wmj8

WorldMedical Journal
Vol. No.4,December200551
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
wma Santiago
General Assembly – Reports
Contents
Editorial
2005 – a Lesson: “Humanity’s need for Care” 85
Medical Ethics and Human Rights
Sponsorship Guidelines 86
Enhancing the WMA Declarations
on Human Rights 86
Medical Science, Professional Practice
and Education
Health Care System Reform in Japan 88
The U.S. Health System: A Question of Access 90
WMA
Assembly Ceremonial Session, Santiago 2005 93
General Assembly, Santiago 2005 94
171th WMA Council Session 95
Resolution on Avian Influenza 97
Statement on Genetics and Medicine 98
Statement on Drug Substitution 100
Statement on Medical Liability Reform 101
General Assembly Associates’ Meeting 102
Beyond statements and resolutions – Working
at the WMA Secretariat in Ferney-Voltaire 103
From the Secretary General’s desk
“Don’t forget the others” 104
WHO
FAO/OIE/WB/WHO Meeting on Avian Influenza
and Human Pandemic Influenza 105
Massive international effort stops polio epidemic
across 10 West and Central African countries 107
Telemedicine via Satellite 108
Regional and NMA News
European Region 108
Latin America and the Caribbean 109
Korean Medical Association 109
Letters to the Editor 110
Review 111
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers and Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
i see page ii
President-Elect President Immediate Past-President
Dr K. Letlape Dr Y. D. Coble Dr J. Appleyard
South African Med. Assn. 102 Magnolia Street Thimble Hall
P.O. Box 74789 Neptune Beach, FL 32266 108 Blean Common
Lynnwood Ridge 0040 USA Blean, Nr Canterbury
Pretoria 0153 Kent, CT2 9JJ
South Africa Great Britain
Treasurer Chairman of Council Vice-Chairman of Council
Prof. Dr. Dr. h.c. J. D. Hoppe Dr Y. Blachar Dr N. Hashimoto
Bundesärztekammer Israel Medical Association Japan Medical Association
Herbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome
10623 Berlin 35 Jabotisky Street Bunkyo-ku
Germany P.O. Box 3566 Tokyo 113-8621
Ramat-Gan 52136 Japan
Israel
Secretary General
Dr O. Kloiber
World Medical Association
BP 63
France
ANDORRA S
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525/Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA S
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-114) 383-8414/5511
E-mail: comra@sinectis.com.ar
Website: www.comra.health.org.ar
AUSTRALIA E
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA E
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931
Fax: (43-1) 51406-933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA E
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-63
Fax: (3741) 53 48 79
E-mail:info@armeda.am
Website: www.armeda.am
AZERBAIJAN E
Azerbaijan Medical Association
5 Sona Velikham Str.
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS E
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 6802
Fax: (1-242) 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH E
Bangladesh Medical Association
B.M.A House
15/2 Topkhana Road,
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2-9566060/9568714
E-mail: bma@aitlbd.net
BELGIUM F
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
E-mail: absym.bras@euronet.be
Website: www.absym-bras.be
BOLIVIA S
Colegio Médico de Bolivia
Casilla 1088
Cochabamba
Tel/Fax: (591-04) 523658
E-mail: colmedbo_oru@hotmail.com
Website: www.colmedbo.org
BRAZIL E
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 317868 00
Fax: (55-11) 317868 31
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA E
Bulgarian Medical Association
15, Acad. Ivan Geshov Blvd.
1431 Sofia
Tel: (359-2) 954 -11 26/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA E
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 9331/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
CHILE S
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: sectecni@colegiomedico.c
Website: www.colegiomedico.cl
Titlepage: Semmelweis Hospital. Prof. I. Semmelweis worked in this hospital, later named after him,
when he left Vienna after the initial rejection of his ideas about the transmission of infection.
Editorial
2005 – a Lesson: “Humanity’s need for Care”
The editorial in the September issue was entitled “Backwards to the future?”. As this year
draws to its close it is natural to look back over the past 12 months and to consider where
we are and where we are going.
