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No. 2, May 2009
Editor in Chief
Dr. Pēteris Apinis
Latvian Medical Association
Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@nma.lv
editorin-chief@wma.net
Co-Editor
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suﬀolk IP143QT, UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor Velta Pozņaka
wmj-editor@wma.net
Journal design and
cover design by Jānis Pavlovskis
Layout and Artwork
The Latvian Medical Publisher “Medicīnas
apgāds”, President Dr. Maija Šetlere,
Hospitāļu iela 55, Riga, Latvia
Cover painting :The picture is of the man
who ﬁrst was called doctor in Iceland,
Hrafn Sveinbjarnarson (a name which is usual
today as well). He was born in 1166 and died
in 1213. He traveled to Norway, England,
France and Italy where it is believed that he
studied medicine at the University of Salermo.
One of the sagas written in the 12th
and 13th
century was dedicated to him and tells stories
of his abilities to heal and cure patients with
various illnesses.
Publisher
The World Medical Association, Inc. BP 63
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Deutscher-Ärzte Verlag GmbH,
Dieselstr. 2, P.O.Box 40 02 65
50832 Köln/Germany
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50670 Köln, No. 01 011 07410
At present rate-card No. 3 a is valid
The magazine is published quarterly.
Subscriptions will be accepted by
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the World Medical Association
Subscription fee € 22,80 per annum (inkl. 7%
MwSt.). For members of the World Medical
Association and for Associate members the
subscription fee is settled by the membership
or associate payment. Details of Associate
Membership may be found at the World
Medical Association website www.wma.net
Printed by
Deutscher Ärzte-Verlag
Köln, Germany
ISSN: 0049-8122
Dr. Yoram BLACHAR
WMA President
Israel Medical Assn
2 Twin Towers
35 Jabotinsky Street
P.O. Box 3566
Ramat-Gan 52136
Israel
Dr. Kazuo IWASA
WMA Vice-Chairman of Council
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Mukesh HAIKERWAL
WMA Chairperson of the Finance
and Planning Committee
58 Victoria Street
Williamstown, VIC 3016
Australia
Dr. Dana HANSON
WMA President-Elect
Fredericton Medical Clinic
1015 Regent Street Suite # 302,
Fredericton, NB, E3B 6H5
Canada
Dr. Jörg-Dietrich HOPPE
WMA Treasurer
Bundesärztekammer
Herbert-Lewin-Platz 1
10623 Berlin
Germany
Dr. Guy DUMONT
WMA Chairperson of the Associate
Members
14 rue des Tiennes
1380 Lasne
Belgium
Dr. Jón SNÆDAL
WMA Immediate Past-President
Icelandic Medicial Assn
Hlidasmari 8
200 Kopavogur
Iceland
Dr. Eva NILSSON-
BÅGENHOLM
WMA Chairperson of the Medical
Ethics Committee
Swedish Medical Assn
P.O. Box 5610
11486 Stockholm
Sweden
Dr. Karsten VILMAR
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
Germany
Dr. Edward HILL
WMA Chairperson of Council
American Medical Assn
515 North State Street
Chicago, ILL 60610
USA
Dr. José Luiz GOMES DO
AMARAL
WMA Chairperson of the Socio-
Medical-Aﬀairs Committee
Associaçao Médica Brasileira
Rua Sao Carlos do Pinhal 324
Bela Vista, CEP 01333-903
Sao Paulo, SP
Brazil
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 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
43
“Glass Pearls for Diamonds”
It is encouraging to see that gender diﬀerences in medicine now
get more attention. In this issue Petra Thürmann gives a general
overview of gender-speciﬁc diﬀerences in pharmacotherapy putting
a spot on an obvious concern in medicine we have long overlooked.
It may not be of any use to blame somebody for this long-lasting
negligence,but it is clear that continuing “as-we-have-always-done-
it”is no option. Petra Thürmann distinguishes between sex as a bio-
logical category and gender as a broader socio-biological concept.
Although overlooking the biological diﬀerences for ages, there will
be more and even more painful revelations when we look deeper
into the sociological diﬀerences in medical treatment.
WMA Past President Jim Appleyard, reminds us that likewise, our
home has not been made when it comes to children.Their weakness
is reﬂected in our apparent inability to properly include them in
medical research and development.The balance between safeguard-
ing children and providing the necessary research inclusion is – and
most likely will remain – one of the most diﬃcult and mind twisting
ethical challenges. Like the research on and for incapacitated pa-
tients and persons this question deserves our attention and care, our
engagement and, most diﬃcult, our dispassionate conclusions.
But not only when looking at gender and age diﬀerences; inequi-
ties are a far bigger problem than we are obviously willing to admit.
Searching ways to bring them to the attention of the individual phy-
sician and his daily practices is the focus of WMA president Yoram
Blachar. His Israeli Medical Association and many other groups
have looked into ways of not only describing but also improving
the chances for patients to get the treatment they need and want,
irrespective of their social, ethnic and economic background. His
call comes in a time when societies and governments,politicians and
economists highlight the problem, while at the same time their pro-
posals and laws turn medicine more and more into an odd mixture
of state control and commodity business,including direct or indirect
rationing which of course increases the existing inequalities.
In the aﬄuent countries of this world the relation of physician to
population is 1/500 or better. In the poorest countries of this world
this goes down to 1/50.000. Just by statistical numbers the chance
for people in poor countries to see a physician is 100 times lower
than in the rich countries. In reality it is even worse: Calling the
chance of an ordinary person in Malawi seeing a physician, as “nil”,
is a fair statement.
To cope with that situation the World Health Organization has
crafted the strategy of task shifting, which means shifting profes-
sional tasks to lay persons. To be quite frank the health professions’
organizations don’t like it. There is a good reason why nurses, mid-
wifes, physiotherapists, dentists, pharmacists and physicians are
trained for years and years, have to be registered, to do continuing
professional development, satisfy quality controls, undergo supervi-
sion, be subject to recertiﬁcation etc.
Do we however, or more importantly, does this world have a choice?
Without the involvement of lay people in health care there will be
no health care for many, if not most people in this world. It is not
the question of whether we do it, rather one of how task shifting is
implemented.
Task shifting, especially when done to save money, may result in the
exodus of even the last health professionals in a respective country
or region. Even worse, a badly managed tuberculosis programme or
a botched anti-retroviral treatment campaign for HIV can turn out
as into a real nightmare and public health catastrophe.
In her contribution Lea Wapner explains the common position
of the health professions to the method of task shifting. It takes a
proactive yet cautious approach, trying to avoid the danger of task
shifting spiralling down the health care systems of poor countries
even more.
Interestingly the concept of task shifting is being driven by the rich
countries, the Europeans, the Canadians and the US, including the
private donor organizations.Their interest in this issue must be un-
der scrutiny as those countries at the same time are the main recipi-
ents of the emigrating health professionals from the poor countries.
One must no be a cynic to see what appears to be the bottom line:
“the rich countries trading in glass pearls for diamonds”.
WMA past president Jón Snædal reports on a ﬁrst WMA seminar on
human resources issues, which are occur in diﬀerent countries in dif-
ferent appearances as “scope of practice”or “skill-mix”issues or some-
times only as an increased in delegation of tasks. The seminar has
been partnered by the Global Health Workforce Alliance (GHWA) a
group consisting of donors and partners in global humanitarian help.
It is attached to the WHO in Geneva. GHWA is now developing
programmes to help poor countries train and retain their workforce
when implementing task shifting. The health professions closely co-
operate with GHWA in their programme for “Positive Practice Envi-
ronments” to improve the workplace for all people working in health
care. A challenge which, by the way, does not only aﬀect the poor
countries – just the opposite As long as the rich countries do not get
their human resource issues in order, the poor countries will continue
to suﬀer from an enormous brain drain.
Dr. Otmar Kloiber, WMA Secretary General
Editorial
44
WMA news
Yoram Blachar
For over 150 years, the existence of health
inequality has been acknowledged world-
wide. However, despite the magnitude of
written documentation accumulated over
this lengthy period, it is only within the last
three decades that countries have been able
to provide conclusive evidence of the social
and economic consequences of inequality
in health and healthcare services. Health
inequalities extract a heavy human cost in
terms of morbidity and mortality rates, as
well as from the moral implications of dis-
crimination, even if unintended, among
populations. They also result in economic
expenses such as rising costs for preventa-
tive healthcare and days lost at work. It is
for these reasons that health inequality is
and should be a top priority for legislation
all over the world.
In 1971, an English family doctor, Julian
Tudor Hart, coined the Inverse Care Law.
This law states that “the availability of good
medical care tends to vary inversely with
the need for it in the population served.”
Dr. Hart came to this conclusion after
working in the coal mining region of Wales.
The signiﬁcance of his declaration lies in his
statement that the quality of services pro-
vided by the health system, and all its com-
ponents, is not in line with the true health
needs of the various population groups, es-
pecially those on the fringes of society.
In Israel, as in many countries, health dis-
parities and inequalities span the ethnic,
socio-economic, geographic and other de-
terminants. Some of these are readily ap-
parent. For example, Arab men and women
have higher mortality rates as compared to
their Jewish counterparts, even when the
rates are standardized according to age.
Despite a large decrease in infant mortality
rates since the founding of the state,the rate
for Arab populations remains twice that of
Jewish populations.Jewish immigrants from
Ethiopia are at a disadvantage in terms of
understanding physician instructions, re-
ceiving quality healthcare and having their
disease and treatment properly surveyed.
Citizens located in peripheral regions have
less accessibility to a number of specialty
services as compared to those living in the
central areas of the country. Other factors
are more insidious, such as the ﬁndings that
low levels of education results in higher
smoking levels among Jewish and Arab
populations. Social factors such as unem-
ployment or social exclusion also impact on
health and the provision of services.
Health inequalities manifest themselves
not only as diﬀerences in morbidity and
mortality rates, but also as diﬀerences in
health risks, accessibility to and usage of
services, provision of quality healthcare, and
treatment outcomes. The main causes for
these inequalities are socio-economic dif-
ferentials, determined by varying levels of
salary, acquired knowledge, occupation and
occupational hazards, housing, exposure to
pollution, infectious diseases, and regional
violence. Many of these elements are a di-
rect result of national governmental poli-
cies,but the healthcare system itself also has
a great inﬂuence on the creation of health
inequalities, particularly in the areas of sup-
plying and ﬁnancing healthcare services. It
is crucial that physicians continue to impact
government so that they devise public poli-
cy that will minimize the inequalities in our
healthcare system. The reasons for health
inequality are complex and include the na-
tional level (governmental policy concern-
ing social inequality in general and health
inequality in particular); the health system
(the Health Ministry, healthcare organiza-
tions, and hospitals); medical professionals;
and the population itself.
In the United Kingdom, national programs
aimed a coping with inequalities in health
and bridging gaps began with The Black
Report, published in 1980. In 2003 a prac-
tical document, Tackling Health Inequalities:
a Programme for Action, was published. In
Sweden, also in 2003, The National Objec-
tives for Public Health in Sweden was pub-
lished and referred extensively to diﬀerences
in Health. In Holland a plan to reduce so-
cioeconomic inequalities in health was im-
plemented in 2001. In the USA, the results
of the Unequal Treatment study appeared
in 2002. In the study, conducted by USA
health institutes, signiﬁcant diﬀerences
were found in medical treatment results be-
tween population groups, according to race
and ethnic background. The Israeli govern-
ment has contributed to eﬀorts to minimize
health inequalities when in 1995 it passed
the National Health Insurance Law. The
intention of this law was to guarantee that
all Israeli citizens are entitled to basic health
care coverage.
As healthcare professionals we must be
aware of these inequalities and not only
take responsibility for any contributions we
might inadvertently make to the problem,
but also advocate on behalf of our patients.
We must provide uniform quality treat-
ment, while remaining culturally sensitive
to our patients’ speciﬁc needs. We must
educate those entering the profession about
this large-scale problem and train them in
speciﬁc ways to reduce the range and extent
of health inequalities.
The Role of the Physician in Combating
Inequalities in Health
45
WMA news
However, actions alone will not lead to
signiﬁcantly minimizing health inequality.
Therefore, comprehensive policy must be
formulated, which will lead to coordinated
activities between the health system and
parallel systems, including the following:
Decision-maker awareness should be in-
creased concerning the grave signiﬁcance
(health, economic and social) for all of the
existing situation.
Medical professional awareness should be
increased concerning the serious implica-
tions of health inequality.
We all need to act in order to:
Prevent the medical outcome of social,•
economic and cultural inequality.
Identify and tackle existing health in-•
equality in order to minimize it.
A multi-annual program must be deter-
mined to meet the deﬁned needs of popula-
tion groups.The diﬀerence in infrastructure
and services between the peripheral and
central regions must be rectiﬁed urgently in
a planned aﬃrmative action process.
Doctors stand in the forefront of providing
medical services to the population. The in-
ability to ﬁnance the required treatment con-
stitutes a digression from the basic principles
of any national medical insurance law.
Healthcare services must be adapted lin-
guistically and culturally to the target popu-
lation,whether in the format of information
provided o the individual and population
groups, in the use of signs in diﬀerent lan-
guages or professional translation rather
than untrained family members, and in sen-
sitivity to the cultural nuances important to
diﬀerent ethnic groups.
Medical professionals should be provided
with knowledge and skills aimed at training
them to work with multicultural populations.
This training must constitute an integral part
of professional studies on all levels (including
medical specialization), especially for those
who are already working in the system.
Our work is not done until everyone will be
able to beneﬁt from quality healthcare ser-
vices, regardless of socio-economic status,
ethnic origin, or locale.
Dr. Yoram Blachar, WMA President
During the last years, three issues have been
discussed inside the WMA in diﬀerent
workgroups, Medical Workforce, Task
Shifting and Prescribing. The General As-
sembly (GA) in Seoul decided to continue
to work on these issues in a seminar with
input from other stakeholders. Further-
more it was decided by the GA to accept
the invitation of the Icelandic Medical As-
sociation to organize the seminar in Reyk-
javik, Iceland in March 2009.The Secretary
of the WMA and the oﬃce of the IcMA
took on the task to organize the seminar.
The idea of this seminar was very well ac-
cepted by the member associations of the
WMA (the NMA´s) as well as by our par-
tners in the Health Service.The three inter-
national associations of health professionals
invited to speak accepted and sent high level
persons to the seminar. These associations
were the International Council of Nurses
(ICN), the International Pharmaceutical
Federation (FIP) and the World Confed-
eration for Physical Therapy (WCPT).
Other stakeholders were the WHO and the
GHWA and the last one agreed to ﬁnance
not only their own representative to attend
but also three representatives from Africa.
The attendance was very good as over 50 repre-
sentatives from all continents participated.The
seminar was held in a new hotel and confer-
ence facilities at the Grand Hotel in Reykjavik.
The Health Minister of Iceland addressed the
meeting at the beginning and the ﬁrst day was
dedicated to input from outside presentations
as well as reports from many diﬀerent NMA´s
Human Resources for Health
and the Future of Health Care
WMA Seminar in Reykjavik (March, 8th
-9th
2009)
46
WMA news
describing their own experience in task shift-
ing and professional collaboration.The second
day was used primarily for the workgroups
which used ideas from the ﬁrst day for their
own work. This was facilitated by the rappor-
teur of the meeting prof.Vivianne Nathanson
from the BMA.
As one of the promoters for this seminar I
am very pleased with the outcome for many
reasons.To work in a seminar like this helps
the members of the WMA to come to con-
clusions in important issues. The WMA
relies entirely on the NMA´s for making
decisions on diﬀerent issues. The discus-
sions are most often taking place in the
standing committees during council meet-
ings or at the GA where the time frame is
tight. The outcome then relies mostly on
the work of those NMA´s which are best
prepared for the issue and others might not
be able to contribute so much. Workgroups
created by the WMA usually do not meet
but rely mostly on the chair of the work-
group to prepare a draft of a document to be
discussed electronically and then at the next
meeting. The electronic method is theoreti-
cally valuable and gives all in the workgroup
the same possibility to participate but in
reality this is not always so. By discussions
on speciﬁc issues in a seminar, the NMA´s
present will then be better prepared for the
ﬁnal decisions made at the following meet-
ing. It is also a pleasure for me to be able to
organize such a seminar in my own country
and give the participants an opportunity to
come to a country that has up to now not
hosted a WMA meeting.Lastly,in my work
inside the WMA I have promoted dialog
with those we have common interests with
or are important recipients of our ideas and
we are many that share this viewpoint. By
that I mean on one hand other health pro-
fessionals and on the other the WHO and
organisations linked to the WHO like the
GHWA. It was a pleasure to witness a suc-
cessful WMA work on very important is-
sues. There will be continuous dialog at the
Council meeting in May in Tel Aviv and
the ﬁnal outcome will hopefully be reached
at the GA in New Dehli next October.
Dr. Jón Snædal , Immediate Past-President
WMA, Icelandic Medical Association
47
WMA news
Tai Joon Moon
The WMA General Assembly Seoul,hosted
by the Korea Medical Association (KMA),
took place over four days, beginning Octo-
ber 15, 2008. Korea was overwhelmed with
pride and honour to welcome the WMA
General Assembly, which was the highlight
event of the year for Korea as it celebrates
its 120th
anniversary of modern medicine
and the centennial of KMA. Modern medi-
cine was ﬁrst introduced to Korea through
medical missionaries from countries such
as Canada and the U.S. Since then Kore-
an medicine has continued its growth and
advancement, including during times of
war and rapid economic development. Ex-
change with the international community
has played a vital role in Korea’s medical
progress.
The General Assembly discussed an agenda
ﬁlled with a broad range of key topics. Of
particular note, a revision of the WMA
Declaration of Helsinki was adopted, as
was a new policy, the WMA Declaration of
Seoul on Professional Autonomy and Clini-
cal Independence. The GA also decided to
devote its next Scientiﬁc Session on Health
and the Environment.
The Declaration of Helsinki on Ethical
Principles for Medical Research Involving
Human Subjects, the focal point of keen at-
tention, was amended after several years of
intensive review to better address recent so-
cial and medical developments. Diﬀerence
of opinion did remain on the use of place-
bos, but, fortunately the Assembly managed
to reach a last minute agreement.
The Declaration on Professional Autonomy
and Clinical Independence was proposed
amidst a huge amount of attention and an-
ticipation from the 90,000 Korean physi-
cians. On behalf of my Korean colleagues,
I express deep gratitude for the unanimous
adoption of the Declaration and the hon-
or of having it named the Declaration of
Seoul. The document includes statements
highly relevant to Korea’s current reality.
Korea began oﬀering universal health in-
surance in 1989. As a result, Koreans have
come to receive medical care without having
to worry about excessive ﬁnancial burdens,
including medicare beneﬁts to the under-
privileged 10% of the population. However,
the payment system has created complicated
relationships among the government, physi-
cians and insurers. In particular, the physi-
cian-patient relationship has suﬀered from
confusion on a number of fronts. Signiﬁcant
sacriﬁce by physicians was required before
the system stabilized and it was our dedica-
tion to patient care that enabled the system
to succeed. However, excessive interference
and regulation by the government has cre-
ated severe friction between the government
and KMA. Some Korean patients, accus-
tomed to traditional medicine, demanded
non-scientiﬁc treatments. For instance, Ko-
rean physicians had to overcome the beliefs
of some patients who strongly believed that
visits to the doctor could not be complete
without a shot. The Seoul Declaration will
provide practical support to Korean phy-
sicians who face such issues daily and will
serve as an important guideline in the future.
I imagine other nations with medical insur-
ance are experiencing similar issues. There
often is a fundamental misunderstanding as
to who exactly is the medical provider. As
physicians, we constantly need to be vigilant
against government or insurer attempts to
take on the role of a provider and interfere
in the physician-patient relationship.
In addition to the main business of the
General Assembly, the Scientiﬁc Session on
Health and Human Rights attracted great
attention from not only physicians but also
the media. Deputy High Commissioner
of the UN High Commission for Human
Rights, Kyung-Hwa Kang, was sent by the
UN Secretary General to speak about glob-
al human right issues related with health.
Other renowned speakers addressed topics
ranging from poverty, human rights abuses
by political suppression, torture, human
rights abuses of prison inmates, the envi-
ronment and human rights and medical ed-
ucation on human rights. During my talk, I
introduced Dr. Oliver Avison, a missionary
doctor who had come to Korea in the late
19th
century and single-handedly corrected
serious social discrimination prevalent at
the time in Korea.Through the true story of
Dr. Avison, I wanted to emphasize the re-
sponsibility we share for human rights and
to demonstrate that we can muster enough
power and inﬂuence to make a diﬀerence if
only we have the will.
I earnestly urge the WMA to continue to
expand our horizons and presence in areas of
traditional interest, such as ethics and phy-
sician-patient rights, as well as other critical
issues,such as human rights and the environ-
ment.Even though physicians alone may not
be able to solve all the human rights prob-
lems around us, the 2008 Scientiﬁc Session
was meaningful in itself for inspiring every-
one to speak up and demand change.
The Seoul General Assembly also adopted
an emergency resolution that reﬂects our
concern as physicians regarding the cur-
rent global economic crisis. The resolution,
which passed unanimously, calls upon all
governments to maintain a high standard
Upon the Completion of the WMA General
Assembly Seoul
48
WMA news
of medical care and not to curb investments
necessary for patient care despite economic
challenges.I applaud the WMA for address-
ing this crisis with a very timely response.
A special seminar on smoking cessation
provided a series of presentations from top
speakers and succeeded in attracting audi-
ences beyond expectations. I hope that the
special seminar has motivated a more ag-
gressive response on the part of the WMA,
national associations and individual physi-
cians to curtail the detrimental health and
ﬁnancial impact of smoking. I promise an
augmented eﬀort by KMA on this front in
the future.
The Seoul General Assembly was attended
by the President, the Prime Minister and
the Minister for Health, Welfare and Fam-
ily Aﬀairs of the Republic of Korea, all
of whom paid high tribute to physicians’
contribution to extended human life and
expressed their gratitude for physicians’ ef-
forts. This should be accepted as their deep
homage to not just KMA but all physicians
around the world – the 8 million colleagues
under the WMA umbrella.
The wide variety of topics on the General
Assembly agenda contributed greatly to en-
riching the outcomes of the meeting. The
sophisticated manner of proceeding and the
high level of participation both left indelible
impressions on Korean members.I express my
deepest gratitude to the WMA leadership –
Dr. Snaedal, Dr. Blachar, Dr. Arumugam, Dr.
