it should be
in private. This means within a room or fa-
cility where the only people present are the
detainee, the person performing the search
and at most one witness. More witnesses
risks the procedure becoming a spectacle,
and demeaning the detainee. A witness
may be necessary to protect both the de-
tainee and the searcher. From the perspec-
tive of the detainee this should be someone
who can be trusted to tell the truth – and to
therefore prevent an abusive search. From
the searchers point of view the witness
should be someone who will stand up to
bullying within the prison and protect him
from accusations of carrying out an abusive
search (provided of course that this is the
truth).
Gender of the searcher
In an ideal world the gender of the searcher
should be the same as that of the detainee.
But this does not protect completely from
the reality that searches could be carried out
in asexually inappropriate manner – in gen-
eral it is likely to lessen the embarrassment
of the detainee that might help to prevent
psychosocial harms.
When the detainee requests
a doctor as searcher
On occasion the detainee might ask for a
doctor to perform the search; doctors can
agree with this, and should ensure before
they search that the detainee is aware that,
on this occasion, the doctor is acting for
the place of detention and not as a prisoner
advocate. Doctors are faced with a difficult
decision when this request is made as doc-
tors are likely to sympathise with the de-
tainee but have to be aware of the risk that
this will undermine the trust that is needed
between detainee as patient and his/her
doctor.
Consent
Doctors should only carry out searches with
the consent of the detainee. They should
seek to persuade detainees who are reluc-
tant to be searched that consent and com-
pliance is in their best interest if it is clear
that the prison authorities will carry out
such searches regardless of consent. They
should also seek to ensure that those carry-
ing out such searches do so only where there
is good reason to perform them, and then
to use the most ethically correct and non-
traumatic approach possible.
Abusive searches (rectal
examinations)
There is emerging evidence that in some de-
tention settings regular, routine ano-rectal
examinations are being performed. This is
clearly abusive as there is no relationship
with specific perceived threats or evidence
of concealments. The “tests” are being con-
ducted without regard to the ethical prin-
ciples and with a clear intent of humiliating
the detainees. This is abuse and unaccept-
able in any jurisdiction. Doctors who are
aware of such abuses must report it or they
become complicit in a serious abuse of hu-
man rights.
The subject of searches is complex – issues
around non-compliance by the detainee,
immediate risk to others, the management
of transgendered persons all raise consider-
able questions.
Transgender persons
The draft includes a clause about the man-
agement of searches in transgender persons.
This is included to flag up the fact that this
group of detainees need to be treated with
special care, in particular as they are likely
to be especially sensitive to such searches,
including to the gender of the person per-
forming the search. The clause is there-
fore intended to sensitise both doctors and
prison authorities reading the guidance to
the specific broader needs of this group of
detainees.
The purpose of the revised WMA guide-
lines is to introduce as a basic concept the
separation wherever possible of the doctor
from the machinery of the place of deten-
tion and the importance of recognizing that
this process might be occasionally essential
but it is always problematic and can be seri-
ously abusive and harmful. That encourages
the WMA member associations and their
members to attempt to preserve the dignity
and bodily integrity of their patients – the
detainees.
As the redrafters of the resolution the Brit-
ish Medical Association will be interested
to see whether the current draft covers is-
sues with sufficient clarity and in enough
depth to be of use to WMA members.
Prof. Vivienne Nathanson,
Chairman, Nathanson Health
Associates Limited;
Consultant to the BMA
on WMA matters; Principle adviser
on public health to the WMA
E-mail: viv.nathanson@googlemail.com
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158 159
Climate ChangeClimate Change
The health risks posed by climate change
are well-recognised, and threaten popu-
lations of both low- and high-income
countries [1, 2, 3, 4]. They range from the
direct health impacts of more frequent
heatwaves, flooding and extreme weather
events such as storms and bushfires to less
direct impacts such as spreading vector-
borne diseases, worsening food security
and malnutrition and population dis-
placement [3, 5]. At the same time, tack-
ling climate change has been called “the
greatest global health opportunity of the
21st
century” [4] due to the significant
health co-benefits of low-carbon solu-
tions.