Internationally there has been much activity in the health field tackling long standing dis-
ease problems, as such HIV/AIDS and Malaria. Preventive policies such as basic immuni-
sation, the provision of impregnated mosquito nets continue to reduce morbidity and save
many lives, when the resources available permit their use and provision. Despite the ef-
forts to eliminate poliomyelitis major efforts are still needed to deal with the threat of sud-
den outbreaks requiring rapid large scale immunisation programmes, and the declaration
by WHO of Tuberculosis in Africa as an emergency, both highlight the need for constant
vigilance and continuing action. At the same time the underlying problem of poverty in
many parts of the underdeveloped, the developing and even the so-called developed
world, appear as far as ever from solution although the global summit meetings may assist.
All this has been complicated by natural disasters, such as those arising in Southeast
Asia, Pakistan and even in such a highly developed and affluent country as the USA, and
made sudden demands on health care resources both in terms of materials and skilled per-
sonnel.
Attention has been focused not only on the global shortage of healthcare personnel but
also on training and retention of physician policies in the face of developments such as
the “skills drain” phenomenon. Health Services Reform remains a high priority in many
countries and, both at national and international levels, continues to exercise those re-
sponsible – health professionals, administrators and politicians – as to how to proceed, at
what cost and at what speed change can or should be effected.
All of the above are having major impacts on many health professionals, including the
physicians. Long standing traditions of practice are being abandoned in the efforts to
meet the huge demands both of deprived populations and of those in more fortunate cir-
cumstances, in a rapidly changing society where speed of access to knowledge and scien-
tific developments are leading to new expectations.
Positive developments, increasing scientific knowledge, proven healthcare reform poli-
cies are of course to be welcomed, and the physicians, like others, should be prepared to
adapt their professional style of practice appropriately – points we have sought to empha-
sise in these columns. The changes are, however, often very radical. Reform of the basic
medical curriculum, the changing role of individual health professionals and professional
working practices are not easy to adapt to the speed which some politicians consider pos-
sible. Adequate consultation and co-operation on all sides is essential to achieve them.
One thing however remains constant regardless of the problems and issues mentioned
above, it is the continuing need for care and relief of humanity’s sick and suffering. This,
the medical profession clearly responded to the crises of the past year. Through the many
challenges which it will continue to face, this must remain at the centre of all its activity
in the future.
Alan Rowe
Editorial
85
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
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Editorial note: Please accept our apologies that unfortunately, due to technical problems,
it has not been possible to include all the reports of the Santiago WMA meeting in this is-
sue. The rest will appear in the next issue.
NMAs and financial relationships with all
outside organisations needed to be consid-
ered Dr. Appleyard (Immediate Past
President) made the point that in any ‘rela-
tionship’ there was potential for ‘influence’
both ways, The WMA was not a passive
partner and we should never compromise
our own internationally accepted ethical
standards, we should rather use any part-
nership ‘platform’ to promote them. Dr. H
Miyazaki (Japan) emphasised the impor-
tance of transparency in all our financial
arrangements Dr. Kloiber, the Secretary
General, said that specific guidance had
been developed for sponsorship by com-
mercial, governmental and charitable part-
nerships for specific projects or pieces of
work which were consistent with existing
WMA policies. He was advised by the
Sponsorship Advisory Committee, which
reviewed all potential developments. Dr.
Kloiber said that he personally had been
one of the greatest critics of commercial
sponsorship. In response to the question
about how much existing sponsors had
attempted to ‘influence’ the WMA, he said
he had not experienced any attempt to
influence the association whatsoever. Dr.
Kloiber felt that a Work Group could iden-
tify the concerns expressed and review the
existing guidelines
The committee agreed unanimously to rec-
ommend “That Council establish a Work
Group consisting of the Chairs of the
Medical Ethics and Finance and Planning
Committees, to review the WMA Corporate
Relationship Guidelines”. This was subse-
quently AGREED by Council. ■
This issue was discussed during the meet-
ing of the WMA Ethics Committee in
Santiago. We feel it to be of sufficient gen-
eral interest to include in the Journal.