Hill and Dr. Kloiber – as well as the leaders
of each country, without whose contributions
the KMA would not have been able to com-
plete this grand mission with such positive re-
sults.KMA now closes its ﬁrst centennial and
prepares for its next. We pledge to continue
our endeavor to become better physicians and
more ethical physicians serving our patients. I
am grateful to share this noble journey with
everyone in the WMA family.
Tai Joon Moon, MD, PhD, President
Emeritus, KMA Chair, KMA
Organizing Committee for WMA
General Assembly Seoul 2008
Leah Wapner
The WMA was faced with a daunting task
at its recent meeting in Reykjavik when
discussing the topic of task shifting. As the
WMA represents over 80 national medi-
cal associations, it is inevitable that diverse
and sometimes opposing views on the im-
plementation of task shifting will arise. For
example, the British Medical Association
encourages the use of multi-disciplinary
teams while the Spanish Medical Associa-
tion is strongly opposed to the implemen-
tation of task shifting in any form. Both
these associations’ views must be taken into
account, along with over 80 others, for the
WMA to adopt a resolution of any scope
on the topic.
The ﬁrst global conference on task shifting
was held in Addis Ababa, Ethiopia in January
2008. Attendance included representatives of
governments, agencies, professional associa-
tions (such as the WMA), education, training
and research institutions.The conference end-
ed with a declaration acknowledging the exist-
ing shortage of healthcare workers and calling
for action to be taken by the various parties
involved. The Addis Ababa Declaration per-
ceived action as necessary in order to address
the human resource constraints obstructing
the implementation of UN Millennium De-
velopment Goals which include: the reduction
of child mortality, improvement of maternal
health and the achievement of universal ac-
cess to HIV and AIDS services by 2010. In
response to the Addis Ababa Declaration, the
World Health Professional Alliance adopted
twelve points on task shifting that were en-
dorsed by the WMA in May 2008.
1) Skill mix decisions should be country-speciﬁc
and take account of local service delivery needs,
quality and eﬀectiveness factors, eﬃciency, the
current conﬁguration of health services and
available resources, as well as production and
training capacity, and include the health pro-
fessions in decision-making.
Country-speciﬁc guidelines are necessary
for many reasons.The extent of a shortage in
health professionals diﬀers between diﬀer-
ent locales and perspectives for dealing with
shortages also diﬀer. Diﬀerent countries
are faced with diﬀerent health threats, with
some threats being easier to deal through
the use of task-shifted positions than oth-
ers. Additionally, each country has its own
history of the evolution of diﬀerent health
care disciplines. The creation of country-
speciﬁc solutions allow for the maintenance
of the highest level of care.
2) Roles and job descriptions should be de-
scribed on the basis of the competencies re-
quired for service delivery and constitute part
of a coherent, competency-based career frame-
work that encourages progression through life-
long learning and recognition of existing and
changing competence.
Competency is very diﬃcult to deﬁne.
Even if a deﬁnition of competency can be
agreed upon and suﬃcient data is available,
comparing competencies is still a challeng-
Words from Reykjavik on Task Shifting as a
Response to the Global Shortage in Health
Care Providers
49
WMA news
ing feat. However, competency must be
achieved, as it is insuﬃcient to simply staﬀ
health care positions if workers are not able
to provide quality care. Once task shifting
has been implemented, the level of health-
care will deteriorate if healthcare personnel
are not exposed to new advances.
3) There needs to be suﬃcient health profession-
als to provide the required selection, training,
direction, supervision, and continuing educa-
tion of auxiliary workers.
While the implementation of task shift-
ing increases the amount of health workers
available to implement more simple tasks,
task shifting cannot blur the boundaries of
each health discipline. Keeping health dis-
ciplines well-deﬁned will assure that the ed-
ucation, progression and deﬁnition of new
areas for expansion of the profession are in
the hands of the correct individuals. It is the
task of physicians to determine the require-
ments for task shifted positions as they are
currently the ones performing these tasks.
4) Regulations for assistive personnel and
task-shifting need to be set with the professions
involved. It should be clearly stated who is re-
sponsible for supportive supervision to assistive
personnel. In any case the curriculum develop-
ment, the teaching, supervision and assessment
should always involve the health professionals
from whom the task is being shifted.
The creation and implementation of a prop-
er legal and social framework is necessary to
uphold such regulations.
5) There must be adequate planning and
monitoring to avoid the danger of generating
a fragmented and disjointed system that fails
to meet the total health needs of the patient, of-
fers a series of disconnected and parallel services
that are both ineﬃcient and confusing, and
may lead to de-motivation and high attrition
rates.
6) Assistive personnel need compensation and
beneﬁts that equal a living wage, a safe work-
place and adequate supplies to ensure their own
safety and that of patients. At the same time
they should be expected to work within the code
of conduct of their employer.
7) Deploying assistive personnel will increase
demand on health professionals in at least three
ways:
increased responsibilities as trainers and•
supervisors, taking scarce time away from
other tasks;
higher numbers will be needed to take care•
of the new patients generated by successful
task-shifting;
health professionals will be faced with patients•
who have more complex health needs (the
simpler cases will be covered by task-shifting)
and thus require more sophisticated analyti-
cal, diagnostic, and treatment skills.
The use of assistive personnel should not be
implemented as a cost-saving measure.New
staﬀ requires adequate compensation.
8) There needs to be credible analysis of the eco-
nomic beneﬁt of task shifting to ensure equal
or better beneﬁt, i.e. health outcomes, cost ef-
fectiveness, productivity, etc. Ongoing evalua-
tion, particularly in skill-mix changes and the
introduction of new cadres and or new models
of care, should systematically consider the im-
pact on patient and health outcomes as well as
on eﬃciency and eﬀectiveness.
Credible analysis is diﬃcult to execute. Inde-
pendent analysis is even more diﬃcult as there
are so many diﬀerent vested interests at play in
the implementation of task shifting. Analysis
must take place over an extended amount of
time as the results of task shifting can rarely be
suﬃciently observed immediately.
9) When task shifting occurs in response to spe-
ciﬁc health issues such as HIV, regular assessment
and monitoring should be conducted on the en-
tire health system of the country concerned. In
particular, quality assessment linked to overall
health outcomes of the population is essential to
ensure that programs are improving the health
of patients across the health care system.
Maintaining focus on the patient is of ut-
most importance when instituting task
shifting.Measurable quality indicators must
be developed to assess an improvement or
deterioration in the level of health. Assess-
ment must be done for both intermediate
and long-term evaluation.
10) Assistive workers should not be employed at
the expense of unemployed and underemployed
health professionals. Task-shifting should be
complemented by fair and appropriate remu-
neration of health professionals and improve-
ment of their working conditions.
The “turf war” issue cannot be ignored. This
issue must be taken into account both for
the profession giving up its practices and for
the profession acquiring additional tasks.
Self-interests of the many diﬀerent players
involved in task shifting must be acknowl-
edged. For example, the World Bank and
national governments have interests in sav-
ing funds.Nurses are interested in acquiring
more responsibilities. Physicians are inter-
ested in transferring responsibilities. With
all these battling interests, it is important to
relay its concern that preserving one’s pro-
fession is legitimate.
11) Where task shifting is meant as a long-
term strategy it needs to be sustainable. If
meant as short term, there needs to be a clear
exit strategy.
12) Assistive workers need to be integrated into
health care delivery systems and treated as part
of the team.
Regardless of existing shortages, the end re-
sult and the most important outcome of task
shifting must be the creation of teamwork.
In conclusion, task shifting remains a topic
which challenges the global medical com-
munity. The Seminar at Reykjavik aided in
clarifying some of the most pertinent issues,
but the World Medical Association is still
faced with the great challenge of creating a
policy which is acceptable to all, or at least
most, its members.
Leah Wapner, Secretary General,
Israel Medical Association
50
Medical Ethics, Human Rights and Socio-medical aﬀairs
Nachiappan Arumugam
There are many requirements for the pro-
vision of eﬀective and responsive health
systems and we all recognise that a criti-
cal ingredient is a suﬃcient and appropri-
ately trained workforce. Currently there is
a growing challenge to maintain the needed
numbers, quality, mix and distribution of
personnel to meet the healthcare needs of
the population The health workforce in-
cludes physicians, nurses, public health
workers, policy makers, administrators,
educators, clerical staﬀ, scientists, pharma-
cists and health managers amongst others.
The myriad of diﬀerent healthcare groups
with overlapping skills and responsibilities
and maldistribution has brought about fric-
tion and disagreements. Various attempts at
developing systems to achieve an amicable
working relationship between the diﬀerent
cadres of workers in the healthcare system
have met with various levels of success.
The conference today on Human resources
for Health and the future of health care in
the world is focusing on some issues per-
taining to task shifting. We have already
heard about the working arrangements in
many countries between healthcare workers,
complementing one another in many areas
while locked in disagreement in other areas.
In this presentation I am going to outline
the development of human resources over
the years in Malaysia and how an external
organisation like ASEAN (Association of
South East Asian Nations) and regional and
international treaties have and might aﬀect
medical human resources in the future.
Task shifting is not a new concept in Malay-
sia; it existed ﬁfty years ago, when Malaysia
obtaineditsindependence.Atindependence,
there were only forty-two primary health
care facilities in the country, and medical
care to the majority of the population was
conﬁned mostly to traditional remedies.
The healthcare facilities that were present
at that time had only a limited number of
doctors and a considerable amount of the
work was delegated to hospital assistants
and midwives. Since then the health care
in Malaysia has notably undergone radical
change through systematic planning and
building of healthcare facilities. The Prima-
ry health care facilities have grown to more
than three thousand, comprising of health,
community and mobile clinics. A range of
comprehensive public health services na-
tionwide is provided, through wide varieties
of clinics and hospitals.
The healthcare system in Malaysia currently
comprises of both a public and a private
sector. The government, committed to the
principles of universal access to health care,
provides both primary health and tertiary
health care to all, for free or at a minimum
cost. The service provided by the govern-
ment is complemented, by a private health-
care sector,which oﬀers a more personalised
and luxury care.Over the last few years with
growing aﬄuence, the demand for private
health care has been escalating and the
number of new private healthcare facilities
has increased rapidly.
Man power planning and training has been
one of the cornerstones of the growth of
the Malaysian health care system. Health
manpower planning has been and is a chal-
lenge in Malaysia as it is in many parts of
the world. Initially there were only a few
training centres in the country and the
manpower needs were supplement by over-
seas trained staﬀ, but steadily the number
of local institutions training workers has in-
creased and the country is nearly attaining
self suﬃciency. Strategic manpower plan-
ning and training was instituted many years
ago to ﬁne tune training to the demands of
the country, but the goal to achieving suf-
ﬁciency in healthcare manpower has been
elusive. The growing number of new medi-
cal facilities, increasing scope of medical
practice and changing world environment
has constantly distorted and outstripped the
number of trained personnel.
There has always been some movement of
doctors and other healthcare workers espe-
cially nurses to and from other countries
without grossly disturbing the total man
power equilibrium. In recent times many
external factors have upset this delicate bal-
ance. Globalisation has made it easier for
healthcare workers to work in other coun-
tries either on a temporary or permanent
basis. It is established that International
migration has risen sharply in the recent de-
cade and has been described as “one of the
deﬁning issues of the 21st
century”. Globali-
sation with rapid universal commercialisa-
tion, the availability of unrestricted infor-
mation and relatively easy travel has fuelled
this evolution This movement of large num-
bers of healthcare personnel from country
to country including Malaysia has caused
uncertainty in the training, employment
and retention of healthcare professionals. In
this uncertain healthcare workers market as
many Malaysians go overseas to work the
country has had to recruit workers from
other countries to run the services here.
The Association of Southeast Asian Na-
tions (ASEAN) is a geo-political and eco-
nomic organization of 10 countries located
in Southeast Asia which was formed on 8
August 1967 by Indonesia, Malaysia, Phil-
ippines, Singapore, and Thailand. Since
then, membership has expanded to in-
clude Brunei, Myanmar, Cambodia, Laos
and Vietnam. These countries have diﬀer-
ent political systems – democracies of dif-
Task Shifting on Health Care
51
Medical Ethics, Human Rights and Socio-medical aﬀairs
fering standards, communist regimes and
monarchies. These countries are at diﬀerent
levels of economic development and their
healthcare standards and availability to the
citizens are grossly diﬀerent. In spite of all
these diﬀerences this grouping is commit-
ted to its aims – the acceleration of eco-
nomic growth, social progress and cultural
development among its members, and has
drawn up many treaties to help move the
agenda forward.
The regional grouping has made the most
progress in economic integration, aiming
to create an ASEAN Economic Commu-
nity (AEC) by 2015. The AEC would have
a combined population of over 560 million
and total trade exceeding US$ 1400 billion.
The foundation of the AEC is the ASEAN
Free Trade Zone (AFTA), a common ex-
ternal preferential tariﬀ scheme to promote
the free ﬂow of goods within ASEAN. The
AFTA is an agreement by the member na-
tions of ASEAN concerning local manu-
facturing in all ASEAN countries. The
AFTA agreement was signed on 28 January
1992. An ASEAN Framework Agreement
on Trade in Services was adopted at the
ASEAN Summit in Bangkok in Decem-
ber 1995. Under AFAS, ASEAN Member
States enter into successive rounds of nego-
tiations to liberalise trade in services with
the aim of submitting increasingly higher
levels of commitments. AFAS is aimed at
substantially eliminating restrictions to
trade in trade in services among ASEAN
countries in order to improve the eﬃciency
and competitiveness of ASEAN services
suppliers.
AFAS provides the broad guidelines for
ASEAN Member Countries to progressive-
ly improve market access and ensure equal
national treatment for services suppliers
among ASEAN countries. All AFAS rules
are consistent with international rules for
trade in services as provided by the General
Agreement on Trade in Services (GATS)
of the World Trade Organisation (WTO).
In fact, liberalisation of services trade under
AFAS shall be directed towards achieving
commitments beyond Member Countries’
commitments under GATS, or known as
the GATS-Plus principle.
MutualRecognitionArrangements(MRAs)
are the more recent development in ASEAN
co-operation on trade in services. MRAs
enable the qualiﬁcations of professional
services suppliers to be mutually recogn-
ised by signatory member countries, hence
facilitating easier movement of profes-
sional services providers in ASEAN region.
ASEAN Member Countries continue to
work on further expanding the negotiations
to cover all sectors and all modes of supply.
The ASEAN Economic Community Blue-
print adopted by the ASEAN Leaders at
the 13th ASEAN Summit on 20 November
2007 in Singapore sets out concrete steps to
be taken to achieve a free ﬂow of services by
2015 with ﬂexibility.MRA on Nursing Ser-
vices signed on 8 December 2006 in Cebu,
the Philippines. MRA on Medical Practi-
tioners, MRA on Dental Practitioners, and
MRA Framework on Accountancy Services
all signed on 26 February 2009 in Cha-am,
Thailand.
Task shifting refers to shifting of tasks from
one cadre of healthcare worker to a lower-
level cadre or shifting tasks to a new cadre.
Though there has not been any recent policy
on task shifting, there is a historical legacy
allowing less specialised health workers to
provide some of the healthcare services.The
provision of healthcare in the remote areas,
especially in the eastern part of the country,
has always been laden with diﬃcult. Gen-
erally para-medical staﬀs that have been
credentialed and registered have played a
crucial role in providing healthcare in these
regions with some amount of supervi-
sion. The involvement of the communities,
through volunteer health workers, has also
helped to extend health services to the re-
mote areas and disseminate public health
matters. The policy of the government is to
train suﬃcient medical personnel to fulﬁl
the manpower needs and this is reﬂected on
the increase from one medical school ﬁfty
years ago to twenty medical schools today
and the establishment of many other train-
ing facilities.
While we are debating the role of diﬀerent
healthcare worker and their responsibilities
lets us also not overlooks how all the new
treaties, groupings, technology and globali-
sation will aﬀect the healthcare worker and
the delivery of healthcare.
Dr. Nachiappan Arumugam,
Immediate Past-President WMA,
Malaysian Medical Association
CPME Subcommittees,Board and General
Assembly met on 13 th
and 14 th
March
2009 in Prague.
The following policy
documents were adopted:
CPME reaction to the Green Paper on the
European Workforce for Health
Although the Green Paper addresses most
of the CPME’s concerns, CPME would
like to highlight some of the issues and put
them higher on the priority list.These issues
are: the scope of the workforce for health,
ageing of the population, sustainability of
health systems, demography and the pro-
motion of a sustainable health workforce,
Public Health capacity, training and man-
aging mobility, global migration of health
workers, impact of new technology, and the
role of health professional entrepreneurs.
In addition to the considerations regard-
ing these issues, CPME wants to steer clear
CPME Board meeting
14th
March 2009 outcomes
52
CPME news
from any healthcare-system discussion and
particularly on their respective advantages
or disadvantages. In the case of entrepre-
neurial stimulation the above mentioned ar-
guments show that a strict equality between
public and private sectors would be needed
in order to achieve the proposed actions.
In its response, CPME identiﬁes several
clear positions that it will submit to the Eu-
ropean Commission for consideration.
CPME reaction to the Communication
from the European Commission on tele-
medicine
Telemedicine can make physical distance
between patients and physicians a less im-
portant factor. Telemedicine can therefore
provide better access to health care to people
in remote areas, improve the quality of life
of chronically ill patients and reduce hos-
pital stays. Subsequently, this will not only
be to the advantage of patients, but also ad-
vantageous for relatives and the health care
sector in general.
Although telemedicine could also enhance
inequity in health care. CPME therefore
calls on health authorities and govern-
ments to ensure that new technology must
be available to all, irrespective of their social
or economic background. Furthermore, it is
also the task of governments to ﬁnd ways to
contain the rising costs of providing health
care and to ﬁnd aﬀordable ways to provide a
reasonable level of care.
The development of telemedicine will most
likely continue to be technological and mar-
ket driven. Health care for the ageing popu-
lation and self-management of chronic dis-
eases will in the near future become a huge
market for health care delivery. CPME
therefore stresses that physicians must have
a central role in the development of tele-
medicine and that the development should
not be driven mainly by industry. Physician
input is needed to ensure that telemedicine
is developed in the best interest of the pa-
tient, as well as to the beneﬁt of the medical
profession.
Legal Control of Tobacco Products
The toll of disease and death caused by the
use of tobacco products as recommended
by their manufacturers is immeasurably
greater than that attributed to the abuse of
any drug which is universally classiﬁed as
« dangerous » and subject to criminal sanc-
tions. Therefore, The CPME calls for the
tobacco manufacturing industry to be given
ten years’ notice of the Committee’s inten-
tion to press for tobacco products to be
classiﬁed as dangerous drugs and controlled
accordingly. The CPME however strongly
believes that smokers and users of other
manufactured tobacco products should not
be incriminated.
Achieving Healthcare information for all
by 2015
The CPME recognises that the availability
of relevant, reliable health information con-
tributes to prevent death and suﬀering and
to increase the eﬃciency of health systems.
The CPME supports eﬀorts to improve the
availability of healthcare information for
professionally isolated healthcare providers
in Europe.
Therefore,the CPME supports HIFA20151
and calls upon other European medical and
health professional organisations and scien-
tiﬁc societies to do the same and to actively
contribute to the international dialogue.
End Water Poverty
In order to address the global crisis in water
and sanitation, CPME joins the End Wa-
ter Poverty campaign2
and urges individual
member associations to do the same.CPME
calls on Governments to establish a Global
1 HIFA2015 is an international campaign and
knowledge network with more than 2000 mem-
bers from 135 countries worldwide. http://www.
hifa2015.org
2 End Water Poverty is an international campaign,
driven by a growing coalition of organisations, call-
ing for immediate action and for water resources to
be protected and shared equitably. http://www.end-
waterpoverty.org
Framework for Action to ensure sanitation
and water for all; and to fulﬁl the commit-
ment made in the EU Agenda for Action
on the Millennium Development Goals.
Mental Health in workplace settings
The CPME recognizes the importance of
mental health in workplace settings and
strongly believes that having healthy work-
ing environments with the right preventive
measures in place will contribute to a drop
in work related mental health problems, a
drop in absenteeism due to mental health
disorders, a drop in accident related to work
rates, an increase in self-conﬁdence and
employee morale in work populations and
employees who are healthy and ﬁt.
The CPME endorses the WMA Declara-
tion of Helsinki
The CPME endorsed the WMA Declara-
tion of Helsinki on Ethical principles for
medical research involving human subjects,
as adopted by the WMA General Assembly
in Seoul, Korea in October 2008.
At its General Assembly meeting in Prague
on 14 March 2009, the CPME elected the
President and Executive Committee for the
period 01/01/2010 to 31/12/2011:
President:• Dr Radziwill, Poland
Vice Presidents:•
Dr Montgomery, Germany
Dr Kubek, Czech Republic
Dr Lemye, Belgium
Dr Pruckner, Austria
Treasurer:• Dr Fjeldsted, Iceland
All CPME Policy documents are available
at: http://www.cpme.eu/policy.php
For more information about CPME, con-
sult our website: http://www.cpme.eu
53
CPME news
CPME representing 2 million physicians,
is delighted that the Members of the Eu-
ropean Parliament have adopted the Cer-
cas Report on the amendment of Directive
2003/88/EC concerning certain aspects of
the organisation of working time.
The European Working Time Directive is
the cornerstone of labour protection in the
EU. Since there is a very strong link be-
tween doctors’ and patients’ health, CPME
welcomes Parliament’s vote. Any amend-
ment to this Directive that would imply a
deterioration of the social conditions and
discrimination of the medical profession
should be rejected.
We therefore congratulate the European
Parliament for sharing their position with
2 million physicians and advocating that:
There should be a maximum average•
working week of 48 hours
All time spent at the premises of the•
employer should be counted as working
time,as it is already recognised by the Eu-
ropean Court of Justice.
CPME celebrates this victory and will con-
tinue the European movement to improve
doctors’ working conditions. We encour-
age the Parliament to keep a ﬁrm stance on
these basic principles towards the Council
during the conciliation phase.
All documents mentioned are also
available directly on CPME website
www.cpme.eu
European Physicians
Congratulate the
Parliament for
Adopting the Cercas
Report
What is the Added Value of EU Health
Policies for National Health Systems?
On 23 April 2009, the European Parliament ENVI Working Group on Health held a
debate on “What is the Added Value of EU health policies for National Health Systems?”
During the discussions, there was a special emphasis on the ﬁnancial crisis and its implica-
tions on the Health Gap between “Old” and “New” Member States.
“First I would like to congratulate the
CPME for having organised this get to-
gether and I hope it will be the start of a
long running initiative.
It is important at EU level to have structured
and competent groups in order to support
health related initiatives and to counterbal-
ance other pressure groups having category
interests opposing our health objectives.