For instance, there is now growing at-
tention on short-lived climate pollutants
(as compared to carbon dioxide, which is
long-lived) such as black carbon and meth-
ane, which result in air pollution that kills
7 million people annually. Specifically, ris-
ing global car use and the use of polluting
fuels such as coal for energy are both ma-
jor contributors to outdoor air pollution,
which is responsible for 3.7 million pre-
mature deaths worldwide [6], so a transi-
tion to renewable energy and active travel
(walking and cycling) could save millions
of lives each year attributable to reductions
in cardiovascular and respiratory mobid-
ity over the short term alone. These twin
imperatives to protect and promote health
in the face of climate change lie behind a
number of recent health sector declarations
and initiatives, from the WHO’s Call To
Action [7] to the ‘Doctors for Climate Ac-
tion’campaign led by the Royal Australasian
College of Physicians [8].
Earlier this month, a historic and unprec-
edented international agreement was ad-
opted at the United Nations (UN) climate
change negotiations in Paris (COP21).This
agreement established a critical new frame-
work for curbing greenhouse gas emissions
and transitioning away from carbon-in-
tensive economies  – thus ultimately tack-
ling climate change and protecting public
health. The Paris agreement is not perfect,
but it is a monumental step toward a co-
ordinated and effective global response and
presents a critical moment for physician and
health sector leadership and engagement on
climate change.
The Paris Agreement:
What it is and what it
means for health…
The Paris Agreement was adopted on
12  December 2015 and represents one
of the most seminal international agree-
ments affecting health to date. Indeed,
World Health Organization Director Gen-
eral Dr. Margaret Chan has described the
Agreement as “a significant public health
treaty, with a huge potential to save lives
worldwide” [9]. Described as “a health in-
surance policy for the planet” [10] by UN
Secretary General Ban Ki-Moon, the
Agreement is a product of years of nego-
tiations under the UN Framework Conven-
tion on Climate Change (UNFCCC).
The UNFCCC was established as part of
the Rio Convention (1992) and includes
196 parties which represent 195 countries
and the European Union which have agreed
to work towards realizing the ultimate ob-
jective of the Convention, “stabilization of
greenhouse gas concentrations in the atmo-
sphere at a level that would prevent danger-
ous anthropogenic interference with the
climate system” [11]. Each year, the Con-
ference of Parties (COP) is held to assess
progress under the UNFCCC. Recogniz-
ing the urgency of action on climate change
and using the framework provided by the
Ad Hoc Working Group on the Durban
Platform for Enhanced Action (ADP),
this year’s COP21 in Paris was preceded
by months of negotiations in anticipation
of a fair, ambitious and binding agreement
to establish an agreement for a coordinated
global response.
Table 1 summarizes key provisions of the
Agreement text that are relevant to health.
Health is explicitly included in terms of the
“right to health”both in the preamble of the
Agreement as well as the decision adopted
in Paris:
“Acknowledging that climate change is a com-
mon concern of humankind, Parties should,
when taking action to address climate change,
respect, promote and consider their respec-
tive obligations on human rights, the right to
health, the rights of indigenous peoples, local
communities, migrants, children, persons with
disabilities and people in vulnerable situations
and the right to development, as well as gender
equality, empowerment of women and inter-
generational equity.”
This language implies that parties, when
taking climate action, should consider and
promote “the right to health”as well as prin-
ciples of human rights and equity.Thus, this
language at least implicitly recognizes and
compels health sector engagement in action
on climate change.
National Climate Action:
The Foundation of the
Paris Agreement
Leading up to the UN Framework Con-
vention on Climate Change (UNFCCC)
Climate Conference (COP21), par-
ties submitted national commitments to
tackle climate change, called Intended
The Climate/Health Nexus at COP21 & Beyond
Nationally Determined Commitments
(INDCs). These voluntary commitments
are designed to support the Paris Agree-
ment and to succeed the Kyoto Protocol
in curbing greenhouse gas emissions. The
UNFCCC conducted an analysis of IN-
DCs submitted prior to 1st
of October
2015 including 119 INDCs, reflecting
commitments of 147 parties to the Con-
vention, and representing 86% of global
emissions in 2010. It concluded that these
submissions were insufficient to meet the
two degree Celsius mitigation goal while
also noting that many parties’ contribu-
tions were conditional on anticipated in-
ternational support [13]. A recent INDC
subgroup analysis by the NewClimate
Institute identified potential missed co-
benefits including approximately 150, 000
preventable premature deaths from ambi-
ent air pollution [14].