(The following report is based on notes
kindly provided by Dr. Appleyard to whom
we are most grateful. Edit.)
Dr. Bagenholm introduced the issue of the
acceptance by the WMA of commercial
sponsorship funding. She indicated that the
current financial situation for the WMA
was difficult in that membership dues did
not cover the WMA’s expenses. Some
member organisations had approached her
with their concerns that the WMA had
become dependent on financial sponsor-
ship from the pharmaceutical industry for
many of its activities. Posing the question
as to why such industries want to sponsor
our activities, she said they became
involved so that they could influence us. If
the WMA was thought to be influenced by
the pharmaceutical industry, it would loose
its credibility. Dr. Bagenholm, recognized
that there were guidelines agreed by the
Council for such sponsorship, but felt that
they needed to be revisited to consider
whether it is ethical to receive sponsorship,
from the pharmaceutical industry and what
would be the financial implications. The
delegate from Denmark agreed that the eth-
ical and financial aspects should be recon-
sidered and suggested a small group com-
prising the Chair of Ethics and the Chair of
Finance and Planning be set up who could
receive information about how NMAs are
coping with these problems in their own
countries. (This was subsequently
approved by Council.) He felt that the
WMA mission was to foster the indepen-
dence of the profession and set the highest
possible ethical standards for physicians
worldwide. Ethics and Human Rights were
fundamental to our profession. National
Medical Associations founded the WMA
with these issues foremost in their minds
Medical Ethics and Human Rights
86
and we are only as strong as the individual
components of the ‘chain’ of our member-
ship associations.
Jon Snaedal, (Iceland) Icelandic Medical
Association and former chair of Ethics
agreed that the WMA needed to be finan-
cially ‘autonomous’ and should not rely on
other sources of finance. If we were seen to
be influenced by our Sponsors the WMA
would cease to be respected.
Dr. Johnson (UK) agreed that the ideal
would be that the WMA was self funding.
With the cost of all the activities at
International level with all our partners this
was not possible and he asked what was the
evidence of the WMA being influenced by
the current sponsors Dr. Kgnosi Letlape,
President Elect, told the meeting that there
were different issues in different countries,
In South Africa the main influence on the
Profession was that of Government and he
felt that Industry was much more under-
standing of the importance of the indepen-
dence of the Profession. Without their part-
nership and support, the Association would
not be able to function the way it does as an
advocate for its members. Ms. Wapner
(Israel) said that where there were matters
of ethics and finance, ethics was preemi-
nent. She recognized the concerns raised.
Any change in standards should apply to all
Medical Ethics and Human Rights
Sponsorship Guidelines
The WMA was founded in 1947 to attempt
to ensure that never again would doctors be
complicit in human rights abuses. The “big
three” WMA declarations – Geneva,
Helsinki and Tokyo – aim to raise ethical
standards globally, and to protect the rights
of the vulnerable. Despite these carefully
drafted words stories of medical involve-
ment in human rights abuses still emerge.
Current draft amendments to the Declara-
tions of Tokyo and Geneva and to the Regu-
lations in Times of Armed Conflict are the
latest attempt to fortify this global consen-
sus.
Enhancing the WMA Declarations
on Human Rights
V. Nathanson
Medical Ethics and Human Rights
87
The sad fact is that prisoners are subjected
to human rights abuses – both torture and
cruel inhuman and degrading treatment in
very many countries. Involvement by doc-
tors, when it occurs, is often a part of the
process; doctors resuscitate the torture sur-
vivor so that he or she can be tortured
again. They certify fitness for harsh inter-
rogations and for frankly abusive practices.