We need a strong representation of patients
and consumers but it is also important to have
by our side the health care providers groups
and ﬁrst amongst them, the physicians.
At political level the many physicians in the
European Parliament can be instrumental
in shaping EU health policies. Who else
but the physicians can advocate for and lead
health actions?
This is even more important at EU level
considering the eﬀorts that are sometimes
required to demonstrate the added value of
health initiatives at EU level.
Indeed the fact that the Member States re-
tain their competences in organising, pro-
viding and funding the provisions of health
care for their citizens should never be a rea-
son for us to disregard the added value we
can bring to their policies due to other EU
speciﬁc ﬁelds of competences but also due
to the huge potential of cooperation which
exists in Europe.
Health is always diﬃcult to promote when
it interferes with economic interests and
private behaviours. Health initiatives could
be seen either to be going against short term
economic gains, or interfering too much
with peoples’ lives.
For all these reasons it is important to be
able to build strong cases for justifying
those health actions where general interest
should prevail.
Living in a media driven society where the
loudest voice seems often to be the right
one, and where unfortunately there still
a lack of active and vocal pro-health lob-
bies, it has became indispensable to advo-
cate, justify and actively promote any public
health initiative.
In the recent past we observed how other
interest groups are organised.
A good example was seen during the recent
discussions on the nutrition proﬁles initia-
tive which should implement the legislation
on nutritional and health claims, where it
was very clear that the « agri and food lob-
by » promoted their ideas loudly, some of
them being good I admit, but most of them
being only in defence of their own sectored
interests.
The voices of consumers, patients and phy-
sicians have not been heard loud enough in
such a context to counterbalance their argu-
ments.
“EU Added-Value in health policies during the ﬁnancial crisis”
Speech by Commissioner Androulla Vassiliou
54
CPME news
More generally in terms of securing public
health objectives, forums like this one today
can help to eﬀectively contribute to creating
a « health » minded network to help achieve
our policy objective of promoting public
health strategies more strongly.
And the promotion of public health strate-
gies will become even more important in a
time of economic crisis.
A key challenge facing Europe and the
world at this moment is to prevent the eco-
nomic crisis spiralling into a health crisis.
We know from past experience that in
times of crisis health outcomes are greatly
aﬀected by changes in the resources avail-
able for health systems.
Many of the human consequences of reces-
sion are becoming apparent – consequences
such as higher unemployment; reductions
in income; and widespread stress and inse-
curity. Economic crisis could also lead to a
food crisis in terms of nutrition and quality
standards.
Many other repercussions may only become
noticeable some years from now – such as
lower productivity and lower labour partici-
pation due to poor health.
Hence it is vital that we reﬂect all togeth-
er upon these challenges and focus our
thoughts on what needs to be done to miti-
gate or prevent a worsening of our public
heath status.
Indeed one of the political consequences of
the current crisis is that it should strengthen
the case for targeted EU actions on health
policy.
I could also take another example where
health systems in EU will be at stake: the
demographic shift in Europe’s population.
The consequences of our ageing population,
will, if nothing is done, have a signiﬁcant
impact on the ﬁnancing of European wel-
fare systems, including healthcare.
One way to relax somehow the pressure
on these systems would be to develop new
technologies at EU level, to increase econo-
mies of scales and to spread and make avail-
able robust health technology assessments
in order to spend the available budget in the
most eﬃcient ways.
In this and in other areas, we need to rec-
ognise that action at EU level can play an
important role to ensure positive synergies
among the Member States through coop-
eration and coordination.
If we consider the existing gaps and diver-
gences between our Member States I be-
lieve that the EU can also assist those states
which aim at modernising their healthcare
and public health schemes, in particular by
helping national health systems to ﬁnd al-
ternative and modern ways of ensuring cost
eﬀectiveness and optimal use of resources.
Another relevant area is that of rare diseases.
Not all Member States have the resources
or expertise to provide eﬀective treatment
for every rare disease.
This is one the reason why the Commission
is promoting the creation of European Ref-
erence Networks on particular conditions.
This aspect is duly taken into account in the
proposal for a directive on patients rights in
cross border health care.
These networks should give patients better
opportunities to gain access to diagnosis
and treatment and will avoid duplication of
eﬀorts by Member State.
The good health of citizens demands long-
term investment. And investment in good
health does not only mean healthcare and
treatment, but also health promotion and
prevention.
In time, this investment will pay oﬀ – in
quality of life, in lower healthcare bills and
in a more productive workforce.
Working with health stakeholders is a key
part of our health strategy. And it is obvi-
ous to me that to respond eﬀectively to the
challenges of the present ﬁnancial crisis we
need their contribution.
I therefore want to engage with networks
of health professionals such as the Standing
Committee of European Doctors (CPME),
to raise awareness about health issues and
help move these issues further up the politi-
cal agenda.
As a body representing all medical doc-
tors in the EU, the CPME is in a unique
position to oﬀer broad expertise in matters
related to medicine and the medical profes-
sion, on which the Commission can build.
I encourage you to be more present, more
vocal in helping me to implement those
policies which our citizens need to beneﬁt
from better health conditions. In your ac-
tions coordination with those of your col-
leagues sitting in the European Parliament
will be essential.
This year is an important year for the Euro-
pean Union – a year to reﬂect on priorities
to be determined at European level, but also
a year when politicians will be absorbed in
trying to tackle the eﬀects of a deep eco-
nomic crisis.
Discussions on the future Community bud-
get post-2013 will start later this year and
continue into next year. Much will depend
on the new Commission and the new Par-
liament to deﬁne the ambition and resourc-
es for future European health policy.
The Commission is making every eﬀort
to help ﬁnd solutions to the problems we
face – to pool resources; to bring people and
institutions together; and to achieve econo-
mies of scale.
I sincerely hope that you will be part of this
eﬀort and help us to strengthen EU health
policy.
You have a central role to play: play it!”
55
CPME news
“I am happy to have the opportunity to
speak about the consequences of the current
economic crises on health care in Eastern
Europe.
The economic crisis in Eastern Europe is
part of the global ﬁnancial meltdown that
can be traced to the real estate crisis in the
United States and the crash of several ﬁnan-
cial pyramids. The result was a break-down
in the ﬁnancial systems of many countries,
including Latvia. In Latvia this crisis was
intensiﬁed by the state’s takeover of the
country’s largest private bank at the end of
2008. In this takeover, the state invested in
the bank an expenditure that corresponds to
one and a half times the annual budget for
health care in Latvia.
These expenses led to a sizable decrease in
the health care budget of Latvia. The cut in
health care occurred despite recommenda-
tions made by the World Health Organi-
zation to avoid compromising health care
during the economical crisis. These rec-
ommendations were documented in state-
ments: the « Impact of the global ﬁnancial
and economic crisis on health » by the Direc-
tor-General of World Health Organization,
Dr. Margaret Chan, in 2008 and “Resolu-
tion on the Economic Crisis: Implications
for Health », adopted by the World Medical
Association General Assembly in 2008.
Since its independence until recently, the
deﬁcit of the Latvian budget never exceeded
3%. The current forecast is that the nation’s
budget deﬁcit could reach a staggering 7 to
10 %. As a result of this deﬁcit, the coun-
try started to cut expenses – it chopped 9%
from the health care budget in December
2008, and another 6% in February, 2009.
We are now faced with the prospect of de-
creasing the health care budget by an ad-
ditional 20% to 40%.
I would like to bring to your attention what
happened in a small African counrty, that
was noted in the world press. Cote d’Ivoire
has one doctor for 6000 inhabitants and
one nurse for more than 2000 inhabitants.
At the same time there are 800 unemployed
doctors in the country. This situation was
caused by directives from the World Bank
and the International Monetary Fund to
decrease the number of state employees.The
number of doctors was lessened, but not the
number of army oﬃcers and civil servants.
It is too early to compare the situation in
Cote d’Ivoire to the predicaments of Latvia,
Lithuania, Hungary
and Romania, the
economic crisis we
are facing raises the
spectre of patients
receiving greatly re-
duced or no health
care services at all.
How did we arrive in
this predicament? I
will take Latvia as an
example and then ex-
pand the discussion.
In the late 1980’s
health care in Soviet
Latvia was regard-
ed as the best in the USSR (which might
not be saying much): maternal and infant
mortality rates were comparable to those
in Western Europe, primary and secondary
health care was good, and other indicators
were also close to Western Europe.
With the dissolution of the Soviet Union,
the communist economic system was re-
placed by a free market economy.The newly
independent and semi- independent states
were confronted with economic breakdown,
high unemployment and social inequality.
Health-wise this manifested itself as de-
pression, alcoholism, high use of tobacco,
poor nutrition, family instability, stress-
related disorders, increased mortality from
cardiovascular diseases,high rates of suicide,
accidents in general and a sharp decline in
the provision of health care.There even was
a term created “transition time losses.” In
Byelorussia, Lithuania, Latvia and Estonia
the life expectancy of men dropped by three
to 3 1/2 years decrease for men and that of
women decreased by 1 1/2 to two years.
In Latvia,as well as other Eastern European
countries, countless changes and reforms
“Economic Crises on Health Care in Eastern Europe”
Speech by Editor-in Chief of WMJ Pēteris Apinis
Commissioner Androulla Vassiliou
Dr. Peteris Apinis, Editor-in-Chief of the World Medical Journal
Dr. Michael Wilks, President Standing Committee of European
Doctors (CPME)
The current co–chairmen of the Health
Working Group Prof. Georgs Andrejevs, MEP
Prof. Victorio Prodi, MEP
56
CPME news
were undertaken. The road was not entirely
smooth, however. In medical care, multiple
new medical establishments developed.
These small institutions competed with each
other, following the dictum of “medicine as
a source of proﬁt”. A typical scene was this:
in a small town – on one side of the street
was a hospital with a new computerized to-
mography unit; on other side of the street
was an out-patient clinic that also needed
computerized tomography to keep up. One
of these devices had been bought by loan,
another – by leasing, so both of them were
acquired under long-term ﬁnancial com-
mitments.
This situation was not unique to health
care: Banks and commerce sectors adver-
tised credits on goods and consumer credit
expanded very quickly in the new national
economic system. In medicine, suppliers
were ready give credit to hospitals and other
health institutions, asking for long-term
paybacks. But at the same time, there was
a decrease in the production industry. Fac-
tories were taken down and housing built.
There was a dramatic price increase in real
estate and a quickly expanding “bubble”that
ﬁnally broke.
In several Eastern European countries,
short-term credits exceed more than 80% of
the budget of the hospitals. Many munici-
palities became insolvent this year because
they took big credits to purchase devices for
their local hospitals. It has been mentioned
in the press that many of the acquired de-
vices bought by Eastern European coun-
tries were overpriced and not adequately
equipped.This raises the concern of whether
corruption played a role in these purchases.
Let us talk about reimbursed medication.
The diﬀerence between reimbursed medi-
cation expenditure in Eastern Europe and
Western Europe is ten fold. Latvia is bud-
geted to spend 42 Euros per capita for reim-
bursed medication (last year it was 48 Eu-
ros). In comparison, in the European Union
the expenditure for medication reimburse-
ment is 350 Euros per capita. In Latvia the
TOTAL expenditure of the state health
care system is only
336 Euros per capita.
Patient payment for
certain services is in-
creased to 75%.
We are now threat-
ened with another
20% cut in the health
budget of Latvia in the
second half of 2009.
This would bring
down the Latvian per
capita health expen-
diture to a mere 269
Euros on average. It
is not surprising that,
according to the Con-
sumer Health Index
prepared by Swedish expert Arne Bjornberg
and Czech Professor Marek Ulrich, Latvia
occupies the last position – number 31.
We may still be ahead of Byelorussia,
Ukraine and Moldova, but to be with them
cannot be the aim for Latvia, a member
state of European Union. In the European
Union public health is measured in terms of
primary health care specialist accessibility,
the number of neglected cases of cancer,the
incidence of heart attacks in diﬀerent age
groups, infant mortality rates, accessibility
of mammography, lost life years, etc. All
these indicators are impaired by the huge
ﬁnancial diﬃculties, as well as bureaucratic
obstacles.
I don’t want to bother you with statistical
data about the concerns of Latvia,the Baltic
States or Eastern Europe. All the statisti-
cal indicators for the health status of the
population are on a strong decline in East
European countries, especially when com-
pared with the health status of people living
in Western European countries.
I would like to say a few words about the
migration of health professionals. Approxi-
mately 10% of our graduates go to work in
Western European clinics during the ﬁrst
year after receiving their medial diplomas.
Another 10% disappear from Latvian pa-
tient care step by step as they continue to
learn, move on to science, to pharmacologi-
cal ﬁrms or research or even worse, into the
business world unrelated to health care.
A major problem for Latvia is the recruit-
ment of doctors and nurses to other West
European countries. In Latvia, at least two
companies constantly work to recruit medi-
cal staﬀ to go to French and English speak-
ing countries as well as to Scandinavia.
Every doctor or nurse who leaves Latvia is
really great loss to the country.Western Eu-
rope takes away our intellectual potential by
oﬀering higher salaries.
In 2006 the European Commission issued
a document: “Health in Europe: strategic
approach.” This marked the starting point
for a new health care strategy. In October
2007 the Commission accepted the White
Paper “Together for Health: A Strategic
Approach for the EU 2008-2013”.
The European Union has decided to give
more political strength to health care. The
EU signiﬁed that Europe had to recognize
citizens’ health as a political, and not only
socio-economic, priority. To ensure the
well-being of European citizens, the impor-
tance of collaboration of European Union
member states in the health care ﬁeld was
delineated as a very important aspect. The
Expenditure for pharmaceuticals for
ambulatory care (EUR per capita) – 2008
Latvia Estonia,
Lithuania
Hungary,
Slovenia,
Cech Republic (average)
EU (average)
57
CPME news
European Union determinated that the
health of European citizens is a common
problem and should be solved in collabora-
tion and not independently.
The Lisbon Strategy sets health as a main
priority in one’s life,so member states should
support health prevention and health care
with eﬀective policies. Even more, there it is
clearly stated that each member state is re-
sponsible for the health status of its citizens.
But, as a ﬁnal consequence this must also
mean that Europe is responsible for health
status of each European citizen. This Lis-
bon document also deﬁnes the fundamental
principles for further development of health
care prevention in Europe.The second prin-
ciple is that the health of each citizen is the
main treasure of each member state and the
whole Union.
The European Union should support ac-
tively – and I mean politically as well as
ﬁnancially – the health care systems in the
new member states.
We need to stop cutting the health cares
systems by 30 % now!
For sick people this support will mean res-
cue for a cancer patient whose treatment
will otherwise no longer be ﬁnanced; it will
mean a rescue for a pneumonia patient who
cannot pay for the antibiotics “out of pock-
et”. And for healthy people it will mean a
boost for the economy. Investing in health
gives a far higher return than all the money
European governments are currently pump-
ing into questionable banks.
How can the European Union help its new
member states, which are struggling? Here
are some concrete suggestions:
We have very little resources to pay for•
outpatient medicines. Thus, many minor
ailments go untreated and become worse,
resulting in hospitalization. The Europe-
an Union could help with medicine com-
pensation for next 2 years by investing 4
billion Euros per year in Eastern Europe
(it is 120 million for Latvia).
Where rural hospitals cannot be main-•
tained, small rural hospitals can be closed
or the number of hospital beds decreased.
However, this creates social tension, loss
of jobs and is not an inexpensive propo-
sition. The European Union can provide
the ﬁnancial means to be able to deal with
these situations.
The European Union could help to pro-•
vide suﬃcient transportation for emer-
gency and non-emergency patients, es-
pecially if health care facilities become
inaccessible when local facilities close.
Medical professionals in Eastern Europe•
are interested in treating patients from
Germany, the United Kingdom and other
European countries. High quality care
can be oﬀered inexpensively in the new
member states of the European Union
if health care facilities are expensive or
strained in your home country. It would
be good to erase national boundaries for
health care in the European Union.
In conclusion, I appeal to You, the honour-
able Commissioners and you –honourable
members of the European Parliament, to
direct your attention to problems of health
care in East Europe and to support the de-
velopment of appropriate policy and the
necessary ﬁnancial means. Maintaining
health of the people is not a cost, but rather
a solid investment. In these times this may
be the only investment that for sure will pay
oﬀ. Don’t miss this opportunity.
Without your attention and eﬀorts the
health care situation in East Europe, es-
pecially in the rural areas, will further de-
teriorate and put the lives and the health of
many people in those regions at risk.
Thank you for giving me the opportunity
to report how the current economic crisis
in Eastern Europe has aﬀected health care
in your new member states. I hope this will
encourage you to act.”
The 2nd
annual Hospice and Palliative Care
in Developing Countries conference is be-
ing held in Fresno, California, USA. UCSF
Fresno auditorium, Friday, September 18 &
Saturday, September 19, 2009. Representa-
tives from South America,Africa,S.E.Asia,
and North America will be presenting. We
are reaching out to medical professionals
that may wish to attend, and to those that
may be interested in exhibiting sponsorship
opportunities.
Our objectives are to:
Understand how diﬀerent cultures view•
death and dying;
Recognize volunteer, educational, and•
partnership opportunities in developing
countries;
Identify factors inﬂuencing healthcare ac-•
cess rural vs. urban;
Learn the complexity and magnitude•
of treating HIV/AIDS in children and
adults suﬀering from TB, Dysentery,
Cancer, Malaria, and malnutrition;
Understand WHO pain management•
protocols and compounding end of life
medications
Understand ELNEC International’s in-•
ﬂuence in developing countries.
Further information, including ﬂyers which
could be distributed, can be obtained by
contacting Nancy Hinds at nancy@hind-
shospice.org or Jill Huﬀ
Jill Huﬀt, Community Development
Coordinator, Hinds Hospice
www.hindshospice.org
The 2nd
Annual Hospice and Palliative
Care Conference
58
Medical Ethics, Human Rights and Socio-medical aﬀairs
James Appleyard
Around 10 million children worldwide un-
der the age of 5 die every year according
to recent statistics from the World Health
Organisation. Many of these deaths are
from treatable conditions, the most com-
mon of which is pneumonia. Others in-
clude diarrhoea,, malnutrition, malaria, and
HIV AIDS. Few countries are on track to
achieve WHO Millennium Developmental
Goal (MDG) No 4, which aims to reduce
by two-thirds, between 1990 and 2015, the
mortality of children under 5 years [1].
Even though eﬀective interventions exist,
these may entail the use of essential medi-
cines, which are not available in dosage
forms for children, particularly in low and
middle income countries. Lack of the avail-
ability of these essential interventions has
been identiﬁed as a major reason for coun-
tries not making adequate progress towards
their MDGs.
It is essential to increase awareness of the
problem, implement known eﬀective inter-
ventions and understand how to be more ef-
fective in achieving progress through audit
and research.
Furthermore Physicians in all countries are
taking signiﬁcant risks when they treat chil-
dren with medications that may have not
been adequately tested for their eﬃcacy and
safety during childhood [2].Such treatment
decisions have to be taken in everyday clini-
cal practice. They tend to be based on trial
and error from the physicians’ personal ex-
perience, advice from colleagues, anecdotal
reports from the literature and extrapola-
tions from adult studies. In addition, medi-
cation errors are a constant hazard in paedi-
atric clinical practice. Continuous changes
of the dosage regime that are necessary dur-
ing a child’s growth and development make
the calculation of the correct dose for each
child diﬃcult. The frequent use of oﬀ-label
medicines with extemporaneous formula-
tions or physician or nurse-made manipula-
tions provide optimal conditions for these
medication errors [1].
Ingredients or excipients for improving
solubility, sterility and the taste of children’s
medicines may also cause toxicity (e.g. ben-
zyl alcohol and diethylene glycol). Severe
adverse drug reactions in children are not
always fully reported. Some of the most
dramatic examples of these are the apnoea
caused by too large a dose of phenobar-
bitone, pethidine and prostaglandin, convul-
sions following the administration of theo-
phylline and hepatic failure associated with
high doses of paracetamol (acetaminophen).
Recognising these signiﬁcant risks in the
care of their patients, practicing pediatri-
cians, particularly in the USA, pressed for
changes in the regulation of medicines for
children. In 1996, the American Academy
of Pediatrics (AAP) [3] reported that only
a small fraction of all drugs and biological
products marketed in the U.S. at that time
had had clinical trials performed in paediat-
ric patients. A majority of marketed drugs
are not labeled for use in paediatric patients.
The AAP also pointed out that many drugs
used in the treatment of both common
childhood illnesses and more serious condi-
tions carried little information in the labels
about use in paediatric patients.
In order to address these inadequacies, the
Food and Drug Administration (FDA)
published (http://www.fda.gov/) regulations
that ensure that manufacturers speciﬁcally
examine the drugs’ eﬀects on children if the
medications are to have clinically signiﬁ-
cant use in children. Paediatric research has
since been encouraged by the paediatric ex-
clusivity provision of the ensuing Food and
Drug Administration Modernisation Act
of 1997. This extended patent protection
to give pharmaceutical companies an addi-
tional six months of marketing exclusivity if
they do studies in children requested by the
FDA. The FDA’s “pediatric rule” required
paediatric studies under certain circum-
stances [4].
In January 1997 the National Institute of
Health in the United States, a major funder
of clinical research worldwide, developed
the policy that children (deﬁned as individ-
uals under the age of 21) must be included
in all human subjects research, conducted
or supported by the NIH, unless there are
scientiﬁc and ethical reasons not to include
them.
In the European Union, the Council re-
solved in 2000 to set their objectives for reg-
ulation on medicinal products for pediatric
use, which aimed to stimulate research into
and to increase the availability of medicines
for children [5]. Draft regulations were
consulted upon in 2004, which proposed
the establishment of a European Paediatric
Board with the European Medicines Evalu-
ation Agency, that all new medicines should
have a paediatric investigation plan with a
six month extension in patent term, and a
new system of granting paediatric use mar-
keting authorizations (PUMAs) for existing
products. These regulations took eﬀect in
2006 and have already had a positive eﬀect
on promoting research in Europe (http://
ec.europa.eu/enterprise/pharmaceuticals/pae-
diatrics/medchild_en.htm).