In the context of engagement of the health
sector in national action to address climate
change, the World Health Organization
(WHO) recently launched the Climate and
Health country profile initiative, through
which it strives to “provide relevant and
reliable country-specific information about
the current and future impacts of climate
change on human health, the opportunities
for health co-benefits from climate mitiga-
tion actions, and current policy responses at
country level” to inform engagement and
advocacy [15]. Currently 15 countries from
different regions have created their coun-
try profile. Identified indicators of national
progress in protecting health from climate
change include:
• Identification of a national focal point
for climate change in the Ministry of
Health;
• Approval of a National Health Adapta-
tion Strategy;
• Inclusion of health implications of miti-
gation policies in national strategy for
climate change;
• Completion of a national assessment of
climate change impacts, vulnerability and
adaptation for health;
Table 1. Summary of Selected Key Health-related Provisions of the Paris Agreement [12]
Health Paris Agree-
ment Preamble,
COP Decision
COP Decision
(Workstream 2)
• Acknowledges the right to health in context of action
to address climate change
• Recognizes “the social, economic and environmental
value of voluntary mitigation actions and their co-
benefits for adaptation, health and sustainable develop-
ment.”
Human
Rights
Paris Agree-
ment Preamble,
COP Decision
• Acknowledges human rights in the context of action to
address climate change
Equity Paris Agree-
ment Preamble,
Art. 2 & Art. 4
• Recognizes that implementation of the Agreement
should “reflect equity and the principle of common but
differentiated responsibilities and respective capabili-
ties.”
Mitigation Paris Agree-
ment Art. 2 &
Art. 4
COP Decision
(Workstream 2)
• Sets the long term goal to “[h]olding the increase in
global average temperature to well below 2°C” and pur-
suing efforts to “limit the temperature increase to 1.5
°C above pre-industrial levels”
• Recognizes mitigation cobenefits
• Recognizes the mitigation co-benefits during the pre-
2020 period
Adaptation Paris Agree-
ment Art. 2
• Includes the ability to adapt to the adverse impacts of
climate and foster climate resilience and low green-
house gas emissions development, in a manner that
does not threaten food production as part of the long-
term goal of the Agreement
Loss &
Damage
Paris Agree-
ment Art. 8
• Includes recognition of the importance of “averting,
minimizing and addressing loss and damage associated
with the adverse effects of climate change”
• Identifies areas of cooperation and facilitation to
enhance understanding, action and support which can
include: emergency preparedness, non-economic losses,
resilience of communities
Financing COP Decision • Sets a new collective quantified goal from a floor of
USD 100 billion per year by 2025, taking into account
the needs and priorities of developing countries
Non-party
Stakehold-
ers
COP Decision • Invites non-party stakeholders to scale up efforts and
support actions to reduce emissions and/or to build re-
silience and decrease vulnerability to the adverse effects
of climate change
Transpar-
ency
Paris Agree-
ment, Art. 13
• Establishes an enhanced transparency framework for
the Agreement implementation
Education Paris Agree-
ment, Art. 12,
COP Decision
• Calls on countries to take measures to “enhance
climate change education, training, public awareness,
public participation and public access to information”
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160
• Investment in institutional and technical
capacities relevant to climate change and
health;
• Implementation of projects/programs
to address health adaptation to climate
change;
• Implementation of activities to increase
climate resilience of health infrastruc-
ture;
• Allocation of domestic and international
funds to build health resilience to climate
change; and
• Assessment of the health co-benefits of
climate mitigation policies [16].
These indicators are an important tool to
assess national action and progress on cli-
mate and health over the next few years.
A recent study of World Federation of
Public Health Associations (WFPHA) of
national governments’ climate and health
policies found a majority of respondent
countries have not comprehensively identi-
fied health risks of climate change, while,
more than 40% have not involved the health
sector in mitigation planning or invested in
climate-health research.These findings sug-
gest a need for more effective health sector
integration and engagement in national ac-
tion to address climate change and protect
health [17]. Similarly, a preliminary analysis
of INDCs by the World Medical Associa-
tion shows that nearly two-thirds of parties
(121) included health in some form in their
initial commitments, however only about
half mention health adaptation (90) and
very few (28) mention health in relation to
mitigation. The analysis found significant
variation across regions with African States
(88.9%), Asian States (69.1%) and Latin
American & Caribbean States (81.8%)
demonstrating leadership in integrating
health, while Western European & Other
States (13.8%) and Eastern European
States (13%) less frequently incorporating
health in INDCs [18].