They falsify death certificates or other key
parts of medical and legal records. At the
same time other doctors are putting them-
selves at risk in decrying the torturers, doc-
umenting abuse, giving evidence in courts,
opposing systematic and episodic practices
that put people at risk of abuse and using
medical knowledge and expertise to protect
the vulnerable and challenge the abusers.
Allegations have emerged from a variety of
sources about the abuse of prisoners in Abu
Ghraib and in Guantanamo Bay.1
While no
cases have been brought against doctors
there are stories in circulation of doctor in-
volvement that would, if true, amount to se-
rious ethical failures. While these are not
the only places where such medical abuses
are alleged they are important as they high-
light apparent weaknesses in current WMA
policy. The BMA has led a WMA Council
working group that has prepared amend-
ments to existing policy that will, we be-
lieve, strengthen the appropriate prohibi-
tions.2
One issue that has arisen in relation to
these allegations as well as to those from
some other countries, is that medical
records are being provided to interrogators
to aid in targeting of harsh interrogation or
torture. Although the Declaration of Tokyo
is read by most people as disallowing this
practice, it does not currently say so ex-
plicitly. In too many countries physicians’
notes, recorded to help their patients and to
inform other health care workers about
their findings and treatment plans, are in-
stead used to undermine the safety and se-
curity of the individual. Some physicians
appear willing to hand over such notes, or
even to help the prison authorities use
medical information to devise a pro-
gramme that will undermine the mental or
physical health of a detainee. They argue
that as the code is silent on the prohibition,
it does not in fact exist. 3
For that reason an amendment has been
suggested to make this prohibition explicit.
This will not only strengthen the hand of
those doctors who refuse to hand over
records to prison authorities, but it may also
help doctors who work for agencies visiting
prisons and detention centres as part of the
checks and balances system of international
regulation, including the Red Cross, the
UNHCHR, Amnesty International and
MSF. This specific amendment has also
been repeated in the Regulations in Times
of Armed Conflict, to make doubly certain
that this prohibition exists regardless of cur-
rent political and security circumstances.
The carefully constructed language of
WMA declarations and regulations can also
become obscure over time as common lan-
guage usage changes. This is why the sug-
gestions for amendments include removing
the concept that physicians’ consciences
should be their guides and its replacement
with a requirement to adhere to internation-
al conventions on human rights, interna-
tional humanitarian law and WMA declara-
tions on medical ethics. The international
laws are easily found; they are the Geneva
Conventions and associated protocols of
which the ICRC acts as guardian. “The oth-
er laws and conventions are available on-
line from the UN or the WMA itself.” All
are clear; torture is prohibited, and we each
have an absolute right not to be subjected to
such treatment.
So are these changes a response to as yet
unproven allegations about Abu Ghraib and
Guantanamo Bay? No; not only to these,
but also to similar allegations to similar
abuses in many places
Many associations reading these changes
may wonder if they are necessary. I believe
that they are; the number of reportsAmnesty
and others can produce of medical involve-
ment in abuse makes change and reinforce-
ment of high norms essential. They give us,
as doctors, a chance to rededicate ourselves
to stopping abuse by doctors, or medical
complicity. They give us a chance to ap-
plaud those colleagues who stick their heads
above the parapet, putting themselves at risk
by adhering to the highest standards. They
give us an opportunity to condemn those we
think unworthy of their medical licences.
They can act as a call to arms for all of us to
defend vulnerable people around the world.
In short; they are an opportunity for the
WMAto reassert its core reason for existing.
Prof. Vivienne Nathanson
Director of Professional Services
British Medical Association
vnathanson@bma.org
1 See, for example, Lewis NA. Red Cross finds
detainee abuse in Guantanamo. New York
Times, Nov 30, 2004: A1. Okie S. Glimpses of
Guantanamo – medical ethics and the war on
terror. NEJM 353;24 15 Dec 05.
2 See WMA paper MEC/Misc/Dec2005
3 Bloche G, Marks J. When Doctors go to War.
NEJM 352:3-6 6 Jan 05
4 http://www.icrc.org/Web/Eng/siteeng0.nsf/
html/genevaconventions.