Clinical Research on Children
An ethical imperative
59
Medical Ethics, Human Rights and Socio-medical aﬀairs
The WHO publication Child Health Re-
search – a foundation for improving Child
Health [6] asserts that “Child health re-
search must address the leading causes and
determinants of morbidity and mortality at
diﬀerent stages of a child’s development and
identify and implement interventions that
address these causes.” Six main areas for re-
search are identiﬁed:
Descriptive epidemiology and burden•
of disease: To describe the scale of the
problem and identify the causes of child
illness and death in diﬀerent communi-
ties;
Aetiology and mechanisms of disease• :
To understand the determinants of child-
hood disease;
Development of interventions• : To de-
sign the most appropriate strategies to
improve child health
Impact and evaluation of intervention• :
To measure the eﬀect of the implemented
strategies including new medications and
raise new research questions;
Health systems• : To increase the eﬀec-
tiveness of child health interventions and
services;
Health policy• : To analyse retrospectively
and monitor prospectively the scaling up
of child health and nutrition interven-
tions.
There are currently several layers of “protec-
tions” for child subjects in clinical research.
The regulatory oversight available in each•
country.
Speciﬁc guidance, e.g., I.C.H. Good•
Clinical Practice – in the absence of com-
pliance with such guidance, most ethical
pharmaceutical companies will not con-
duct a clinical trial [6, 7, 9].
Professional ethical codes of practice•
such as the Declaration of Helsinki [8]
provide the external governance of medi-
cal researchers, who individually need to
internalise the principles to form their
professional conscience – an essential in-
ternal governance.
Establishment of local research eth-•
ics committees and institutional review
boards in the USA which provide essen-
tial ethical scrutiny by their professional
and lay membership.
No clinical research project should proceed
without the informed consent of parents
and consent/assent of the child.
In my view it has now become an ethi-
cal imperative, in the words of the Ethics
Committee of the Conference of European
Specialists in Paediatrics [5] that “Children
should share in the beneﬁts from scientiﬁc
research relevant to their individual age-
related health needs.”
Although FDA, the European Commission
and WHO have brought a new emphasis on
research on drug development for children,
there remains a reluctance to include chil-
dren in this research and especially in clini-
cal trials.There are several reasons for this:
Because of a child’s increased vulnerabil-•
ity,there is an understandable parental re-
luctance to add any risk to their children’s
welfare;
Children have diﬀerent physiological,•
psychological and pathogenic features oc-
curring at the diﬀerent ages and stages of
their growth and development from the
premature newborn infant through ado-
lescence;
Risks to child subjects are increased both•
in the short and long term;
Because of the complexity, high cost and•
relatively low ﬁnancial return, pharma-
ceutical companies reluctance to invest in
this ﬁeld;
And importantly,outside North America,•
Europe and Japan there is a lack of uni-
versal ethical and regulatory guidance for
researchers and sponsors upon which pa-
rental trust depends.
Every child and young person under eigh-
teen has rights and responsibilities that are
protected by the United Nations Conven-
tion on the Rights of the Child (UNCRC).
The Convention was adopted by the United
Nations General Assembly in 1989 and has
been ratiﬁed by 191 out of 193 countries,
territories and states, making it a truly glob-
al bill of rights (see note.) UNICEF uses
the UNCRC as a framework for its work
for all the world’s children.
But there is a lack of universal ethical guid-
ance. The WMA’s current initiative is seeks
to redress this. Families with children need
to understand the need for clinical research,
have conﬁdence in the research process (the
research protocols), and trust those who
conduct research on their children – ex-
perienced paediatric researchers and their
teams
Codes of professional ethics have been de-
veloped. Following the original Declara-
tion of Helsinki in 1964, which did not in-
clude any reference to the speciﬁc needs of
children, the Belmont Report in the United
States highlighted three ethical principles –
respect for persons (autonomy), beneﬁcence
and justice. Recent publicity about adverse
events in clinical trials has heightened pub-
lic anxiety and revealed the serious failures
related to issues of non malfeasance, hon-
esty and transparency.
These are underpinned in my view by seven
core ethical principles [9], namely
Autonomy•
Beneﬁcence•
Non malfeasance•
Fidelity•
Truthfulness•
Conﬁdentiality•
Justice•
These principles need to support the state-
ments in medical professional ethical codes
and codes of practice. They should be inter-
nalized to form the medical conscience of
the physician and physician researcher upon
which the trust by children and their fami-
lies can be built.
The recently revised WMA Declaration of
Helsinki (2008) encompasses these princi-
ples. The Declaration is the only universal
guide to medical ethical practice in all the
nations of the world Child subjects, how-
ever, need special protections beyond those
important general principles that apply
to all research subjects [8]. In the revised
60
Medical Ethics, Human Rights and Socio-medical aﬀairs
Declaration, children are included under
the safeguards required for “incompetents”
as is illustrated by the relevant paragraphs:
11, 12, 27 and 28.
Paragraph 11: For a potential research sub-
ject who is incompetent, the physician must seek
informed consent from the legally authorized
representative. These individuals must not be
included in a research study that has no likeli-
hood of beneﬁt for them unless it is intended to
promote the health of the population represent-
ed by the potential subject, the research cannot
instead be performed with competent persons,
and the research entails only minimal risk and
minimal burden.
Paragraph 12: When a potential research sub-
ject who is deemed incompetent is able to give
assent to decisions about participation in re-
search, the physician must seek that assent in
addition to the consent of the legally authorized
representative. The potential subject’s dissent
should be respected.
Paragraph 27: For a potential research sub-
ject who is incompetent, the physician must seek
informed consent from the legally authorized
representative. These individuals must not be
included in a research study that has no likeli-
hood of beneﬁt for them unless it is intended to
promote the health of the population represent-
ed by the potential subject, the research cannot
instead be performed with competent persons,
and the research entails only minimal risk and
minimal burden.
Paragraph 28. When a potential research sub-
ject who is deemed incompetent is able to give
assent to decisions about participation in re-
search, the physician must seek that assent in
addition to the consent of the legally authorized
representative. The potential subject’s dissent
should be respected.
The general wording of the Declaration of
Helsinki [8] does not reﬂect the integrity and
relative autonomy of an “incompetent”person
such as a child. Children diﬀer from adults
biologically, with their increased vulnerability,
age speciﬁc needs with gradual maturation,
and growth and development potential.
Then there is the key issue of risk. The Dec-
laration of Helsinki insists that the risk to
any subject who lacks competence is only
“minimal.” Yet in practice there is of ne-
cessity a hierarchy of risk for children that
needs to be assessed in relation to the seri-
ousness and severity of any clinical condi-
tion. Children and their families must be
conﬁdent that the necessary safeguards
related to the risk taken by their child are
in place. This underpins the trust in their
physician researcher.
The WMA Declaration of Ottawa on the
Right of a Child to Healthcare (1998) in-
cludes a short protective sentence on Re-
search under the General Principle 4: “to
protect every child from unnecessary diag-
nostic procedures, treatment and research.”
In order to both promote yet protect chil-
dren in medical research, a proposed State-
ment on “Ethical Principles for Medical
Research on Child Subjects” was referred
by the Associate Members to the WMA
Council at the General Assembly in Co-
penhagen in 2007. The Council decided to
set up a working group to revise the Decla-
ration of Ottawa and include a section on
Research in Children within it. This signiﬁ-
cant revision is now out for consultation.
There needs to be clear statements on the
ethical principles that ﬂow from the fact
that children involved in research need spe-
cial protection. Each statement that follows
is both self standing and inter related to the
others.
Scientiﬁc necessity
There must be a scientiﬁc necessity for•
any research to be undertaken on chil-
dren, i.e., children should not be enrolled
in a clinical investigation unless abso-
lutely necessary to answer an important
scientiﬁc question about the health and
welfare of children.
Biomedical studies involving children as•
research subjects should be focused on
the knowledge of epidemiology, patho-
genesis, diagnosis and treatment of dis-
eases or conditions of childhood.
A child should not be involved in research•
that can be carried out on laboratory
models, animal subjects or adult persons.
Physicians must respect the personhood•
and relative autonomy of a child.
Consent
The issues of consent, assent and dissent•
are of key concern in the pediatric age
group which are not speciﬁcally covered
by the Declaration of Helsinki.
Children are minors who have not reached•
the legal age for self responsible consent.
Informed• consent means the permission
of the child’s parents or legal represen-
tative for the participation of their child
in a research study, following suﬃcient
information to enable them to make an
informed judgment.
Informed• assent means the agreement of
the child to participate in the research,
following information being provided in
a form understandable to his/her age
Where possible, the consent of both par-•
ents should be sought prior to enrolling a
child in a biomedical research project.
There must be no forced or undue inﬂu-•
ence, ﬁnancial or otherwise on the child’s
decision to participate in the research or
on the parent’s/legal representative’s per-
mission.
The refusal to participate in the research-•
dissent – by a child, if capable, must be
respected.
Risk
Risk is deﬁned as potential harm (real or•
theoretical) or potential consequence of
an action. It may be physical, psycho-
logical, or social, and may be immediate
or delayed. It may vary according to age
groups. Risk should be assessed in terms
of probability, magnitude and duration.
There is thus a need to balance the poten-•
tial direct or indirect beneﬁts to children
with the degree of risk involved in the
research.
Physicians should avoid unnecessary•
risks, discomfort, stress or potential harm
leading to physical, psychological, social,
spiritual impairment
61
Medical Ethics, Human Rights and Socio-medical aﬀairs
Minimal• risk involves routine procedures,
questionnaires, observation and measure-
ments
A minor increase over minimal risk may•
be undertaken when:
– the research is concerned with diagno-
ses and treatment and the direct and
indirect beneﬁts to the child subject
outweigh the known or anticipated
risks involved;
– where the research is likely to yield
justiﬁable generaliseable knowledge
of vital importance about the child’s
disorder or condition, which is of vital
importance for the understanding or
amelioration of the disorder or condi-
tion;
– the research presents a reasonable op-
portunity to further the understanding,
prevention, or alleviation of a serious
problem aﬀecting the health or welfare
of children;
– the research provides the only oppor-
tunity to identify, prevent or alleviate a
rare disease conﬁned to childhood.
Study Protocols
Study protocols and study designs must•
be child speciﬁc and include the scientiﬁc
justiﬁcation for the research.
The performance of a study must be guar-•
anteed to be conducted by experts compe-
tent in childhood diseases and disorders,
empathetic and truly conversant with
children, parents and the legal require-
ments where the interests of the child are
paramount.
Conﬁdentiality
All personal and health related informa-•
tion collected and stored about the child
subject and the family must remain con-
ﬁdential.
Research Ethics Committees
The interests of the child subject should•
always be represented on independent
research ethics committees by members
who are knowledgeable in pediatric,clini-
cal, psychosocial and ethical issues.
These statements should act within the
Declaration of Ottawa as reference ethical
standards for all physicians and physician
researchers throughout the world, against
which they will be judged by their peers.
Each national medical association can de-
rive from them local culturally sensitive
guidelines. With the trust that is earned
when medical researchers act in an ethi-
cal and transparent manner to prevent the
ethical abuses of the past [12] and to plan
for the future [13,14], it is hoped that more
parents will recognize the beneﬁts that re-
search on their children can bring to them
and all children worldwide.
References
1. World Health Organisation. Better medicines
for children: 60th World Health Assembly, Ge-
neva, Switzerland, 14-23 May 2007 [homep-
age on the Internet]. [cited 2009 March 30];
Available from http://www.who.int/gb/ebwha/
pdf_ﬁles/WHA60/A60_25-en.pdf
2. Seyberth HW,Demotes – Mainard J,Wrobel P.
Developing a European framework for research
on children’s medicines. Paediatric Nephrology
2005; 1537-1540.
3. Unapproved uses of approved drugs: the phy-
sician, the package insert, and the Food and
Drug Administration: subject review. American
Academy of Pediatrics Committee on Drugs.
Pediatrics 1996; 98(1): 143-5.
4. Additional Safeguards for Children in Clini-
cal Investigations of FDA-Regulated Products.
Food and Drug Administration. 21 CFR Parts
50 and 56, 2007.
5. Ethical principles and operational guidelines
for good clinical practice in paediatric research.
Recommendations of the Ethics Working
Group of the Confederation of European Spe-
cialists in Paediatrics (CESP). Eur J Pediatr
2004 Feb; 163(2): 53-7.
6. World Health Organisation. Child health re-
search – A foundation for improving child
health. 2002.
7. Clinical Investigation of Medicinal Products in
the Paediatric Population. Guideline for Good
Clinical Practice. Food and Drug Administra-
tion, 2000.
8. Clinical Investigation of Medicinal Products
in the Pediatric Population. ICH Harmonised
Tripartite Guideline. Food and Drug Admin-
istration, 2000.
9. World Medical Association Declaration of
Helsinki: ethical principles for medical research
involving human subjects [homepage on the
Internet]. [cited 2009 March 30]; Available
from https://www.wma.net/e/policy/b3.htm
10. Appleyard WJ. Who cares?: the Declaration of
Helsinki and The Conscience of physicians.Re-
search Ethics Review 2008; 4: 106-111.
11. World Medical Association Declaration of Ot-
tawa on the rights of the child to health care
[homepage on the Internet]. [cited 2009 March
30]; Available from https://www.wma.net/e/
policy/c4.htm
12. Krugman S. Experiments at the Willowbrook
State school. Lancet 1971; 1(7706): 966-7.
13. Choonara I. Regulation of drugs for children in
Europe. BMJ 2007; 335(7632): 1221-2.
14. Sammons HM, Gray C, Hudson H et al. Safety
in paediatric clinical trials – a 7-year review.
Acta Paediatr 2008; 97(4): 474-7.
Note
The 1989 United Nations Convention on the
Rights of the Child (CRC) is a comprehensive
human rights treaty which enshrines speciﬁc
children’s rights in international law.These rights
deﬁne universal principles and standards for the
status and treatment of children worldwide.
Human rights are founded on respect for the
dignity and worth of each individual, regard-
less of race, gender, language, religion, opinions,
wealth or ability and therefore apply to every
human being everywhere.
The Convention on the Rights of the Child is
presently the most widely ratiﬁed international
human rights treaty – all UN member states
except for the United States and Somalia have
ratiﬁed the convention.
In addition, the CRC is the only international
human rights treaty which includes civil,politi-
cal,economic,social and cultural rights,and sets
out in detail what every child needs to have for
a safe, happy and fulﬁlled childhood. It is the
most complete statement of children’s rights
ever produced and has 41 substantive articles.
James Appleyard, MD FRCP
FRCPCH,Children’s Physician
President of the WMA (2003/2004)
62
Medical Ethics, Human Rights and Socio-medical aﬀairs
Petra A. Thürmann
Background – gender-speciﬁc
diﬀerences in physiology, aging
population and social aspects
The terms sex and gender are frequently
used and also frequently misunderstood
in medical science. Whereas sex relates to
the biological concept, gender includes so-
cial background, culture and history [1].
However, it is not always possible to make
a clear distinction between these aspects of
life, since social behaviour may have an in-
ﬂuence on biological aspects. For example,
smoking results in enzyme induction and
thereby explains diﬀerences in drug me-
tabolism. In this articles, the terms sex and
gender will be used as appropriately as pos-
sible, keeping in mind the aforementioned
considerations.
It is a widely acknowledged fact that gen-
der diﬀerences do exist in relation to the
frequency, perception and peculiarities of
symptoms and diseases, with myocardial
infarction being one of the most promi-
nent and typical examples [2]. Due to dif-
ferences in the physiology between sexes,
diﬀerences in drug absorption, distribution
and metabolism can be assumed and will be
addressed in this article. More over, physi-
ological sex diﬀerences on the level of re-
ceptors and enzymes result in variances in
drug eﬀects, eﬃcacy and safety proﬁle.
The following example highlights the in-
terplay between pharmacology, epidemiol-
ogy and society: in the German Network
of Regional Pharmacovigilance Centers,
adverse drug reactions (ADRs) resulting in
hospitalisation are documented [3].Women
are at least twice as likely as men to suﬀer
from severe dehydration and electrolyte
disturbances [4]. One explanation is the
higher prescribing frequency of these drugs
to women, as well as the fact that there are
more aged women than men. In addition,
animal experiments show a higher sensitivi-
ty of female rats to thiazide and loop diuret-
ics when compared to male animals [5,6].
These observations stimulated further re-
search revealing pronounced sex diﬀerences
in the pharmacokinetics, for example, of
torasemide, explaining stronger treatment
eﬀects [7]. As a conclusion, the epidemio-
logical observation can only be explained by
a combination of sex and gender aspects.
Sex-speciﬁc diﬀerences in
pharmacokinetics
Due to sex diﬀerences in body weight, dis-
tribution of water,muscle and fat,diﬀerenc-
es in the pharmacokinetics of drugs can be
expected. The most relevant diﬀerences are,
at present, known for drug metabolism, es-
pecially via the cytochrome P450 enzymes,
which are responsible for major metabolic
pathways.The most frequently involved en-
zyme is CYP3A4, which is expressed to a
higher percentage in female than male liv-
ers [8]. Substrates of this enzyme such as
methylprednisolone, midazolam, nifedipine
und verapamil are therefore eliminated
somewhat faster in women when compared
to men [9]. The betablocker metoprolol is
mainly metabolised via CYP2D6. Follow-
ing a 100 mg dose, women exhibit 40 %
higher plasma levels than men and an ap-
proximately two-fold higher area under the
concentration/time curve (AUC) [10]. This
results in more pronounced eﬀects on blood
pressure and heart rate. Women suﬀer more
frequently than men from serious ADRs
following betablockers metabolised via
CYP2D6 (metoprolol, propranolol, carve-
dilol, nebivolol). For those betablockers that
are independent of that enzyme no sex dif-
ferences occurred [11]. Since betablockers
in daily practice are carefully titrated, these
diﬀerences go in most cases unnoticed and
become obvious only after gender-sensitive
statistical evaluation of databases.
The enzyme CYP1A2 metabolising, for ex-
ample, theophylline and caﬀeine, exhibits
a slightly lower activity in women than in
men, resulting in approximately 35 % high-
er plasma levels of clozapine in comparison
to men. Likewise, plasma levels of the anti-
depressants ﬂuvoxamine and sertraline are
70 – 100 % and 50 – 70 % higher in female
than in male patients, respectively [12].
Sex-speciﬁc diﬀerences occur within other
metabolic pathways as well [13]. A remark-
able ﬁnding in cancer chemotherapy may
be used for illustration: 5-ﬂuorouracil is
metabolised more slowly in women than in
men [14], resulting in approx. 25 % higher
plasma levels associated with a signiﬁcantly
higher toxicity during chemotherapy in pa-
tients with colorectal cancer [15].
Sex, gender and diﬀerences
in eﬀects of drug therapy
As already shown in the introductory ex-
ample, pharmacodynamis play a major – al-
though not well-studied – role in sex-diﬀer-
ences of drug therapy. In patient-controlled
analgesia, men required 40 % higher mor-
phine doses than women to control pain
following major abdominal surgery [16].
In general, women show a greater response
than men to kappa-opioids, e.g. pentazo-
cine, and they more frequently experience
Gender-speciﬁc Diﬀerences in
Pharmacotherapy
63
Medical Ethics, Human Rights and Socio-medical aﬀairs
opioid-associated side eﬀects such as vom-
iting and respiratory depression [17].
With regard to psychotropic drugs, one
should keep in mind that depression is
more frequently diagnosed in women and
symptoms are diﬀerent between genders
[18]. Besides the already-described diﬀer-
ences in pharmacokinetics of psychotropic
drugs, pre-menopausal women especially
tend to respond better to selective sero-
tonin-reuptake-inhibitors (SSRI) than to
tricyclic antidepressants or norepinephrine-
reuptake-inhibitors [19]. Interestingly, re-
sponse of post-menopausal women seems
to be comparable to men [20].
The most extensively studied medical spe-
cialty with respect to sex and gender is the
cardiovascular ﬁeld. Acetylsalicylic acid
(ASS) given for primary prevention of
myocardial infarction does not reduce these
events in women when compared to men,
but lowers the risk for stroke signiﬁcantly –
by 17 %; only women above the age of 65
years beneﬁt from primary prevention with
ASS [21]. However, in secondary preven-
tion both sexes show comparable eﬃcacy
with respect to cardiovascular morbidity
and mortality [22].
The therapeutic beneﬁt of cardiac glyco-
sides seems to be rather limited in women,
as shown by a retrospective analysis of the
DIG trial [23]. However, cardiac glycosides
are still widely prescribed and an analysis of
German ADR-data showed that more than
two-thirds of all serious ADRs related to
these drugs occur in women. In about 90 %
of these ADRs the low body weight and the
slow elimination rate of frail elderly women
has apparently not been considered [24].
Even in oncology sex and gender-diﬀerenc-
es may appear. In a retrospective analysis of
227 patients (80 females) with non-small-
cell lung cancer receiving chemotherapy
with carboplatin and paclitaxel, remarkable
diﬀerences appeared for tumor type, treat-
ment response and overall survival. Be-
neath numerable considerations one aspect
seems noteworthy: 83 % of male patients
were smokers and only 24 % of the female
patients. As shown by molecular pathol-
ogy, adenocarcinoma of smokers exhibit
a certain RAS-mutation, whereas tumors
of non-smokers are more likely to develop
mutations in the epidermal growth-factor
(EGFR) signalling pathway. This may re-
sult in malignancies with diﬀerent prog-
ress characteristics and diﬀerences in the
response to drugs such as geﬁtinib, which
inhibits the EGFR-tyrosine kinase [25].
Women experience more
side eﬀects than men
The higher reported rate of side eﬀects in
women may be a result of the higher likeli-
ness to talk with their doctors and the higher
drug consumption of females. However, the
observed frequency of ADRs per 10.000 pa-
tient-months is higher in females compared
to males across all age groups,irrespective of
drug consumption [26]. It remains unclear
why women report more ACE-inhibitor-
associated cough than men [27] or more
frequently develop cutaneous reactions to
nevirapine [28]. It has been demonstrated
in animal experiments [29] and epidemio-
logical studies that females have a higher
risk for QT-prolongation when compared
to males, irrespective of drug class and in-
dication [30, 31]. Even diﬀerences detected
in women during the menstrual cycle could
be demonstrated [32]. It should be noted
in this context, that QT-prolongation is an
ADR that resulted in market withdrawal or
restriction of use for numerous drugs such
as astemizole, terfenadine, grepaﬂoxacin,
cisapride and budipine.
Treatment with neuroleptics may lead to
hyerprolactaemia and other metabolic dis-
turbances, which occur more frequently in
female than in male patients and increase
the risk for osteoporosis particularly in fe-
males [33]. Since osteoporosis in general is
a problem more strongly related to the fe-
male sex, potential pro-osteoporotic side ef-
fects warrant closer surveillance in women.