Climate and Health Summit
2015: Engaging with Health
in a Post-2015 World [19]
The Climate and Health Summit at COP21
brought together health professionals,
policy-makers, negotiators, and academics
working at the climate and health nexus
around the theme of ‘Engaging with Health
in a Post-2015 World’. Coordinated by the
Global Climate and Health Alliance in col-
laboration with the WHO and a number of
partner organizations, the Summit included
a diverse array of sessions ranging from
health adaptation and community resilience
to communicating climate change through
health to exploring how the health sector
can best engage with other sectors. During
the Summit, an unprecedented alliance of
Health Sector @ COP21
The health sector has been involved in the negotiations leading up to the Paris climate
change conference [17] and had a significant presence both within the negotiating space
as well as in the surroundings with many health-focused events. Some of the key health
sector events during COP21 include:
• The Paris Conference on Climate Change and Healthcare (Organized by Health
Care Without Harm with the French Hospital Federation) [18]
• Health professionals in action for Healthy Energy and Climate (Organized by
the Health and Environment Alliance – HEAL in collaboration with the Con-
seil National de l’Ordre des Médecins (CNOM), the World Medical Associa-
tion (WMA) and the International Federation of Medical Students Associations
(IFMSA) [19]
• Sustainable energy for all and the climate-health- development nexus: Lancet
Commission on Health and Climate Change (Organized by The Lancet Com-
mission on Health and Climate,the Global Alliance for Clean Cookstoves,Helio
International and the United Nations Foundation)
• Evaluating the Health and Climate Benefits of Clean Cooking (Organized by
the UN Foundation, the Global Alliance for Clean Cookstoves, the Fondation
Maison des sciences de l’Homme)
• Why the Climate Change Agreement is critical to Public Health (World Health
Organization)
• Effects of Climate change on the Social and Environmental Determinants of
Health in Africa: What can communities do to strengthen their climate resil-
ience? (Organized by the WHO AFRO Regional Office)
• Health Central to Climate Change Action (Organized by the Principality of
Monaco and the Health and Environment Alliance (HEAL))
• Healthy Lives on a Healthy Planet: What is Next for Research and Policy? (Or-
ganized by The Université Sorbonne Paris Cité (Centre Virchow-Villermé for
Public Health Paris-Berlin) together with The University of Geneva, the Lon-
don School of Hygiene and Tropical Medicine, the University of Heidelberg, the
World Health Organization, the Rockefeller Foundation, and The Lancet)
• The Cost of Coal Film Festival (Pacific Environment, Greenpeace East Asia,
Healthcare Without Harm, Ecodefense, groundWork, Climate and Health Al-
liance (CAHA))
There was a wide range of additional side events covering the intersection between cli-
mate change and public health which are not listed above.
doctors, nurses, and other health profes-
sionals from every part of the health sector
came together to announce declarations
representing over 1,700 health organiza-
tions, 8,200 hospitals and health facilities,
and 13 million health professionals, bring-
ing the global medical consensus on climate
change to a new level. The event issued a
resounding message that the health sector is
now engaged and is committed to continu-
ing to work to protect health from climate
change, and to advocate for public policy
which puts health at the centre of climate
action.
Post-Paris: What’s Next?
The Paris Agreement establishes a new mul-
tilateral framework for effective and coordi-
nated global climate action across sectors.
Drawing on the momentum of COP21,
it is critical that parties work to meaning-
fully integrate health by promoting health
sector engagement, incorporating health in
adaptation, mitigation, and loss and dam-
age, as well as ensuring adequate financing
[20]. This includes, for example, technical
assistance to the UNFCCC in order to best
integrate health in relevant areas of work
as well as assistance offered on the national
level for adequate consideration of health in
national climate change planning.