5 https://www.wma.net. ■
Nurses and Physicians Welcome Libyan Court’s Decision
to Reverse Death Sentences
The International Council of Nurses and the World Medical Association have welcomed the decision of
Libya’s Supreme Court to reverse the death sentences and order a retrial for five Bulgarian nurses and
a Palestinian doctor, accused of deliberately infecting more than 400 children with AIDS. The supreme
court has quashed the sentences and accepted the appeal against the lower court ruling on both sub-
stance and procedure. Prosecutors agreed with defence lawyers that there were “irregularities” in the
arrests and interrogations of the accused. Expert evidence that the cause was probably poor hygiene at
the hospital appeared to have been ignored. Indeed, infections were believed to have occurred before
the accused started work at the hospital, and continued after their arrests.
ICN and WMA call for a speedy retrial that will consider the evidence presented by international
experts and liberate the health professionals.
Japan is experiencing a lowering of the
birth rate and an aging of the population. In
1985, population from 0 to 4-year-old
accounted for 6.2% of the total population.
In 2004, the figure declined to 4.5%. On the
other hand, the elderly over 65 years old
accounted for 10.3% of the total population
in 1985 and increased to 19.5% in 2004. As
this indicates, the population structure is
rapidly changing. In the current year, 2005,
population aged 4 years old or below is
4.5% of the total population, and this figure
is estimated to decrease to 3.6% in 2025.
People aged 65 years or over, however,
account for 19.9% of the total population in
the current year, 2005, and this is estimated
to increase to 28.7% in 2025. These trends
of declining birth rate and aging population
are expected to continue at an even more
accelerated rate in the future. This situation,
combined with the deteriorated financial
basis of the nation, is calling for social
security reform. Health care system reform
is currently underway to keep the system
sustainable in the future, supported by bal-
anced economic and fiscal foundation.
The government proposes a basic policy
plan for health care system reform. It is
necessary to radically change all parts of
the health care system, while taking into
account changes in the medical environ-
ment, the rapidly declining birth rate and
aging population, and the current stagnant
economy, as well as advances in medical
technologies and shifts in the public’s atti-
tude. It is also essential to reform the health
care system, health care delivery system,
medical fee programme, and the health
insurance system. In other words, a health
system that meets the demands of the
changing environment is required. In addi-
tion to the basic points for reform, the gov-
ernment also proposes the following
improvement, They are, the importance of
respecting the patients’ point of view, pro-
motion of disclosure of health information,
reestablishment of safe and assured health
care, provision of quality and efficient
health care, establishment of a health care
delivery system of high quality and effi-
ciency, separation of roles between medical
institutions for more focused and efficient
medical services, ensuring necessary health
services in communities, cultivation of
human resource in health care and improve-
ment of their quality, improvement of the
structural basis for health care, and the
improvement of the foundation for health
care to support lives in the 21st century.
However, the government is pushing poli-
cies to “contain health costs” to “ensure
appropriate health costs” because of wors-
ening national finances. It is trying to intro-
duce the total budget system of health care
costs as well as controlling the increasing
costs to suppress the growth of social secu-
rity costs lower than the economic growth.
What is needed for health care from the
general public is improved quality and safe-
ty of health care. From the government’s
point of view, however, it is containment of
health costs. The problem may be how well
the medical profession can meet these
needs. The Japan Medical Association
(JMA) advocates that it is fundamentally
necessary to ensure the health insurance
system which permits every citizen to
equally receive health services with an
insurance card, anytime and anywhere,
which may be most characteristic of
Japan’s health system.
The JMA considers that all the people have
a right to lead a healthy life, and enhance-
ment of social security for this purpose is
an obligation of the government. Health
care is an asset for the public good, and
development of the foundation of the health
care system is the responsibility of the
nation. The government should not fit
Medical Science, Professional Practice and Education
88
health care to the economy. The economy
should be fitted to health care. To secure
quality health care and provide safe health
services, financial resources to cover the
health costs are necessary. We maintain
that the policies to contain health costs
surely lead to lowered quality of health
care and may block the promotion of safer
medical services.