In a randomised, controlled trial compar-
ing metformin, glyburide and rosiglitazone
over 4 years, the number of fractures under
rosiglitazone was twice as high as in the
other treatment groups (5.1 %, 3.5 % and
9.3 %, respectively) in female study par-
ticipants – in male patients no diﬀerences
were seen in this regard [34]. Rosiglitazone
given over 14 weeks to post-menopausal
women reduced bone density measured at
the proximal femur by 1.9 % in comparison
to placebo with 0.2 % (p = 0,003) [35].
Opportunities for research –
actions required
There are numerous indicators suggestive
of sex- and gender-speciﬁc diﬀerences in
pharmacotherapy. Particularly the accu-
mulation of side eﬀects in women should
generate research questions considering sex
and gender eﬀects. Even today, women ap-
pear to be underrepresented in clinical tri-
als investigating eﬃcacy and safety of new
drugs and results are not presented in a sex-
sensitive manner [36,37]. Trials submitted
to the US Food and Drug Administration
between 1995 and 1999 were analysed with
respect to sex-distribution: approximately
25% of trial participants were female and
during phase II and III women were ap-
parently equally represented [38]. However,
this relates only to those trials, where the
sex of participants was recorded: in a con-
siderable number of studies this was not the
case, despite eﬀectual guidelines. A recent
evaluation of the European Agency EMEA
revealed that in some indications women
were not enrolled in clinical trials accord-
ing to the expected female prevalence for a
given condition investigated [39].
In conclusion, pharmacokinetic diﬀer-
ences between sexes tend to be small, but
may result in higher rates of side eﬀects in
women. The simple approach of consider-
ing body weight and renal function (espe-
cially in frail elderly women) before each
prescription could contribute markedly to
safety of drug therapy in males and females
as well. Complex sex and gender diﬀerences
in pathophysiology and pharmacodynam-
ics remain obscure for many symptoms and
conditions and ﬁndings are often obtained
by chance and lead to surprise.
64
Medical Ethics, Human Rights and Socio-medical aﬀairs
Concerning clinical research, some aware-
ness of the relevance of sex and gender has
been achieved, however stringent follow-up
and transfer of existing data into medical
practice is still in its infancy.
The author reports no conﬂict of interest
References
Kim JS, Nafziger AN. Is sex or is it gender? Clin1.
Pharmacol Ther 2000;68:1-3.
Patel H, Rosengren A, Ekman I. Symptoms in2.
acute coronary Syndromes: does sex make a dif-
ference? Am Heart J 2004; 148: 27-33.
Schneeweiss S, Hasford J, Göttler M, et al. Ad-3.
missions caused by adverse drug events to internal
medicine and emergency departments in hospi-
tals: a longitudinal population-based study. Eur J
Clin Pharmacol 2002;58:285-291.
Thürmann P, Janhsen K, Werner U, et al. Sex-dif-4.
ferences in the rate of adverse drug reactions asso-
ciated with diuretics. Düsseldorf: German Medi-
cal Science GMS Publishing House; 2008 (http://
www.egms.de/en/meetings/gaa2008/08gaa11.
shtml).
Chen Z, Vaughn DA, Fanestil DD. Inﬂuence of5.
gender on renal thiazide diuretic receptor den-sity
and response. J Am Soc Nephrol 1994;5:1112-
1119.
Brandoni A, Villar SR,Torres AM. Gender-relat-6.
ed diﬀerences in the pharmacodynamics of furo-
semide in rats.Pharmacology 2004;70:107-112.
Werner D, Werner U, Meybaum A, et al. Deter-7.
minants of steady-state torasemide pharmacoki-
netics: impact of pharmacogenetic factors, gender
and angiotensin II receptor blockers. Clin Phar-
macokinet. 2008;47:323-332.
Wolbold R, Klein K, Burk O, et al. Sex is a ma-8.
jor determinant of CYP3A4 expression in human
liver. Hepatology 2003;38:978-988.
Cotreau MM, Moltke LL, Greenblatt DJ. The9.
inﬂuence of age and sex on the clearance of cyro-
chrome P450 3 A substrates. Clin Pharmacokinet
2005;44:33-60.
Luzier AB, Killian A, Wilton JH, Wilson MF,10.
Forrest A, Kazierad DJ. Gender-related eﬀects
on metoprolol pharmacokinetics and pharmaco-
dynamics in healthy volunteers. Clin Pharm Ther
1999;66:594-601.
Thürmann PA, Haack S, Werner U, et al. Tolera-11.
bility of beta-blockers metabolized via cytochrome
P450 2D6 is sex-dependent. Clin Pharmacol Ther
2006;80:551-553.
Meibohm B, Beierle I, Derendorf H. How impor-12.
tant are gender diﬀerences in pharmacokinetics?
Clin Pharmacokinet 2002;41:329-342.
Thürmann PA, Hompesch BC (1998) Inﬂuence13.
of gender on the pharmacokinetics and pharma-
codynamics of drugs. Int J Clin Pharmacol Ther
36: 586-590.
Gusella M, Crepaldi G, Barile C et al. Pharma-14.
cokinetic and demographic markers of 5-ﬂuorou-
racil toxicity in 181 patients on adjuvant therapy
for colorectal cancer. Ann Oncol. 2006;17:1656-
1660.
Sloan JA,Goldberg RM,Sargent DJ,et al.Women15.
experience greater toxicity with ﬂuorouracil-based
chemotherapy for colorectal cancer. J Clin Oncol
2002;20:1491-1498.
Pleym H, Spigset O, Kharasch ED, Dale O.16.
Gender diﬀerences in drug eﬀects: implications
for anaesthesiologists. Acta Anaesthesiol Scan
2003;47:241-259.
Zun LS, Downey LVA, Gossmann W, Rosen-17.
baum J,Sussman G.Gender diﬀerences in narcot-
ic-induced emesis in the ED. Am J Emerg Med
2002;20:151-154.
Kornstein SG, Sloan DM, Thase ME. Gender-18.
diﬀerences in depression and treatment response.
Psychopharmacol Bull 2002; 36: 99-112.
Martenyi F, Dossenbach M, Mraz K, Metcalfe S.19.
Gender diﬀerences in the eﬃcacy of ﬂuoxetine
and maprotiline in depressed patients: a double-
blind trial of antidepressants with serotonergic or
norepinephrinergic reuptake inhibition proﬁle.
Eur Neuropsychopharmacol 2001;11:227-232.
Kornstein SG, Schatzberg AF, Thase ME et al.:20.
Gender diﬀerences in treatment response to ser-
traline versus imipramine in chronic depression.
Am J Psychiatry 2000; 157:1445-1452.
Ridker PM, Cook NR, Lee I-M et al. A ran-21.
domized trial of low-dose aspirin in the primary
prevention of cardiovascular disease in women. N
Engl J Med 2005; 352: 1293-1304.
Berger J, Roncaglioni MC, Avanzini F, Pangrazzi22.
I,Tognoni G, Brown DL. Aspirin for the primary
prevention of cardiovascular events in women and
men. JAMA 2006; 295: 306-313.
Rathore SS, Wang Y, Krumholz HM. Sex-23.
based diﬀerences in the eﬀect of digoxin for
the treatment of heart failure. N Engl J Med.
2002;347:1403-1411.
Schmiedl S, Szymanski J, Rottenkolber M, et al24.
für die Deutsche Pharmakovigilanz-Studiengrup-
pe: Fingerhut – ein alter Hut? Eine Analyse sta-
tionärer Aufnahmen durch digitalisassoziierte un-
erwünschte Arzneimittelwirkungen. Med Klinik
2007;102:603-611.
Yamamoto H, Sekine I, Yamada K, et al. Gender25.
diﬀerences in treatmetn outcomes among patients
with non-small cell lung cancer given a combi-
nation of Carboplatin and paclitaxel. Oncology
2008;75:169-174.
Martin R, Biswas PN, Freemantle SN, et al. Age26.
and sex distribution of suspected adverse drug re-
actions to newly marketed drugs in general prac-
tice in England: analysis of 48 cohort studies. Br J
Clin Pharmacol 1998;46:505-511.
Kubota K, Kubota N, Pearce GL, Inman WHW27.
(1996) ACE-inhibitor-induced cough, an adverse
drug reaction unrecognised for several years: stud-
ies in Prescription-Event Monitoring. Eur J Clin
Pharmacol 49:431-437.
Pitche P, Drobacheﬀ-Thiebaut C, Gavignet B,28.
Mercier M, Laurent R. Cutaneous drug-reac-
tions to nevirapine: study of risk factors in 101
HIV-infected patients. Ann Dermatol Venereol
2005;132:970-974.
Ebert SN,Liu XK,Woosley RL: Female gender as29.
a risk factor for drug-induced cardiac arrhythmias:
evaluation of clinical and experimental evidence. J
Women’s Health 1998;7:547-557.
Drici MD, Clement N. Is gender a risk factor for30.
adverse drug reactions? The example of drug-in-
duced long QT syndrome.Drug Saf 2001;24:575-
585.
The University of Arizona College of Pharmacy.31.
http://www.azcert.org/medical-pros/drug-lists/
drug-lists.cfm (last access March 22nd 2009)
Rodriguez I, Kilborn MJ, Liu XK, Pezzullo JC,32.
Woosley RL: Drug-induced QT prolongation in
women during the menstrual cycle. JAMA 2001;
285:1322-26.
Aichhorn W, Whitworth A, Weiss EM, Mark-33.
steiner J: Second-generation antipsychotics. Is
there evidence for sex diﬀerences in pharmacoki-
netic and adverse eﬀect proﬁles? Drug Saf 2006;
29: 578 – 598.
Kahn SE, Zinman B, Lachin JM, et al. Diabetes34.
Outcome Progression Trial (ADOPT) Study
Group. Rosiglitazone-Associated Fractures in
Type 2 Diabetes. Diabetes Care 2008;31:845-
851.
Grey A, Bolland M, Gamble G, et al. The per-35.
oxisome proliferator-activated receptor-γ agonist
rosiglitazone decreases bone formation and bone
mineral density in healthy postmenopausal wom-
en: a randomized, controlled trial. J Endocrinol
Metabol 2007;92:1305-1310.
Pinn VW. Sex and gender factors in medical stud-36.
ies. Implications for health and clinical practice.
JAMA 2003;289:397.
Lee PY, Alexander KP, Hammill BG, Pasquali37.
SK, Peterson ED. Representation of elderly per-
sons and women in published randomized trials of
acute coronary syndromes. JAMA 2001;286:708-
713.
Evelyn B,ToigoT,Banks D,et al.Women`s partic-38.
ipation in clinical trials and gender-related label-
ing. A review of new molecular entities approved
1995-1999. FDA, 2001, August 24: http://www.
fda.gov/cder/reports/womens_health/women_
clin_trials.htm (last access: March 22nd 2009)
Müllner M, Vamvakas S, Rietschel M, van Zwi-39.
eten-Boot BJ. Are women appropriately repre-
sented and assessed in clinical trials submitted
for marketing authorization? A review of the da-
tabase of the European Medicines Agency. Int J
Clin Pharmacol Ther 2007;45:477-484.
Tenter U, Thürmann PA.:References to sex-spe-40.
ciﬁc diﬀerences of drug eﬀects in german SPCs
for new entities from 1999 – 2004. Int J Clin
Pharmacol Ther 2006;44:531 (abstr.)
Petra A. Thürmann, Prof. Dr. med. Philipp
Klee-Institute of Clinical Pharmacology,
HELIOS Klinikum Wuppertal,Chair
of Clinical Pharmacology,
University of Witten/Herdecke
65
Medical Ethics, Human Rights and Socio-medical aﬀairs
The development of Bioethics in Ukraine
is an example for other countries. First, lo-
cal Bioethical Committees in Ukraine were
created in 1992 in two organizations: the
Institute for Occupational Health of Acad-
emy of Medical Science of Ukraine in the
scope of Ukrainian/American Chernobyl
Ocular Study (UACOS) and in the Insti-
tute of Obstetrics and Gynecology of Acad-
emy of Medical Science of Ukraine in the
scope of the joint Ukrainian-USA Project
“Mother and Child”.
These two inter-governmental projects have
been performed jointly with Columbia Uni-
versity and the University of Illinois in the
United States. For these projects, informed
consent forms for medical examinations of
subjects, the Declaration of rights of patients
and,separetely,of investigators,and other re-
lated documents [ 1, 2] have been developed
and adopted in both the Ukraine and the
USA.The Statutes of the committees dealing
with medical aspects of these projects were
adopted by the Government of Ukraine and
the USA. Historically, resolution of dissimi-
lar or even conﬂicting bioethical restrictions
between participating countries has been
achieved on an ad hoc basis.
The next step was taken in 1995.The model
of the Declaration of patients’human rights
support was adopted in Ukraine. Standard
documents have been developed for re-
viewing medical ethical aspects of scientiﬁc
projects with human participation. These
documents were tested in twelve regions of
Ukraine before implementation into medi-
cal practice.
Ten year ago, owing to the initiative of the
Presidium of National Academy of Scienc-
es of Ukraine (NAS), and to Boris Paton,
President of the National Academy of Sci-
ences, systematic and successive activity in
the ﬁeld of bioethics began at the national
level. The Committee on Bioethics, estab-
lished as a branch of the Presidium of NAS
of Ukraine, takes an advisory, organizing
and coordinating role, aiming to reach the
level of the international community in this
respect.
The Committee on Bioethcs deals with all
aspects of ethics in science and practical
aspects of medical ethics and international
activity. At the First National Congress on
Bioethics in September 2001, with interna-
tional participation, a set of standardized
documents was adopted. This accomplish-
ment provided great support for next steps
of development [ 3].
This was extremely important for fur-
ther development of the collaboration of
Ukrainian scientists with foreign partners.
Within that period such international or-
ganizations as UNESCO, WHO, and the
Council of Europe placed bioethics among
priority subjects. Ukraine was determined
to join the world in this important subject.
Also, in our country, bioethics was preceded
by a thousand years of experience in medi-
cal ethics and doctor’s deontology, based on
established universal ethics and morals.
Under this commission, more than 250
bioethical committies and associations now
work in all parts of Ukraine. All this was
done with the enthusiastic participation of
people who understand the requirements of
a new moral approach to the relationship
between patients and doctors.The members
of this commission are prominent scientists,
public decision-makers and other individu-
als, such as Academician Elena Lukyanova,
Vice-Director of the Institute of Obstetric
and Gynecology Academy of Medical Sci-
ences of Ukraine (AMS), Professor Nikolay
Kiselyov, Director of the Institute of Phy-
losophy of NAS, Vice-President of AMS,
Professor Yuriy Zozulya, Director of the
Institute of Neurosurgery of AMS, Leader
of the Parlament administration, Vadim
Demchenko, Main Editor of the newspa-
per “Mirror of Week” Vladimir Mostovoy
and a number of other participants totaling
twenty-one people.
This Commission is a top-level organization
in the country. The head of this Commission
is Professor Kundiiev, member of NAS and
AMS, Vice-President of AMS of Ukraine.
The Commission organizes its meetings one
or two times each month. The main task
for these meetings is to develop answers to
highly important issues for Ukrainian soci-
ety, e.g., attitudes toward cloning or discus-
sions on the discrepancy in the ethical review
of the investigation protocol for executors of
large multicentral medical scientiﬁc projects
with human subjects involved.The Commis-
sion, as an advisory board, develops reccom-
mendations for executors, members of the
parliament or for other governmental orga-
nizations, such as the Ministry of Health of
Ukraine and others. Once or twice a month
members of this Commission have articles
published in newspapers or are interveiwed
on television.
During voting, under the Statute of this
Commission, members of this organization
must reach consensus on important solu-
tions concerning human rights.
On the other side, intensive eﬀorts in bio-
ethics have brought to light information
obstacles in common aproaches to main
principles of bioethical reviews, driven by
ever-accelerating biotechnological innova-
tion wherein developments are ultimately
dependent on constantly increasing needs
for human and animal subjects for clinical
trials. These facts and the current unprec-
edented movement toward globalization of
all aspects of life,including scientiﬁc health-
related research, serve only to increase the
sense of urgency for all countries to accept
and apply internationally agreed, at least
minimum, bioethical principles for policy
standards. They should be incorporated as
critical components of Good Laboratory
Practice and Good Clinical Practice, related
to studies standards, respectively.
In view of such questions and under the gov-
erning body of the National Bioethics Com-
Development of Bioethics in Ukraine
66
Medical Ethics, Human Rights and Socio-medical aﬀairs
mittee, medical ethics problems are solved
in the Independent Ethics Committies of
Academy of Medical Sciences of Ukraine in
Ministry of Health of Ukraine and under the
Ukrainian Medical Association.
The UACOS experience, which was pro-
grammatically organized around protocols
existing in many western countries, can
serve as a model for the design and imple-
mentation of the administrative infrastruc-
ture necessary to apply bioethical standards,
being fully consistent with modern society
in the twenty-ﬁrst century.
Over the past 10 years there have been nu-
merous successes. The most signiﬁcant re-
sult is that bioethics took its proper place in
the activity of the majority of high-proﬁle
medical and biological institutions; bioeth-
ics is taught at biological faculties and in
higher medical educational institutions and
even at high schools and universities. At the
same time, there are many complicated is-
sues that remain to be solved.
In recent times, as a result of scientiﬁc and
technological progress, rapid development
in life sciences, and the deciphering of the
human gene, we face more and more acute
problems and contradictions that require
moral judgments to resolve. What is pos-
sible for science and technology and what
is morally purposeful and acceptable? Our
ethical views and principles should be based
on an understanding of these diﬀerences.
We wrestle with questions of strategies for
mass prevention of morbidity, via vaccina-
tion in particular, to which the attitude in
recent times is ambivalent. New issues arise
related to assistive technologies, the scales
of which ever increase each year. Now, in
Ukraine, about 4,500 children have been
born as a result of such technologies. We
must remember that the ﬁrst of these was a
girl,Katya,born in 1991 in Kharkiv. Within
this period of demographic crisis, more at-
tention should be paid to these technologies
and to the problem of transplantation of
organs and tissues. In Ukraine, these issues
are regulated by the legislation; though it is
not yet perfect.There are similar regulations
in other countries as well. Despite such
regulations, there are often media reports
about abuse in these spheres, particularly
with respect to the sale of organs and tissue.
Compromising ethics for ﬁnancial gain in
this regard is a serious problem, indicating
clearly that regulation alone will not solve
all problems. Eﬀorts to educate the public
and inform social opinion through innova-
tive approaches must be prioritized.
Use of genetically modiﬁed organisms and
food products, as well as genetic tests, create
great concern in society. Discussions around
the problem of cloning a human and his/her
organs remain complex and diﬃcult. Great
attention is now being paid to issues related
to stem cells.
What is the driver of moral assessment in
terms of implementation of new technolo-
gies as they relate to human life? It is, ﬁrst
of all, respect for human dignity and pro-
tection of human rights, raising the respect
for human life to its highest value. Unfor-
tunately, this key question of bioethics, and
ethics in general in society, remains a sec-
ondary one, resulting in a great number of
social and socio-political contradictions.
Pharisaism is a becoming more and more
prevalent – temples are being built while
moral principles are in ruins. There is some-
times an impression that people lose the
ability to honestly analyze their reality.
It is necessary to realize that changes have
taken place that aﬀect our understanding of
life – indeed, the role of life itself on the
earth – and these changes require proper
action at the national, regional and inter-
national levels. One such event was the
adoption by UNESCO in October 2005 of
the Universal Declaration on Bioethics and
Human Rights. The Declaration highlights
that moral responsibility and analysis of
ethical problems should be an integral part
of the scientiﬁc and technological progress
and that bioethics should play a leading role
in decision-making when progress and new
developments raise diﬃcult issues.
Of course, we should agree with this.
Strictly speaking, the key is the need to
eliminate the gap between two branches of
knowledge – natural and humanitarian.The
bridge between the two should join scien-
tiﬁc and technological achievements and
moral and ethical principles. Van R. Potter,
the founder of bioethics, called it a bridge
to the future.
In Europe, and in the world in general,
priority signiﬁcance was given to bioethics
after the adoption of the Universal Declara-
tion of UNESCO in 2005.The Ukraine has
made a signiﬁcant eﬀort,in the aftermath of
this Declaration, to take two steps forward
in this respect.
The work of the National Board is executed
and will be performed by the Committee on
Bioethics of the National Academy of Sci-
ences of Ukraine. Boris Paton, President
of Academy, who supports this work, will
promote this activity in the future. We are
conﬁdent of this commitment.
In the ever-increasing search for new tech-
nologies, moral principles are often neglect-
ed. We often forget the purpose for which
we pursue advancement. Human rights and
human dignity become detached from tech-
nological progress. Again, we can take stem
cells as an example. There is no doubt that
the pluripotential of stem cells gives us great
hope for breakthroughs in medicine; we see
on the horizon new methods of treatment
of many diseases for which medicine today
is essentially powerless. There is a need for
consensus on many issues related to embry-
onic tissues and cells of an adult person. We
have no ﬁrm answers to the question about
the role of somatic mutations, about the ac-
tion of viruses, or why there are so few stem
cells in the healthy man, whereas the need
in them is very high. In order to respond
to these and many other questions, funda-
mental research is being conducted, namely
within a new Institute of Regenerative and
Genetic Medicine, formed within the sys-
tem of the Academy of Medical Sciences of
Ukraine.
67
Medical Ethics, Human Rights and Socio-medical aﬀairs
Meanwhile, very often commercial inter-
ests prevail. Currently, stem cells are widely
used in many clinics, including in countries
where their use is forbidden by legislation.
The principle laid down in the Universal
Declaration on the Human Genome and
Human Rights and the International Dec-
laration on Human Genetic Data, adopted
by UNESCO, provides for maximum di-
rect and indirect beneﬁts for patients and
those participating in research in the use of
achievements and scientiﬁc knowledge. It
also stresses the need to ensure that, in med-
ical practice, the use of new technologies
cause no harm. It is necessary to do one’s
best to avoid any risks.This principle is often
violated in respect of not only novel technol-
ogies, but in such spheres as clinical trials of
pharmacological preparations. The number
of clinical trails themselves is notable. Over
the last ten years there have been 2,200 such
trials in Ukraine, far more than in any other
European countries. The question is – why?
To begin, such trials are less expensive to
conduct in our country. Second, regulations
related to trials of new drugs are not as strict
as in Western countries.
The low cost of clinical trials in Ukraine is
due to not only poor salaries of physicians
and scientists but also to very low expenses
related to health and life insurance in the
case of negative eﬀects from testing new
medicines. In the USA, for instance, insur-
ance for such cases amounts to 1.5 million
dollars, in Ukraine, 7.5 thousands Hryvna
(Ukrainian Currency), i.e. one thousand
times less. In EU countries, clinical trials
are not proﬁtable for pharmaceutical com-
panies for the same reasons. Under such
circumstances Ukraine and the health of its
population can be considered at-risk. We
must not forget about the tragedy caused by
thalidamid exposure.