Internationally, health professionals can
meaningfully engage in:
• Collaboration with non-health profes-
sionals to ensure appropriate valuation of
health co-benefits of mitigation policies;
• Development and implementation of ad-
aptation initiatives within and beyond the
health sector to consequences of climate
change;
• Engagement with the Warsaw Inter-
national Mechanism, the mechanism
tasked by the UNFCCC to address loss
and damage associated with impacts of
climate change, in ensuring adequate
valuation of health losses due to climate
change.
National medical associations and similar
organizations are well-positioned to engage
in post-Paris climate action and the Agree-
ment implementation. Relevant avenues for
future engagement include:
• Educating members on the climate-
health nexus and opportunities for cli-
mate action;
• Integrating climate-health education
and competencies into medical school
curricula, licensure/credentialing and/or
continuing medical education require-
ments;
• Engaging in the development and imple-
mentation of national climate plans;
• Participating in climate and health advo-
cacy through organized national climate
and health groups, such alliances where
one exists, or consider forming an advo-
cacy alliance;
• Engaging media on the numerous health
sequelae of climate change,and the health
opportunities of acting on the causes of
climate change;
• Promoting local and national policies and
initiatives to address climate change’s ad-
verse health effects;
• Mainstreaming climate change and
health into existing horizontal and verti-
cal public health programs, such as uni-
versal health coverage [21], maternal and
child health, infectious and non-commu-
nicable disease prevention and control,
etc.
• Undertaking local research to better
quantify the health-related risks of cli-
mate change and the health co-benefits
of mitigation;
• Addressing the carbon footprint of the
health sector itself and to build climate
Climate ChangeClimate Change
The World Medical Association participated in climate change negotiations as observers. The WMA
delegation included Dr. Xavier Deau (WMA Immediate Past President), Dr. Peteris Apinis (Lat-
vian Medical Association), Dr. Peter Orris (University of Illinois – Chicago), Dr.YassenTcholakov
(Junior Doctors Network), Dr. Elizabeth Wiley (Junior Doctors Network), Dr. Knut Erling Mok-
snes (Norwegian Medical Association), Dr. Jaroslav Blahos (Czech Medical Association), Dr. Ma-
rie Colegrave (French Medical Council),Dr. Bjorn Oscar Fagerberg (Swedish Medical Association),
Dr. Lujain Al-Qodmani (Kuwait Medical Association/Junior Doctors Network), Mardelangel
Zapata Ponze de Leon (Colegio Medico de Peru/Junior Doctors Network), Dr. Georgiana Luisa
Baca (Junior Doctors Network), Dr. Otmar Kloiber (WMA Secretary General), Clarisse Delorme
(WMA Advocacy Advisor), Dr. Bayazit Illhan (Turkish Medical Association). (although not all
pictured)
BACK TO CONTENTS
IV
resilience in order to help withstand cli-
mate impacts which cannot be avoided;
and
• Continuing to advocate for 1.5o
C to pro-
tect public health and engage with coun-
tries’ mitigation strategies to ensure this
aim is included in national policies.
The Paris Agreement is a significant sym-
bolic and substantive accomplishment with
the potential to catalyze a coordinated glob-
al response to climate change. It is essential
that physicians and organized medicine rec-
ognize the relevance of this victory to our
patients and public health – and, as mem-
bers of the health sector, engage in imple-
mentation on a local, national and/or global
level to ensure the Agreement’s success.
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HealthsisteragendastowardsHealthForAll.html
Elizabeth Wiley, MD, JD, MPH,
University of Maryland, Baltimore, USA,
Yassen Tcholakov, MD, MIH, McGill
University, Montreal, Canada
Isobel Braithwaite, MPH BSc,
University College London, UK
Claudel P-Desrosiers, University of
Montreal, Montreal, Canada
Pablo Vega, MD, MPHc,
Universidad de Chile, Chile
Edgardo Vera, MD, MPHc,
Universidad de Chile, Chile
Lujain Alqodmani, MD, BMSc,
University of Kuwait, Kuwait
Kimberly Williams MD, MSc,
University of Calgary, Canada
Sudhvir Singh, MBChB, BMedSci,
University of Auckland, New Zealand
Luisa Georgiana Baca, MD, MSc
MedEd candidate, UCL, London, UK
Charlotte Holm-Hansen, MD,
University of Copenhagen, Denmark
Renzo Guinto, MD, Health Care
Without HarmAsia and Reimagine
Global Health, Philippines