The number of establishments responsible
for clinical trials is constantly increasing;
presently, there are nearly 400 of them. It is
clear that requirements of Bioethical Com-
mittees should be ever stricter; the level of
knowledge of members of these commit-
tees should be higher to avoid mistakes
and violations. Revised requirements for
accreditation and attestation of, at the very
least, heads of committees of diﬀerent levels
should be developed as soon as possible.
The pharmacological market, with its re-
lations, is developing rapidly in Ukraine.
When medical and social direction do not
prevail to regulate this market, it turns into
naked business, where extravagant incomes
are achieved at the expense of human suf-
fering.
Let us take at least one example. It is logi-
cal to suppose that, as cardiovascular disease
is the highest cause of morbidity, priority
should be given to it in terms of develop-
ment of treatment and disease prevention.
However, aggressive advertising interferes
in this process, pushing other priorities
on patients. That is why the advertising of
pharmacological preparations in most cases
is forbidden. The same should be done in
Ukraine.
Currently, great hopes for mankind rest on
the development of nanotechnologies. Not
only scientists, but politicians as well, speak
about this now. Much can be done with
their use in medicine,beginning with devel-
opment of new drugs and diagnostics facili-
ties, removal of pollutants, new methods of
treatment and prevention. However, world
social opinion is divided between hopes for
the beneﬁts, and fear of the potential harm-
ful eﬀect on the environment, their use for
the development new-generation weaponry,
and so on.
With this in view, UNECSCO was com-
pelled to gather experts to examine the vex-
ing ethical and political questions related
to the application of nanotechnologies in
general and in medicine in particular. The
discussions resulted in the article “Nano-
technologies,Ethics and Policy”.We plan to
establish a chair of “Nanotechnologies and
Ethics” in Kyiv as an international Board.
We should emphasize one more peculiarity
of the III National Congress on Bioethics.
Much attention was paid to the position of
ethics in science. Very interesting reports on
these problems were given at plenary and
sectional meetings. In particular, report by
Popovich,Naumovets and other members of
the Academy of Sciences were delivered.We
would like to underline that these questions
were focused directly on the Conference of
European Federation of the Academy of
Sciences, which ﬁnished its work in 2008 in
Lisbon.The focus was the need to be guided
by the “Code of Ethics of a Scientist”, high-
lighting the need for moral responsibility for
falsiﬁcation of data and plagiarism,as well as
for the signiﬁcance and reliability of the pre-
sented information. It also focused on the
need for research to be well conceived and
independent, for reasonable use of resources
in order to avoid unnecessary expenses, and
to address improper behavior of partners in
international projects.
Unfortunately, the number of cases of in-
fringement of ethical principles in scientiﬁc
research in medicine has not decreased. It
is therefore timely that the National Acad-
emy of Sciences takes the role of an active
leader and guide of ethical principles in all
branches of scientiﬁc and practical activity
in Ukraine.
We can conclude that the development of
bioethics and the adoption of general ethics
principles in medical society will move us
towards better protection of human rights
and human dignity in Ukraine.
References:
1. Faden RR, Beauchamp TL. A history and
theory of informed consent. New-York: Oxford
University Press, 1986.
2. Kundiiev II,Vitte PN,Lyzogub VG,Stepanen-
ko A. Creation a national infrastructure for
good clinical practice in clinical trials in
Ukraine.Pharmaceutical Medicine 2008; 22(6):
355-358.
3. Kundiiev I., ed. Anthology of bioethics. Lviv:
BaK, 2003.
I. Kundiiev, P. Vitte, M. Chaschin
Ukrainian Medical Association,
National Academy of Sciences of Ukraine,
Informational Center on Bioethics
68
International, Regional and NMA news
Vivienne Nathanson
The British Medical Association celebrated
its 175th
birthday two years ago. During our
long existence we have developed many fac-
ets, many sides to the personality that faces
our members, and the stakeholders with
whom we engage.
Established ﬁrst as a voluntary professional
association we are also a major medical pub-
lisher and a trade union. The three major
strands of activity ﬁt together in a complex
mesh with interactions in unexpected areas.
For doctors in the UK we oﬀer services which
support them in their workplaces and in their
training from the day they arrive at medical
school until well after retirement. And in our
professional association role we help doctors
make a diﬀerence to the health and wellbeing
of the wider public,not only the individual pa-
tients so many are treating every day.
One of the BMAs earliest reports was an
investigation into Quackery. In the 1830s a
large percentage of those practising as doc-
tors in the UK had no qualiﬁcation. The
report led to the establishment of the Gen-
eral Medical Council and the registration of
medical practitioners – including recogni-
tion of speciﬁc qualiﬁcations. We remain
involved in similar areas today, working to
help groups of other healths professions, to
establish themselves as registered practitio-
ners, especially a few of the complemen-
tary and alternative therapies. The motive
is exactly the same – only through restrict-
ing practice to those on a register can you
assure patients and potential patients that
their therapist has gone through a course
of training and should be practising to an
agreed high standard.
Our trade union work absorbs most of the
BMAs resources; rightly so as this is work
that enables our members to practice as
doctors in settings that will enable them to
deliver high quality care to their patients,
and to be appropriately rewarded for this
work. There is, it seems, always at least one
of the major branches of practice which has
a national standard contract up for nego-
tiation with the government and with the
employers organisations. In the current
global economic crisis such negotiations are
complex and diﬃcult, but we rightly have a
reputation for tough negotiation. The other
side of the union work is local representa-
tion – sadly doctors like all other workers
can run into trouble with their employers
and our role is to represent them. As an ad-
junct to this we have a 24 hour telephone
help line with counsellors to help members
in distress and which is frequently accessed
by those facing a hostile work environment.
Our publishing continues with the BMJ
Publishing Group – a wholly owned sub-
sidiary. Its best known brand is the British
Medical Journal, published weekly in Eng-
lish and weekly or monthly in other lan-
guage editions. It also publishes more than
24 other journals, many in partnership with
special interest groups. The editor of the
BMJ has complete editorial independence;
sometimes uncomfortable for the BMA,
but essential if it is to remain a high status,
independent peer reviewed journal.
A major area of expansion for the BMJ over
the last decade has been the production of
learning and knowledge tools for doctors.
BMJ Learning on-line has more than 450
modules for continuing professional devel-
opment. Most are designed for doctors, but
the expertise has been recognised by other
groups of health workers and the BMJ has
been commissioned to produce modules for
nurses and paramedics.
Some work appears to fall between the trade
union and the professional association – in-
cluding work on task shifting, human re-
sources for health and medical migration.The
BMA does not get precious about this; work
is done by those with the right skill set and
much of it crosses internal boundaries. Key to
everything is networking.The group, working
to make sure that the views of doctors is an
essential part of planning for the NHS-wide
information technology developments in the
UK, works with doctors from all branches of
practice and with experts from ﬁelds such as
ethics to ensure that both clinical practicalities
and ethical principles are upheld.
But to the public the face they see most
often is the professional side of the BMA.
From the directorate of Professional Activi-
ties we produce materials designed to help
doctors be the very best they can be in their
medical careers, and we also work to keep
the environment in which they work con-
ducive to clinical excellence.
A set of activities that straddles this apparent
divide is the lobbying work we carry out on
the health of the public. We know – because
they tell us – that our members care deeply
about the major health problems that we see
across our population. Most are working with
individuals to deal with those problems, but
they want to have a bigger impact.The eﬀects
of using tobacco is a clear example.Individual
doctors see patients with heart disease, with
cancers,with end-stage respiratory failure as a
result of their cigarette smoking.They want to
help the individuals but also to turn back the
tide, to have a real impact in preventing these
illnesses. Only a small number work in re-
search,epidemiology or public health,and the
The British Medical Association – a world of
service for doctors
69
International, Regional and NMA news
BMA works with and for the greater number
in trying to reduce this disease burden.
For several decades we have not only lob-
bied government for better tobacco control
measures, but also commissioned research
and published on a wide variety of aspects.
Many of our publications are metanalyses of
clinical papers, leading to conclusions and
policy directions. One example was a report
on the evidence of the harmful eﬀects of sec-
ond hand or passive smoking, published in
time to inﬂuence the four governments in
the UK in their deliberations of whether the
four countries should go smoke free in public
places. This work was not a one-oﬀ. It fol-
lowed several decades of reports on related
issues which are part of a network of con-
tributions that have signiﬁcantly reduced the
number of smokers in the UK. Sadly, there is
a great deal more to do; too many children
and young adults are still starting to smoke
and many will ﬁnd quitting diﬃcult or im-
possible.We will not stop this work until no-
one in the UK ever starts smoking and all
existing smokers have successfully quit.
There is a nice interaction here with the
BMJ. It was here that Richard Doll and
Austin Bradford Hill published their semi-
nal work on the eﬀects of smoking on the
lives of doctors. By showing over 50 years
ago that doctors who smoked died younger
than doctors who did not, Doll and Brad-
ford Hill had a salutary eﬀect on smoking
rates amongst doctors.UK doctors’smoking
rates are about 2.5% against a population
rate of near 25%. Doctors were signiﬁcantly
aﬀected not just by knowing that smok-
ing kills but speciﬁcally that smoking kills
doctors. Perhaps this is a lesson we have
been slow to learn in directing and design-
ing anti-smoking messages for population
sub groups. When we make the message
relevant it is more likely to aid behaviour
change than when it is general.
Today the BMA is working with others to try
to persuade the Westminster parliament to
legislate for a ban on point of sale advertising
of cigarettes and an end to cigarette vending
machines. Here another UK development
comes into play.We now have four legislatures
and we saw with smoke-free public places
that administrations in Scotland, Wales and
Northern Ireland were keen willing and able
to pass banning laws. That helped get West-
minster to do the same for England. It may
well be that enthusiasm for more legislation
is stronger in these other countries and those
of us in England will then use that to help us
persuade Westminster to follow suit. For the
WMA this may be an important lesson as
well. Are we good at asking countries where
desirable legislation has been passed how it
happened? Do we exchange information reg-
ularly? And if not,why do we not do this?
There are other major public health challeng-
es today that are mimicking tobacco in their
complexity and in the impact they are having
on shortening lives and stretching health care
budgets. The two biggest of such challenges
are alcohol and obesity. The BMA is facing
these as it faced tobacco; we are working with
large numbers of other interested parties, we
are engaging doctors throughout the UK, we
are looking for policies that work and we are
trying to make sure that the lessons of what
worked and what did not work with tobacco
are learned. In both cases we need policies
that involve many government departments.
Alcohol abuse in not just a health problem.
It clearly causes problems for law and order
and is encouraged by tax and pricing poli-
cies (to simplify a complex matrix) and by
smuggling. So we have to work with a series
of government departments and encourage
them to think in a joined up manner.We also
have to encourage all politicians to look at
the long term. Major advances from changes
in diet and exercise will take many years to
produce signiﬁcant changes in health expen-
diture. Political short-termism must not stop
expenditure for longer term beneﬁts.
Climate change is another public health
challenge, but one on which action in one
country alone will have relatively little im-
pact.There are still some who do not believe
the science. The science is, of course com-
plex, and diﬀerent elements have diﬀerent
levels of “proof ”. Our policy is to say that
the science is what it is, but that we are see-
ing the planet warm and there are clear con-
sequences that follow from that. We add to
this that carbon emissions are a signiﬁcant
element and that doctors have two roles to
play in reducing these – the ﬁrst as inﬂuen-
tial citizens and societal leaders in demon-
strating that they will make changes to their
lifestyles, and the second is to try to reduce
the carbon impact of health care systems.
In my professional lifetime I can make a
case that medicine has been revolutionised
by plastics and disposables. That comes at a
carbon cost. In addition health care build-
ings are designed for a variety of eﬃciency
factors, and we must add carbon emission
eﬃciency to that matrix. The BMA pub-
lished advice last year on these areas and we
are already updating that web resource.
There are many ethics departments in uni-
versities around the UK, as with the rest of
the world, producing ethics materials and
publication of enormous intellectual rigour.
Why does the BMA still publish advice in
the face of this glut of competitors? Sim-
ply, because we know doctors, we know
their work-place, we know the clinical situ-
ations in which they have to make ethical
judgements. As one academic philosopher
said: “The BMA advice has to be, and is,
practical and relevant to the doctor in the
clinical situation.The fact that it is also aca-
demically excellent is a great bonus.” Com-
mon problems include questions about data
protection, conﬁdentiality and information
governance as well as speciﬁc matters such
as withdrawing and withholding treatment,
and non-treatment decisions. And again the
BMA gets into lobbying mode.
In January 2009 the government published
the Coroners and Justice Bill. Our parlia-
mentary oﬃce noticed that clause 152 would
allow government ministers to share infor-
mation from databases between government
departments to enable public policy, after
balancing the eﬀects against individual rights.
There were no limits to this provision, and it
explicitly stated that this could include setting
aside other laws or regulations that stopped
such data sharing. For doctors this was a po-
tential catastrophe; no doctor would be able
70
International, Regional and NMA news
to assure a patient that information in their
personal health record would be immune to
such sharing as no-one could know what
ministers might ﬁnd desirable in the future.
We worked with the media, with other pro-
fessional bodies including those representing
lawyers and the public, to raise concerns as
well as going both to parliamentarians and
to ministers. No one was able to tell us of a
problem to which this was the solution. The
intense lobbying got a result – the clause was
removed from the bill. Although the govern-
ment has committed to return to the issue in
other legislation it will be, they assure us, in a
modiﬁed form. We continue to press for the
complete exclusion of personal, identiﬁable
health information from any such legislation.
So far we have achieved a victory – one that
will help to maintain that trust between doc-
tor and patient over information given to us
by patients for the purposes of their care. But
we will continue to watch and to press for dis-
cussion before a new clause is drafted so that
patients are protected and doctors do not ﬁnd
themselves in a no-win situation.
Sometimes work on legislation is far less pub-
lic.Weworkwiththosedraftingandamending
legislation to make sure it works in the inter-
ests of patient care not against it.These teams
of people working on legislation are grateful
for our expertise in understanding the impact
of the words they write on clinical practice
and on our ability to ﬁnd viable alternatives
that achieve worthwhile goals without dam-
aging trust or other elements of patients care.
In some cases we presage that work by calling
together interested experts from around the
health care world to make sure we have a com-
mon“bottom line”on what is acceptable or not
in the draft legislation.
The ethics team produce books on ethics and
law, and on human rights as well as guidance
notesandon-line“booklets”formembers.They
are also working with the BMJ – another nice
collaboration – to produce ethics e-learning
modules. And of course their web pages and
advice enjoy thousands of hits by members re-
freshing their personal ethics expertise.
Every day at the BMA is diﬀerent. But there
are common threads. Our “raison d’etre” is
to help doctors. We do that by negotiating
advantageous contracts and by ensuring that
the conditions in which they work also work
for optimal medical practice. And we try to
help them by providing education and learn-
ing support materials. As one of our leaﬂets
says – “the BMA – a World of Service”.
Dr. Vivienne Nathanson, Director of Profes-
sional Activities, British Medical Association
Liu Zhi
The Chinese Medical Association (CMA) is
a non-proﬁt registered academic and com-
monweal corporate body voluntarily formed
by Chinese medical science and technology
professionals, and an important social force
in the development of medical science and
technology in China.
The CMA, established in 1915, now has 84
specialty societies under its umbrella, cover-
ing all medical ﬁelds.The CMA has a mem-
bership of about 460,000,and publishes 119
medical journals, one medical information
newsletter and one popular magazine. The
CMA is closely related to the local medical
associations in the provinces, municipalities
and autonomous regions. The CMA Head
Oﬃce is in Beijing.
The CMA mission includes uniting medi-
cal professionals, upholding medical ethics,
and advocating social integrity. It operates
with democratic principles, supports free-
dom of scholarship, and seeks to raise tech-
nical skills of the medical professionals. It
promotes the prosperity and development
of medical science and technology, and the
popularization of medical science and tech-
nology knowledge. It promotes the growth
of medical science and technology work
forces and the integration of medical sci-
ence and technology with China’s economic
development. All these are for the purpose
of providing services for its members and
for medical professionals, for the health of
the Chinese people, and for socialist mod-
ernisation in China.
The scope of the work of the CMA includes:
organising academic exchange programs on
medical science and technology, publishing
medical journals and electronic audio-visual
products, promoting international academic
exchange programs and co-operation, carry-
ing out continuing medical education projects,
organizing technical appraisal of medical proj-
ects,selecting and presenting awards for excel-
lence in medical and technological research
and publications, ﬁnding, recommending and
training outstanding medical talents, organis-
ing technical assessment of medical incidents,
undertaking projects entrusted by the govern-
ment, promoting transformation and practical
application of medical research results, and
relaying suggestions and requests from the
medical professionals to the government and
serving as an important linkage between med-
ical circles and the government.
The President of the CMA is prof. Zhong
Nanshan (Academician of the Chinese Acad-
emy of Engineering, and Director of the
Guangzhou Institute of Respiratory Diseases).
Full time Vice President and Secretary Gen-
eral of the CMA is prof.Wu Mingjiang.
Liu Zhi,Director,Department of International
Relations, Chinese Medical Association
Chinese Medical Association (CMA)
71
International, Regional and NMA news
Since 1847, the American Medical Asso-
ciation (AMA) has fought for high quality
health care for all Americans, and to improve
public health at home and abroad. The AMA
mission statement, which has remained un-
changed for more than a century, provides
our compass: “To promote the art and sci-
ence of medicine and the betterment of public
health.” As the largest association of Amer-
ica’s physicians, the AMA represents certain
core values, including leadership, excellence,
integrity and ethical behavior. Through these
benchmarks, the AMA stands as an essential
part of the professional life of every physician.
The AMA shares these goals and values with
the World Medical Association.
AMA Advocacy Agenda
While the AMA plays a role on the interna-
tional health care stage,physicians face press-
ing concerns here in the United States. Over
the decades, the U.S. health care system has
developed weaknesses that leave too many
patients without regular access to quality care.
That is why the AMA is promoting compre-
hensive health care reform. The global eco-
nomic slump that has also created economic
uncertainty in the U.S. is contributing to the
sense of urgency that the nation’s health care
system needs fundamental changes in order to
control costs, improve quality, expand cover-
age and enhance value. The AMA is playing
an important role in shaping the debate. As
the largest body of America’s physicians, and
guardian of their patients,the AMA is willing
to listen to all sides of the arguments,consider
the nuances of each,and work toward the best
possible solutions.
Reforming America’s
health care system
In the U.S., 2008 was a national election
year. The AMA seized the opportunity to
unveil the Voice for the Uninsured cam-
paign, which educated candidates, voters
and the media about the ongoing problem
of people who lack health care coverage in
the U.S.Through advertising,appearances at
public events and through the news media,
the AMA transmitted its plan for universal
health insurance coverage to government
oﬃcials, elected leaders and patients. The
AMA held meetings and follow-up con-
versations with the major presidential cam-
paigns to educate them about the AMA’s
Proposal for Expanding Coverage and
Choice.
The AMA launched the Voice for the Un-
insured Campaign website to showcase the
AMA proposal and give the 46 million
Americans without health insurance a voice
to tell their story.The success of this initiative
ampliﬁed the AMA’s voice as a champion for
health system reform. It was another reason
why America’s physicians will have a role in
the 2009 eﬀorts to expand health insurance
and in other health care initiatives.To achieve
these goals, the AMA is working with many
diverse organizations representing patients,
hospitals, insurers and employers to identify
common ground on approaches to compre-
hensive health system reform. This eﬀort
shares a common message: in order to ﬁx
the ailing economy, the U.S. needs reforms
that address the related problems of health
care costs and the uninsured. The issues the
country’s health care system faces have been
decades in the making,but the need for solu-
tions is immediate.
The Uninsured
At the center of the AMA’s vision is the
belief that every American, regardless of
means, should have access to health insur-
ance. Every patient should maintain the
freedom to choose his or her own physi-
cians and health plans, and maintain con-
trol over his or her own care. That includes
the 46 million Americans who do not have
health insurance. They live sicker and die
younger. Four out of ﬁve uninsured persons
are in a family where at least one person is
employed. This is not just a statistic, it is
a serious public health problem and a poor
use of national resources.
America’s current health insurance problems
began during World War II. At that time,
President Franklin Roosevelt imposed wage
and price controls to counter wartime inﬂa-
tion. Since employers couldn’t raise wages,
other means were sought to reward Ameri-
can workers. One way was for employers to
start paying for employees’ health insurance
costs. From there, employer-based health
insurance became the dominant means of
coverage in the United States.
The AMA “Plan for Reform”, which rests
on three pillars, calls for an end to linking
health insurance to employment, which is
no longer practical in the modern economy.
1) Provide tax credits for the purchase of
health insurance. This would enable pa-
tients to buy their own health insurance
plan they could take with them from job
to job.
2) Promote individual ownership of plans.
Patients could choose their own doc-
tor, their own hospital and the coverage
they want in their price range.
3) Reform the insurance market through
more competition and less insurer in-
terference and bureaucratic meddling.
Some of these solutions have been incorpo-
rated into government proposals for health
care reform. But much work remains to be
done.
Medicare Payment
The AMA is also active in eﬀorts to reform
Medicare, the government-run health care
plan for Americans over the age of 65 and
with severe disabilities. A seemingly an-
nual problem faced by physicians who treat
Medicare patients is that the reimburse-
The American Medical Association
and the WMA
Global Partners for Physicians
72
International, Regional and NMA news
ment for medical care is threatened with
cuts. The formula that determines Medi-
care payments is based on the US gross na-
tional product, and not on the actual cost of
providing that care.
In 2008, physicians faced a 10.6 percent
cut in Medicare payments. A cut this steep
would cause senior citizens to lose access to
care by driving physicians away from the
Medicare program. Physicians and patients
across the country worked together to over-
ride a presidential veto of the legislation – a
remarkable event that rarely happens in our
country. Physicians and seniors won this
battle because they contacted Congress by
the tens of thousands and because the AMA
ran powerful advertisements on TV and in
local newspapers encouraging lawmakers to
protect access to care for the elderly.
However, this victory is only temporary.The
ﬂawed system for reimbursing physicians
for treating Medicare patients will result in
payment cuts to physicians of 21 percent in
2010. Unless the formula is changed, cuts
will total 40 percent by 2015. However,
physician practice costs will increase by least
20 percent over this same time period. That
is why the AMA is working with Congress
and the President to build a system that im-
proves quality and better protects access to
care for seniors.
Cost of Care
The AMA is also developing strategies to
restrain rising costs while maintaining qual-
ity of care. Medical science and technology
have moved forward at a lightning pace.
The AMA wants to ﬁnd new ways to enable
doctors to use promising new technology
while developing new methods to measure
and improve the quality of care.
Physician Autonomy
The AMA believes that America’s patients
will be best served when our country elimi-
nates the disproportionate inﬂuence of in-
surers and government on medical decisions.
These important decisions must be placed
back in the hands of the
patient and the physi-
cian.The AMA has also
been active on behalf of
physicians when the is-
sues turn to the business
of medicine. One such
area is in obtaining an-
titrust relief. The AMA
seeks to make it possible
for physicians to negoti-
ate as a group, instead of
as individuals, to coun-
ter the powerful advan-
tage held by insurance
companies.
Medical Workforce
Considering the con-
ﬂicts with the health
insurance industry, the
problem of medical li-
ability lawsuits and
erratic Medicare reim-
bursement, America
could face a shortage of
physicians in some ﬁelds
by the year 2020. The
AMA seeks to increase
medical school class
size, allow for additional
residency slots to train
physicians, and improve
the distribution of phy-
sicians to underserved
and undersupplied spe-
cialties, especially in the
primary care ﬁeld.
Quality of Care
The AMA is not only concerned with the
quantity of physicians serving American
patients, but also with the quality of care.
The AMA’s eﬀorts in clinical quality im-
provement begin with performance mea-
sure development – measures designed by
physicians for physicians.
The AMA houses a group called“The Physi-
cian Consortium for Performance Improve-
ment”.The Consortium works with national
quality groups and government agencies to
develop “quality measures” that doctors can
rely upon. To date, the Physician Consor-
tium for Performance Improvement has de-
veloped more than 250 individual measures
covering 42 clinical topics. They were de-
veloped by the Consortium in collaboration
with specialty societies, and often with the
National Committee for Quality Assurance.
For ease of use, each measurement set can
be implemented in practices using diﬀer-
ent data sources and can be integrated with
both paper and electronic medical records.
73
International, Regional and NMA news
In other words, rather than the government
telling doctors what is best, the AMA is
helping the government understand what is
best, as determined by scientiﬁc research.
Other Issues
The AMA is also encouraging more atten-
tion to issues across the health care spec-
trum, such as:
Directing more resources and eﬀort to-•
ward disease prevention;
Helping Americans lead more healthful•
lifestyles;
Eliminating gaps in care, particularly for•
racial and ethnic minorities, the elderly,
and low-income families;
Preparing adequately for large-scale•
health care emergencies.
Despite its problems,the U.S.health care sys-
tem does have real strengths. One is choice:
patients can choose the kind of insurance they
want,their physicians and their hospitals. The
U.S.systemalsohasatremendousabilitytoin-
novate and generally has convenient access to
treatment and procedures without long waits.
The American system of medical education is
highly respected. Promising students from all
over the world hope to train in U.S. medical
schools,which teach the advanced techniques,
treatments and procedures that make the sci-
ence of American medicine among the best
in the world.
In the United States, the ﬁnancial crisis
has aﬀected everyone’s life. But America’s
physicians will not be deterred from their
responsibilities to patients and their com-
munities. The AMA will continue to help
doctors help patients, champion the art and
science of medicine, advocate for the in-
terests of member physicians and provide
them with the tools and resources they need
to succeed, through good times and bad.
The AMA’s Role in WMA
The AMA’s active participation in the WMA
has provided the opportunity to work with our
colleagues to pursue solutions to global health
problems. This sort of interaction is irreplace-
able as the world becomes smaller and the
global village larger. Microbes do not respect
borders, as international outbreaks of SARS,
malaria and the West Nile virus attest.
The international public health agenda is
so vast that no single sector or organization
can succeed alone. Bridges need to be con-
tinually built and ties renewed.Through the
AMA’s membership and involvement in the
WMA, the AMA:
Strengthens its own policy development;•
Identiﬁes emerging issues and ﬁnds solu-•
tions to common problems;
Fulﬁlls a professional obligation to share•
knowledge;
Identiﬁes new ways to educate and assist•
physicians worldwide.
The AMA believes it is important that the
WMA succeed and thrive in its mission to
ﬁnd common ground among the world’s
physicians. That is why the AMA works
to help shape the structure and governance
procedures of the WMA. The AMA has
helped establish bylaws and operating poli-
cies, promoted the per capita membership
system in the Assembly and Council, and
drafted new bylaws that required each na-
tional medical association to certify the
character, integrity, and competence of their
members who run for WMA oﬃces.
The AMA has made signiﬁcant contribu-
tions to WMA policy on professional lia-
bility,medical education,ethical research on
humans, bioterrorism, alcohol and health,
tobacco use, and obesity. Most recently, the
AMA has worked toward revisions to the
Declaration of Helsinki, called for reduc-
tions in mercury use and dietary sodium in-
take, and urged more cooperation between
human and veterinary medicine.
These changing times bring new challenges.
Meeting them will require the uniﬁed ef-
forts of physicians and patients not just in
the United States, but around the world.
That is why the AMA values its involve-
ment with the World Medical Association
so highly, and encourages all physicians in
every country to do the same.
AMA, Communications Department
I.The French Medical Association
(AMF) was established on
22 December 1992.
The association’s purpose are: research, ac-
tivities, studies or common actions accord-
ing to European,international or worldwide
guidelines concerning health in the teach-
ing of medicine, medical science, medical
practice, medical ethics and medical care
insofar as the doctors represented in AMF
can achieve it.
II.The Association is composed of:
Founding members:
The National Order of Physicians•
(CNOM)
The Confederation of French Medical•
Unions (CSMF)
The Federation of the Doctors in France•
(FMF)
The French Mutual Insurance of Health•
Corps (MACSF)
The Medical Insurance and Professional•
Defence Society (Le Sou Médical)
Members:
The “Pasteur Mutualité” group• (AGMF)
The Former Interns Association• (AIHPP)
The French Medical Association
(L’ Association Médicale Française)
74
International, Regional and NMA news
III. AMF’s Operative ﬁelds:
Within the AMF and within international
medical organisations, the AMF seeks to
achieve the best possible standards: in eth-
ics, training, healthcare quality, professional
practices,publichealth,andhumanrightsas-
sociatedwithindividualandcollectivehealth.
The AMF helps practitioners, protects pa-
tients, provides accurate information and
represents health professionals.
IV. Current policy:
extension of the AMF
By communicating to medical professionals
the French medical practices embodied by
the AMF.
By accessing and participating actively
within the International Medical represen-
tative bodies:
Currently : World Medical Association•
(AMM / WMA) created on 18 Septem-
ber 1947 in Paris (initiated especially by
Pr. E. MARQUIS).
In the future: the European Forum of•
Medical Associations (EFMA), etc …
V. AMF participating in
ongoing activities:
The International Code of Medical Ethics•
Patient’s rights, the children’s rights
Task delegating•
Medical liability, professional autonomy•
Health and environment, health alerts•
Medical participation in capital punish-
ment cases, etc …
VI. AMF work in progress
AMF assists the Medical Associations of
French-speaking countries and developing
countries to participate, alongside and after
their approval, in activities in international
medical bodies.
The AMF contributes, through its cross-•
representation, to providing medical
terms in French and French-speaking
social-professional topics both in Europe
and internationally.
The AMF wishes to contribute to a « med-•
ical diplomacy by and for the doctors » in
order to save the profession’s autonomy,
notably through meetings, team work,
seminars: Tuberculosis, HIV / AIDS,
parasitic, environmental, Helsinki Dec-
laration, counterfeiting, insurance, com-
pensation, autonomy and professional re-
sponsibility, and assistance to colleagues
in diﬃculty.
VII. AMF Projects:
Present and defend in France the funda-
mental principles of medical practice: ethics,
responsibility,solidarity,liberal spirit,justice,
public health management, risk compensa-
tion, training, skills and best practices.
Develop a collaborating spirit with other
independent Medical Associations in order
to compare, propose, take up and conﬁrm
activities after debate and consensus.
Maintain the profession’s international au-
tonomy within representative bodies and
spread proven knowledge.
Recall and develop the French medical
presence in the AMM (WMA) since its
inception in 1947.
VIII.Through its international
contacts, the AMF promotes
information sharing
among practitioners
particularly regarding their demands on
health systems, contracts, professional in-
surance and medical risk insurance and the
various unions and scientiﬁc activities in
France and abroad.
IX. By cross-representation based on the
AMF one can learn about the policies of
continuing medical education, prevention
of medical accidents, updating of knowl-
edge and assistance to colleagues.
X.The AMF is able to assume future part-
nerships within the framework of actions
falling within the scope deﬁned by its stat-
utes.
The AMF is helped by its members to be
informed of developments in the health sys-
tem and contributes to the achievement of
national economic policy and research.
For more information, join us on the site
http://www.assmed.fr
Dr. Louis-Jean Calloc’h, Secretary General,
The French Medical Association
Paris:working party of AMF with the Medical Associations of Mali, from the Senegal, from Cote
d’Ivoire and their Presidents
Paris: working party of AMF with the Medi-
cal Association Canadian (CMA) and its
President the Dr. Ouellet
75
International, Regional and NMA news
The Belgian Association of Medical Trade
Unions (ABSyM) was created in 1963 to
ﬁght the law that would ﬁx the conditions
of medical practice. After long and unsuc-
cessful negotiations, the medical body went
on strike. It was the ﬁrst medical strike in
the world.
The government eventually agreed to change
the law and a system of agreement between
doctors and mutual insurance companies
was set up. This system has allowed the co-
existence of a social ﬁnancing and a liberal
practice ever since.
Every year in the beginning and every other
year now, the medical trade unions and the
mutual companies negotiate an agreement
about fees and practice conditions.
From 1993, the agreement must be done
inside a ﬁxed budget.
Individual doctors may decline the agree-
ment and ask for free fees. They have a
month at their disposal to do so.The agree-
ment is only enforced if 60 % of doctors (at
least 50 % of specialists and 50 % of GPs)
don’t decline this agreement. If they accept
the agreement, they are entitled to receive
an amount (currently 3000 €) for their re-
tirement pension.As self-employed,doctors
are only entitled to a very low legal pension
(about 800 € a month).
Up to now, between 80 and 90 % of doc-
tors accept the agreement every time. Only
twice in 45 years have medical trade unions
rejected any agreement. On these occa-
sions, the minister proposed an agreement
to individual doctors, but their agreement
was refused by more that 50 % of specialists
and 50 % of GPs in the whole country.This
agreement was not able to be enforced.
What is characteristic of Belgian practice is
a large freedom for the doctor, but also for
the patient.
Doctors are free to accept the agreement or
not, but if they accept it they are still free to
do it only for a part of their working time.
In that case, they must notify the periods
of time when they respect the fees of the
agreement and the periods when they do
not.
If they don’t mention it, they are considered
as committed for their whole activity, but
they are still free to set fees if the patient
has any special requirements (for instance
an individual room in hospital). On the
other hand, fees resulting from the agree-
ment are not very high (about 22 € for a
consultation).
Patients also have freedom of choice. They
may choose their doctor. They may consult
a specialist without being referred by a GP.
They may go directly to the hospital if they
need.They may call an ambulance.They may
choose their hospital.They may change doc-
tors without any administrative or ﬁnancial
sanction. They may have a second opinion
without diﬃculty.
There is no waiting list and the average time
devoted by doctors to their patient in a face
to face meeting is about twenty minutes.
If access to health care is easy,it is not free of
charge. Patients have to pay a contribution.
This contribution varies with the patient’s
income. About 20 % of the population enjoy
a preferential reimbursement.
Patients with chronic illness or families with
high expenses in health care have care free
of charge when they have reached a certain
level of expenses every year.
ABSyM is in favour of this patient contri-
bution instead of rationing.
As one can see, the ABSyM’aims are to de-
fend Hippocratic principles:
freedom of choice for the patient•
doctor’s independence•
medical secrecy•
but also to defend access to health care•
for everybody and to promote quality of
care and risk management.
With regard to quality, ABSyM negotiated
a free system in 1993. This system has been
implemented since 1994.
Doctors who follow CME attend a local
Peer Review and those who commit them-
selves to comply with quality norms are ac-
credited.
Accreditation is not only a label of qual-
ity. It also entitles the accredited doctor to
higher fees and such doctors receive a yearly
lump sum (600 €) to insure an independent
CME.
Accreditation is free, but more than 85 % of
doctors are accredited.
Unfortunately, not everything is perfect.
Because of chronic overspending, measures
of cost containment have been taken and
doctors are more and more under pressure.
The medical control service has been given
large prerogatives to investigate medical ac-
tivities, with penalties for doctors who have
not complied with the rules.
The medical advisers of mutual insurance
companies may limit access to expensive
drugs, and there are more and more restric-
tions for access to new drugs and new tech-
nologies.
The administrative load is taking more and
more doctors time at the expense of the
time devoted to patients.
While the budget is now balanced, patients
and doctors may pay the price with the free-
dom that they had enjoyed up to now.
Roland LEMYE, President, ABSyM
Liberal practice in Belgium
76
International, Regional and NMA news
Vasile Astarastoae
The Romanian College of Physicians was
founded in 1995. At the end of last year, a
new board has been elected. Prof. Dr. Vasile
Astarastoae is the new president, replacing
Prof.Dr.Mircea Cinteza,who has led the or-
ganization for a decade.The Romanian Col-
lege of Physicians is also led by three vice-
presidents:Prof.Dr.VladTica,Dr.Gheorghe
Borcean and Dr. Constantin Carstea.
The Romanian College of Physicians is orga-
nized and functions within the provisions of
the Act no.95/2006,as the physicians’national
professional organization,being an institution
of public interest, non-governmental, non-
political and without patrimonial purpose.
The Romanian College of Physicians is a
juridical entity and has institutional auton-
omy in its relation with any public authority,
exerting its attributes without any possibil-
ity of interference.
The Romanian College of Physicians has as
its main objective the control and surveil-
lance of the practice of medical profession,
the application of laws and rules that orga-
nize and establish the practice of the pro-
fession, the representation of the physician’s
interests and the observance of the prestige
of the medical profession within society.
One of the main concerns of the organiza-
tion is physicians’ emigration. Romania has
only half of the necessary number of physi-
cians. There are counties which do not have
at least one cardiologist or one endocrinolo-
gist. In Botosani county, there is no cardi-
ologist.A number of 98 towns or villages do
not have a family doctor. In these circum-
stances, Romania’s joining the European
Union has allowed very many physicians to
leave and work in a country belonging to
the EU. Last year, approximately 4% of the
total number of physicians have left Roma-
nia, according to a recent study made by the
Romanian College of Physicians. Almost
500 physicians have left the capital, Bucha-
rest. Within the last two years, 10 % of the
medical staﬀ has worked in a EU country.
France, Germany and Great Britain are the
favourite destination countries for Roma-
nian physicians. The most required special-
ties in these countries are: family medicine,
anaesthesiology and psychiatry.“We are fac-
ing a crisis as to the number of the medical
staﬀ,a crisis that nobody wants to admit”,says
Prof. Dr. Vasile Astarastoae, president of the
Romanian College of Physicians. Another
goal of the Romanian College of Physicians
are the Guidelines of Medical Practice. “The
guidelines of medical practice will be made
up according to the priorities related to the
state of health in Romania. The Romanian
College of Physicians will coordinate both
the making up of the medical guidelines and
will also monitor their implementation”, said
Prof. Dr. Vasile Astarastoae, the President of
the Romanian College of Physicians.
“It is demonstrated that the guidelines of
clinical practice are eﬀective means of chang-
ing the process of medical assistance and im-
proving the results in the sanitary ﬁeld. Be-
ing one of the instruments which help health
professionals and organizations to improve
the quality of the patients’ treatment, the
guidelines oﬀer the persons who use them
the possibility to improve the way in which
decisions are taken, improving team work,
sharing their knowledge based on experience
and reducing the changes in practice. At the
same time, the guidelines permanently bring
to date the knowledge of health profession-
als and make them give up the methods used
until that moment in order to follow the best
recommended practice“, declared Prof. Dr.
Vlad Tica, Vice-president of the Romanian
College of Physicians. Last year, in Romania
there have been endorsed the Guidelines of
Obstetrics and Gynaecology. 11 guidelines
are elaborated and other 15 are still to be elab-
orated. ”A priority of the Romanian College
of Physicians is the making up of a Guide of
Guidelines which should oﬀer the common
methodology in elaborating all guidelines.We
have suggested this guide to the European
Union of Specialist Doctors (UEMS), the
Romanian College of Physicians being the
only representative body from Romania that
has been accepted within this imposing insti-
tution. In the European countries, the aver-
age time for elaborating a guide is 18 months”
added Prof.Dr.Vlad Tica.
Last year, the Romanian College of Phy-
sicians has become a full member of the
UEMS. In this position, the representative
of the Romanian College of Physicians,Prof.
Dr. Vlad Tica made two important sug-
gestions. The ﬁrst refers to the possibility
to award international credits for national
activities, which are ranked as high qual-
ity. Now, EACCME (the European institu-
tion for awarding the credits of continuous
medical education) has as its goal rising the
physicians’ level of knowledge, free move-
ment,equal accreditation.We have suggested
that, if a national CME activity is ranked as
good, CME credits could be also recognized
in Europe. This way, we can increase physi-
cians’access as 80% of the scientiﬁc activities
are national. The second suggestion we have
sent to UEMS is related to the Guidelines
of Medical Practice. UEMS does not have
a textbook connected to the elaboration of
guidelines. For this reason we have thought
to make up a Guide of Guidelines, which
should receive UEMS approval. We must
make up a guide of good quality,otherwise it
willnotbeapproved”,saidProf.Dr.VladTica.
Vasile Astarastoae, President of the Romanian
College of Physicians
The Romanian College of Physicians
77
International, Regional and NMA news
The Icelandic Medical Association (IcMA)
was founded in 1918, thus it was 90 years
old last year. Iceland is a volcanic island
in the mid north Atlantic ocean, its size is
103 000 square kilometres which is almost
the size of England, but the island is very
thinly populated as the population is only
320 000.
The IcMA has available several small cot-
tages in Iceland that members can rent.This
is popular for hiking during the summer.
When the IcMA was founded in 1918, Ice-
land was still a part of the Danish kingdom.
The Republic of Iceland was established in
1944. Approximately 80 % of the popula-
tion lives in south west region of Iceland,
in and around the capital Reykjavik. The
University of Iceland in Reykjavik was es-
tablished in 1911 by fusion of pre-existing
schools that gave training in medicine,
law and theology. There is one University
hospital in Reykjavik and three regional
smaller ones in rural Iceland. Some smaller
hospitals are also in suburban Reykjavik
and surrounding area with speciﬁc tasks in
co-operation with the University Hospi-
tal. Most Icelandic doctors have graduated
from the Medical Faculty of the University
of Iceland, but have received their specialist
training overseas. Currently there are 1800
members of the IcMA and approximately
1200 are active at home. There is currently
no shortage of doctors, and neither is there
any unemployment amongst the profession.
Icelandic doctors commonly live and work
in the Scandinavian countries, USA, UK,
Netherlands and several other countries,
mostly in Europe.
The IcMA consists of nine diﬀerent region-
al societies. It is a small association even if
over 90 percent of active doctors in Iceland
are members, and its function is not stipu-
lated in any law. It is not obligatory to be
a member of the association if you work
in Iceland as a doctor, but if you receive a
salary by a contract the
IcMA negotiates with the
government you have to
pay dues to the association
which is the same amount
as the membership fee.
The IcMA is both a trade
union and professional so-
ciety. The main purpose of
the society according to its statutes is:
To enhance the wellbeing and honour•
of the Icelandic medical profession, to
enlarge their acquaintance and aware-
ness of society matters.
To safeguard the independence of doc-•
tors and watch over their interests.
To enrich the further education of doc-•
tors and interest them in professional
matters.
To enhance doctors’co-operation in all•
matters that lead to progress in health
aﬀairs
To participate internationally to fur-•
ther the common interests of doctors.
To work towards better health of the•
public and be opinion makers in health
aﬀairs.
Working towards these goals the oﬃce has a
total staﬀ of 3.5 people, one is a doctor who
is President of the IcMA and a CEO is a
lawyer.The board of the IcMA has 9 mem-
bers and have a role in co-operating with
the authorities, both inside the ministries
and in parliament.The opinion of the IcMA
is often taken into consideration, during the
law-making process. Most of health care
is run by the public sector, even if private
enterprise is permitted. The private part of
the health sector is to a great extent sub-
ject to contracts with the National Health
Insurance, since we do not have any private
health insurance in Iceland.
New Honorary Members of the
Icelandic Medical Association
The IcMA takes very seriously its social
responsibilities. Ethical issues, professional-
ism and matters of good conduct are writ-
ten into the statutes of the IcMA and its
Ethical Code and we urge ours members to
work and live by them. Continuous medi-
cal education and personal development
at home is prioritised in the IcMA’s work
as is international participation. IcMA is a
founding society both in the European and
global context. We currently have focused
upon Nordic co-operation, when working
both in the Permanent Committee of Eu-
ropean Medicine (CPME) and the World
Medical Association (WMA), since there
we feel most similarities.
Dr. Jón Snædal , Immediate Past-President
WMA, Icelandic Medical Association.
The Icelandic Medical Association
The General assembly of Icelandic Medical As-
sociation in September 2008, elected two Hon-
orary Members nominated by the board. Dr. Jon
Snædal and Dr. Stefan B. Matthiasson. Dr.
Snædal, has through many years worked in
medical ethics both at home and Internationally.
Dr. Snædal is since 2004 president of the IcMA’s
ethical committee. He is past President of World
Medical Association. Dr. Stefan B. Matthias-
son has for many years worked for IcMA in the
ﬁeld of Continuous Medical Education. He was
President of CME Committee for The Reykja-
vik and Icelandic Medical Associations 1987-
2001.Here seen with the President of IcMA Dr.
Birna Jonsdottir, from right Dr. Snædal, Dr.
Jonsdottir and Dr. Matthíasson.
78
International, Regional and NMA news
Armin Ehl
“This is not a doctors’ strike, this is a slave
revolt!” This is what was written on many
of the hand-painted banners during the
great doctors’ strikes in the years 2005 and
2006. Although, at the beginning of the
strike campaign, this slogan seemed some-
what exaggerated to many German citizens,
everyone in our country knew what it was
all about after ﬁfteen weeks of the doctors’
strike. There is a great discrepancy between
the often used image of the “demigods in
white” and the workaday reality in German
hospitals. Reducing this discrepancy has
been the job of the Marburger Bund since
its foundation in 1947.
Of course, there have been many develop-
ments in the German health care system
during the more than 60 years since its
foundation. The professional situation of
doctors has changed signiﬁcantly through
legislation and the increasing economisa-
tion of the health care system. Nevertheless
the motives which led to the foundation of
the Marburger Bund remain relevant: hu-
mane working conditions, performance-re-
lated remuneration, state-of-the-art medi-
cal qualiﬁcation as well as quality-focused
post graduate training for doctors.
Doctors in Germany are unionised either
voluntarily or as mandatory members in
various organisations.In Germany there are,
in total, about 312,000 physicians in gainful
employment. All of them are mandatory
members of one of the 17 State Chambers
of Physicians in Germany, one for each fed-
eral state (only North-Rhine Westphalia
has two Chambers of Physicians). These
State Chambers have joined forces to form
the German Medical Association, which is
the head organisation of the so-called doc-
tors’self-administration.The responsibilities
of the Chambers include, amongst others,
the representation of vocational interests of
all physicians and the promotion of a stan-
dardised code of professional duties and
guidelines for medical activities in all ﬁelds
as well as for further vocational training.
Among the physicians in gainful employ-
ment, about 140,000 are self-employed in
private practice, as general practitioners or
as medical specialists. The doctors in pri-
vate practice have joined to form the Kas-
senärztlichen Vereinigungen (Regional
Associations of Statutory Health Insur-
ance physicians). These KVs are somewhat
like “co-operatives” that conclude frame-
work agreements – particularly with the
over 200 statutory health funds in Ger-
many – regulating the payment of doctors
in private practice for services rendered to
those citizens covered by a public health in-
surance plan. (In Germany about 90% of
the population are members of a statutory
health fund, the remaining 10% are covered
by private insurance). At the moment there
is great cause for dissatisfaction in Germany
among doctors in private practice because
the overall payment is too low and the
repartition of these poor means among the
diﬀerent branches and regions in Germany
is very controversial.
In addition to self-employed physicians,
approximately 148,000 physicians are em-
ployed, mostly by the approximately 2100
German hospitals. These physicians are
represented by Marburger Bund. The in-
terests of employed physicians are manifold
and are reﬂected in the work of Marburger
Bund. First of all, Marburger Bund is the
organ representing medical interests vis-à-
vis politics on a regional, respectively na-
tional, as well as on a European level. Last
year, for example, the reform of hospital
funding was an important issue in Ger-
many. Together with hospital operators, the
German Medical Association (BÄK) and
the trade unions for the care sector Mar-
burger Bund constituted an active coalition
that culminated in a demonstration of more
than 130,000 employees of German hos-
pitals at the Brandenburg Gate in Berlin.
Regular talks with the Federal Ministry of
Health and Social Security – and even talks
with Federal Chancellor Merkel – showed
the importance of Marburger Bund.
On a European level we are greatly con-
cerned at the moment about the proposed
amendment of the EU Working Time Di-
rective.For many years Marburger Bund has
fought for on-call services to be counted as
labour time and for weekly working hours
to be limited for physicians. The European
Court of Justice conﬁrmed in two impor-
tant rulings [SIMAP 2000, Dr. Jäger (Mar-
burger Bund member) 2003] that on-call
services are to be counted as full labour time,
thereby strengthening explicitly the labour
protection of physicians,as well as declaring
illegal mammoth services of 30 hours at a
stretch or a weekly working time of over 70
hours. And now the clock is to be turned
back due of economic reasons. Marburger
Bund is in close contact with the European
Parliament and provides arguments for the
maintenance of the protective function of
the Working Time Directive and against
the continued exploitation of physicians.
From Slave Revolt
to Chamber Presidency
Marburger Bund in turbulent times
79
International, Regional and NMA news
Mali is located in the heart of West Africa
surrounded by eight neighbouring countries
and with no land access to the sea. It is a
vast country spread over 1 242 238 square
km and inhabited by 13 518 000 people.
The population is mainly rural engaged into
agriculture, cattle breeding and ﬁshing ac-
tivities. The main agricultural products are
cotton, millet and rice. The economic fea-
tures of the country are changing with the
fast growing gold mining industry.The cap-
ital city is Bamako where more than 3 mil-
lion Malians live and contribute to improve
national wealth. Across centuries, several
famous empires have emerged and waned
in Mali, making this country a unique place
for cultural tourism.
Divided into eight administrative regions,
Mali became independent from France on
22nd
September 1960. French has remained
the oﬃcial language.
Only later, in 1985 the law No
185/AN-RM
was promulgated which authorised private
practice for health related professions. Sub-
This leads us to the second pillar of work of
the Marburger Bund, which has become in-
creasingly important during the past years,
namely, Marburger Bund as the doctors’
trade union. Until 2005 there was a collec-
tive labour agreement in force for all public
servants, and this also applied to employed
physicians. It was, however, too undiﬀer-
entiated. The working conditions of physi-
cians in hospitals are in no way comparable
to those of lawyers in public service or of
teachers in schools.There is another consid-
erable diﬀerence to the other professional
categories: physicians are scarce and many
positions in hospitals remain vacant for a
long time. After all, German physicians,
unlike teachers and lawyers, are very much
in demand abroad, where they ﬁnd, more
often than not, better working conditions
and higher remuneration.All this prompted
Marburger Bund to demand a speciﬁc la-
bour agreement for physicians in 2005.
When the employers refused to split phy-
sicians oﬀ from the overall labour agree-
ment that applied to all public servants, it
led to the above-mentioned doctors’ strike.
University hospitals were on strike for 15
weeks with another seven weeks at the ap-
proximately 700 municipal hospitals. In
particular, the long weekly working hours
(keyword: slave revolt) played an important
role in the public debate and brought the
public to our side. As a result Marburger
Bund obtained its own wage agreements
and considerably better working conditions
in the hospitals. The pictures of the strike
went around the world and encouraged
many medical organisations abroad to take
a similar approach in their countries. Thus,
the emancipation of German hospital phy-
sicians and of Marburger Bund became the
role model for many others. Frank Ulrich
Montgomery, our chairman at that time,
Rudolf Henke, our current chairman and
the signing author, were engaged in many
debates about this in other countries and at
the annual meetings of the World Medical
Association, the Standing Committee of
European Doctors (CPME) and the Eu-
ropean Forum of Medical Associations and
WHO (EFMA).
The strikes also brought about unprecedent-
ed solidarity among physicians. Many phy-
sicians, apolitical up until that time, came
to join the Marburger Bund, making us a
very strong organisation.There are currently
108,000 members, creating one of the the
biggest medical association, with free mem-
bership in Europe.
To round oﬀ the representation of interests
for employed physicians, there is the work
within the medical chambers. For years we
have been playing an important part in deci-
sionmakingwithintherelevantbodiesofthe
medical self-administration, with respect to
the training of physicians,the code of medi-
cal ethics, as well as post graduate medical
training. Marburger Bund is represented in
this process by excellent personalities such
as Prof. Karsten Vilmar, honorary president
of the German Medical Association and
honorary chairman of Marburger Bund, or
Prof. Jörg-Dietrich Hoppe, president of the
German Medical Association and honorary
chairman of Marburger Bund, as well as by
many other members of Marburger Bund in
prominent positions.
Finally we have concluded a frame contract
with a bank and several insurance compa-
nies so that our members may be assisted in
nearly all aspects of life by their union.Thus,
becoming a member of Marburger Bund is
really worth it. We stand for the interests of
employed physicians and therefore – as we
see it – also for the interests of patients.The
stronger the union, the better the represen-
tation of interests of employed physicians.
We do not get anything for free, we have to
ﬁght for everything as the recent past has
shown. Repartition of the sparse funds will
become increasingly diﬃcult in our society,
a problem which can only be solved by a
well organised medical profession.
The representation of physicians is getting
more and more international. We are ex-
tremely interested in ﬁnding similar medi-
cal unions in as many European countries as
possible and throughout the world, in order
to reach agreements with them and to pool
our resources, if required. Therewith, we
want to ensure that in all the countries phy-
sicians are not treated anymore as “slaves”
but adequately, as beﬁts their position as
high-level service providers in the society.
Armin Ehl, Secretary General,
Marburger Bund, Berlin
Mali National Board of Physicians
(Ordre National des Medecins du Mali)
80
International, Regional and NMA news
The World Confederation for Physical
Therapy (WCPT) was founded in 1951 in
Copenhagen, Denmark, with 11 founding
member organisations. Today, representing
101 member organisations and more than
300 000 physical therapists worldwide,
WCPT provides the sole international voice
for the physical therapy profession (called
physiotherapy in some countries). WCPT’s
mission is to improve the quality of global
health by representing physical therapy
and physical therapists internationally, col-
laborating with national and international
organisations, supporting communication
and information exchange among regions
and member organisations of WCPT and
by encouraging high standards of physical
therapy research, education and practice.
Historically, two world wars resulted in un-
precedented numbers of casualties on all
sides. Physical therapy played an important
part in the huge advances made in the man-
agement of traumatic injuries. The contri-
bution of physical therapy to restore body
functioning was clear and the concept of re-
habilitation was extended to include thera-
peutic activities supporting participation in
life areas such as work and leisure.
sequently the law No
86-35/AN-RM insti-
tuted the National Board of Physicians.
The National Board of Physicians is com-
posed of one National Council, several
Central and Regional Councils.
The mission of the Board of the National
Council is to:
Ensure that principles of morality,•
probity, and dedication essential for
practicing the profession are respected
throughout the whole country with
help from the Central and regional
Councils;
Ensure the defence of the honour and•
independence of the profession;
Ensure that all members adhere to pro-•
fessional duty and that Deontological
ethics code rules are followed.
Main tasks of the Board of the National
Council are:
To address any issue in relation with•
the Board;
To pronounce disciplinary sanctions;•
To help resolve conﬂicts between phy-•
sicians on one side and between physi-
cian and clients;
To manage the property of the Board•
including the ﬁnancial resources from
members regular contributions and
from others sources allowed by law
with the aim to cover Board ﬁnancial
responsibilities with regard to the rights
of the members and their families;
To create and liven up the Board news-•
letter;
To evaluate suggestions and make pro-•
posals to improve the quality of medi-
cal activity.
The Board of the National Council is com-
posed of:
Ten members elected at the General•
Assembly of the physician members of
the Board;
Two additional members practicing•
medicine and residing in Bamako.
The Board of the National Council is as-
sisted by three experts representing various
administrations. These experts can advise
but cannot vote. They represent the follow-
ing structures:
Ministry of Health•
Ministry of Justice•
Faculty of Medicine, at the University of•
Bamako.
As of today the Board has registered 2,300
medical doctors across Mali. By law, a phy-
sician cannot practice medicine in Mali if
not registered with the Board of the Na-
tional Council.
The Board of the National Council has es-
tablished working relationships with dif-
ferent institutions across Africa. Among
those are the West African Organization
for Health (OOAS) of the ECOWAS
(Economical Community of West Afri-
can States), the Economical and Monetary
Union of West Africa (UEMOA).The UE-
MOA has established recently a network
of Chairs of National Boards of Physicians
from West African member countries of
the UEMOA. The aim is to ease the free
movement of physicians and to strengthen
their right to set up in any country in the
UEMOA area.
The Mali National Board of Physicians is
member of the World Medical Association
since the General Assembly held in Seoul,
South Korea, in October 2008.
Alhousseini AG Mohamed, President of Mali
National Board of Physicians
Alhousseini AG Mohamed
Movement for Health: the Role of the World
Confederation for Physical Therapy (WCPT)
81
International, Regional and NMA news
The ﬁrst decade of its existence was a time
for the Confederation to create a global
proﬁle, particularly among oﬃcial bodies.
WCPT made contact with the United Na-
tions (UN) and its agencies and entered into
oﬃcial relations with WHO in 1956.
The Physical Therapy Profession
Today, physical therapists provide evidence
based services for individuals and popu-
lations to develop, maintain and restore
maximum movement and functional ability
throughout the lifespan. Physical therapy is
concerned with identifying and maximis-
ing quality of life and movement potential
within the spheres of promotion, preven-
tion, treatment/intervention, habilitation
and rehabilitation. This encompasses physi-
cal,psychological,emotional,and social well
being. Physical therapy involves the inter-
action between physical therapist, patients/
clients, other health professionals, families,
care giver, and communities in a process
where movement potential is assessed and
goals are agreed upon, using knowledge and
skills unique to physical therapists. Physical
therapists are active members of multipro-
fessional teams. How the skills of qualiﬁed
professionals, including physical therapists,
are used to best eﬀect across the full path-
way of care and across settings is vital to
clinically and cost eﬀective health service
delivery. Taking a patient-centred, ﬂexible,
collaborative and open approach, acknowl-
edging the competencies of each profes-
sional group, is essential to this.
Membership and Governance
WCPT members are national professional
associations representing physical thera-
pists.They are organised in ﬁve regions: Af-
rica, Asia Western Paciﬁc, Europe, North
America Caribbean and South America,
which assist the development of the profes-
sion in their geographic area. WCPT’s sev-
en subgroups are organised to promote the
advancement of physical therapy, and the
exchange of scientiﬁc knowledge in speciﬁc
ﬁelds of interest.
WCPT holds a general meeting every four
years.The meeting approves changes to arti-
cles of association,elects the president,vice-
president and members of the executive
committee, approves policies and debates
motions. The executive committee agrees
the priorities for the four year period.
WCPT Activities
A range of position papers and policies on
various aspects of the profession provide
information for WCPT’s member organi-
sations, individual physical therapists, gov-
ernments, international non-governmental
organisations, the media and the public.
Examples of policies include a description
of the profession, entry-level curriculum
guidelines, standards of practice and disas-
ter management and preparedness.
Many policy areas are further supported
by project work. For example, following
the earthquake which struck in May 2008
in Sichuan, China, in co-ordination with
Handicap International, WCPT issued a
call for physical therapists to assist in the
post-disaster rehabilitation. In addition,
while China is not a member organisation
of WCPT, representatives have visited to
advise on the development of education
programmes and the profession.
A common set of data items to describe the
member organisations of WCPT, the regu-
lation of the profession, the education of
physical therapists and elements of practice
in the countries represented is currently un-
der development. The aim of the collection
is to provide information for representation
of the profession by WCPT on the global
stage, but also for use by regions and mem-
ber organisations for regional and national
strategic policy setting.
A key element of eﬀective practice is good
information on the way people function and
communication of information across ser-
vice settings and between professionals. In
this regard WCPT supports the use of the
International Classiﬁcation of Function-
ing, Disability and Health (ICF). An active
programme of education, resource sharing
Catherine Sykes Tracy Bury Brenda Myers
82
International, Regional and NMA news
The International Relations Committee of the American College
of Surgeons requests posters from sister societies around the world
for public display at the 95 Annual Clinical Congress, which will
take place 11-15 October 2009 in Chicago, Illinois.
We will have space to display approximately ten posters. Therefore,
we will mount the ﬁrst ten suitable posters that we receive. Please
note that we would prefer to receive posters from societies, publi-
cizing the activities of the societies, rather than posters from indi-
vidual members of those societies.
If your society would care to participate in this display, please send a
poster to the following address:
Ms Kate Early International Liaison Section American College of
Surgeons 633 North St Clair Street Chicago, IL 60611-3211 USA
We would like to receive all posters by Monday,28 September 2009
in order to convey them to the convention center in a timely man-
ner. Should you have questions, please contact Ms. Early via email,
at kearly@facs.org.
Thank you in advance for your interest in this request. I hope to
greet many of you in Chicago.
HugoV. Villar, MD, FACS
Chair, International Relations Committee
and participation in collaborative work with
WHO has resulted in a range of ICF appli-
cations by physical therapists as evidenced
in the research literature.
WCPT’s programme of work on evidence
based practice (EBP) includes providing
an on-line resource facilitating access to a
wealth of materials that will support physi-
cal therapists in providing eﬀective practice.
This includes access to on-line journals and
databases, clinical guidelines and method-
ological support.
Communication
Congress: Every four years WCPT hosts
a scientiﬁc congress showcasing advance-
ments in physical therapy research, practice
and education.
Website: The WCPT website is the main
means by which WCPT can communicate
with members, providing the profession
worldwide with a valuable range of mate-
rial, such as policy statements, brieﬁng pa-
pers and access to on-line resources as well
as the opportunity to exchange information
and share expertise.
WCPT News: WCPT News keeps the
membership informed about professional
developments and global programmes and
policies aﬀecting physical therapists.
World Physical Therapy Day: World Physi-
cal Therapy Day falls on 8th September ev-
ery year, and is an opportunity for physical
therapists from all over the world to raise
awareness about the crucial contribution
the profession makes to keeping people
well, mobile and independent. WCPT sup-
ports this with a ‘toolkit’ made up of online,
inexpensively produced materials for mem-
bership organisations to use.
Representation
WCPT oﬃcers represent the profession at
the WHO, the UN and other global fora.
In 2008, in collaboration with the World
Health Professions’ Alliance, the Confed-
eration was involved in the organisation of
the ﬁrst-ever inter-professional and inter-
national conference on regulation of health
professionals in Geneva, Switzerland.
As part of its work to identify and imple-
ment solutions to the health workforce
crisis, WCPT has joined with the world’s
leading health and hospital professional
associations to deliver a Positive Practice
Environments campaign. Supported by
funding from the Global Health Workforce
Alliance the campaign produced the ﬁrst-
ever joint guidelines on incentives for the
retention and recruitment of health profes-
sionals.
Global Health
Physical therapists are exercise specialists.
There is abundant evidence for the beneﬁts
of exercise and the contribution of physical
therapy in relation to cardiovascular dis-
ease, diabetes, arthritis, mental illness and
recovery from trauma. In addition, physical
therapists implement strategies to prevent
and manage the consequences of physical
inactivity associated with ageing and a wide
range of chronic diseases.
Further work is required to look at provision
of services in areas of severe shortage. This
remains a signiﬁcant challenge for all pro-
fessions and a focus for further research and
policy development. The way to progress
this is through multi professional collabora-
tion that embraces innovation and recogn-
ises the evolving scope of practice and com-
petencies of each professional group.
To address many of the issues that aﬀect
global health WCPT is working with pro-
fessional associations, governmental and
non-governmental international agencies,
underlining the profession’s commitment to
collaborative practice.
Visit: www.wcpt.org
Catherine Sykes, Professional Policy Advisor,
Tracy Bury, Professional Policy Advisor,
Brenda Myers, Secretary General
American College of Surgeons
95th
Annual Meeting
83
International, Regional and NMA news
Since 1968, the American College of Surgeons has oﬀered Inter-
national Guest Scholarships to competent young surgeons from
countries other than the United States or Canada who have dem-
onstrated strong interests and accomplishments in teaching and
research. Applications are now being accepted for International
Guest Scholarships for the year 2010. The deadline for receipt
of scholarship applications and all supporting documents is 1
July 2009.
Each Scholarship oﬀers a stipend of $8,000 US, participation in
the Clinical Congress, and the expectation of visits to several North
American clinical and research sites of the Scholar’s choice. A men-
tor will be assigned to assist the Scholar in planning his/her tour.
I seek your cooperation in publicizing the availability of the
International Guest Scholarships. The International Relations
Committee of the College has requested that the requirements for
the International Guest Scholarships be widely distributed in your
country. This goal can be eﬀectively accomplished by sharing the
information about the program requirements.
This information is available in English from the College’s Web
site at this location: http://www.facs.org/memberservices/igs.html.
Applicants are welcome to read the requirements, and then apply
to the program by using the link to the direct, online application
form at the bottom of the requirements page. The requirements
are also available in Spanish (http://www.facs.org/memberser-
vices/igsespanol.html) and in French (http://www,facs.org/mem-
berservices/igsfrancais.html). Please note that all applications
must be submitted in English,
Surgeons interested in applying for these Scholarships must
apply directly from the College’s Web site. Questions may be di-
rected to Ms. Kate Early, International Liaison Administrator, at
the College’s airmail address shown on our stationery, via fax at
312-202-5021, or via email at kearly@facs.org,
I would greatly appreciate your cooperation in disseminating this
information in order to ensure a large number of excellent pro-
spective scholarship applicants. To date. International Guest
Scholarships have been awarded to 220 promising young surgeons
worldwide (1968-2009).
Paul E. Collicott, MD, FACS
Director, Division of Member Services
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
The Role of the Physician
in Combating Inequalities in Health. . . . . . . . . . . . . . . . . . . . . 44
Human Resources for Health
and the Future of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . 45
Upon the Completion of the
WMA General Assembly Seoul . . . . . . . . . . . . . . . . . . . . . . . . 47
Words from Reykjavik on Task Shifting as a Response to the
Global Shortage in Health Care Providers . . . . . . . . . . . . . . . . 48
Task Shifting on Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . 50
CPME Board meeting 14th
March 2009 outcomes . . . . . . . . . 51
European Physicians Congratulate
the Parliament for Adopting the Cercas Report . . . . . . . . . . . . 53
What is the Added Value
of EU Health Policies for National Health Systems? . . . . . . . . 53
The 2nd
Annual Hospice and Palliative Care
in Developing Countries Conference . . . . . . . . . . . . . . . . . . . . 57
Clinical Research on Children. . . . . . . . . . . . . . . . . . . . . . . . . . 58
Gender-speciﬁc Diﬀerences in Pharmacotherapy . . . . . . . . . . . 62
Development of Bioethics in Ukraine . . . . . . . . . . . . . . . . . . . . 65
The British Medical Association –
a world of service for doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Chinese Medical Association (CMA) . . . . . . . . . . . . . . . . . . . 70
The American Medical Association and the WMA . . . . . . . . . 71
The French Medical Association . . . . . . . . . . . . . . . . . . . . . . . 73
Liberal practice in Belgium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
The Romanian College of Physicians . . . . . . . . . . . . . . . . . . . . 76
The Icelandic Medical Association . . . . . . . . . . . . . . . . . . . . . . 77
Between Slave Revolt and Chamber Presidency . . . . . . . . . . . . 78
Mali National Board of Physicians . . . . . . . . . . . . . . . . . . . . . . 79
Movement for Health: the Role of the World Confederation
for Physical Therapy (WCPT) . . . . . . . . . . . . . . . . . . . . . . . . . 80
Esteemed Colleague in Surgery. . . . . . . . . . . . . . . . . . . . . . . . . 82
Correction: We apologise to the author of the article » National Helath Service(England) for the mis-spelling of his name at
the beginning of the article (WMJ 55(1)). It should have read » Tom Frusher ».The contact e-mail address is
TFrusher@bma.org.uk
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