In relation to the health status of Japan,
according to the report by WHO, Japan
retains the longest average life expectancy
in the world. As for the health care costs,
when total health care costs are compared
with GDP, Japan has the 17th lowest health
care cost among the OECD countries.
Furthermore, in comparison with other
countries for health achievement, Japan
ranked No. 1 in life expectancy and in
overall rating of health achievement.
Japan’s health insurance system is an
excellent system with high performance at
low cost.
Looking at the trends of national health
care expenditure and live expectancy, the
growth of expenditure and average life
expectancy for females, is in proportion. Of
course, there are other factors such as
advances in medical technologies and
increase disease in the elderly. However,
the increase in expenditure is obviously
linked and corresponds with the growth of
average life expectancy. The containment
of health expenditure could, therefore,
shorten life expectancy.
The financial resources of Japan’s health
costs consist of public expenditure (taxes),
premium from employers and the insured,
and patient cost sharing. From 1990 to
2002, the percentage of public expenditure
showed little changes. As for the premi-
ums, the burden on the employers
decreased, while the percentage of patient
cost sharing increased. This is because of
the increase in the patient’s co-payment for
medical services from 20% to 30% after
April 2003 and the establishment of the
fixed amount of payment by the elderly
which started in October 2002. In Japan, a
limit is set for patients’ co-payment at
72,300 yen (approximately 650 US dollars)
for the general public, except for low-
income earners. However, the government
Medical Science, Professional Practice and Education
Health Care System Reform in Japan
Hideki Miyazaki, MD, Ph.D
Vice President, Japan Medical Association
Presented at WMA Scientific Session, Santiago
has been taking policies to increase the
costs to be paid by the patient in the past
few years. It is contrary to the principles of
insurance when you consider that the
insured who pays the premiums to be cov-
ered by the insurance has to pay extra costs
to receive health services.
There is a large gap between the employ-
ee’s pension insurance rate and the health
insurance rate. This partly accounts for the
deficit of the health costs. The health insur-
ance rate has hardly changed since 1980. In
2003, the employee’s pension insurance
rate dropped because premiums were
charged for total remuneration, including
bonuses. The insurance rate up to the year
2018 has been set by law. However, there is
no policy to increase the health insurance
rate further and when compared with the
employee’s pension, it is undervalued. The
health insurance rate, if increased, will help
to secure resources for the health costs.
Japan’s national contribution ratio which is
the ratio of tax burden and social security
burden has been showing around 37% for
the past 18 years which is very low. In the
government’s policy, the rate should be
suppressed below 50% at the highest, but it
is already at a low level, compared with
other developed countries.
The comparison of the ratio of national
health expenditures to GDP, and the break-
down of public and private spending in
major countries, suggests that health costs
in Japan need an increase of 1 to 2% of pub-
lic spending to GDP when compared with
Sweden, France, and Germany. From this
point of view, the government should allo-
cate more of its money on health care areas.
I have just explained the current situation in
Japan. The problem in the health care sys-
tem reform to be discussed here is that the
number of insurers in Japan is extraordinar-
ily large when compared with health care
insurance systems of other countries. In the
Revised Health Insurance Act enacted 2
years ago, integration and unification of
different kinds of insurances is one of the
items to be studied in the future.
In 2004, the number of insurers managed
by the national government is 1, while
those managed by health insurance soci-
eties is 1,674 and those managed by sea-
men’s insurance is 1. As for the mutual aid
insurance, the number of insurers managed
by the national government employees
mutual aid associations is 23; those man-
aged by local government employees mutu-
al aid associations is 54; those managed by
private school teachers & employees mutu-
al aid is 1. As for national health insurance,
the number of insurers managed by munic-
ipalities is 3,224 and those managed by
associations is 166. The total number of
insurers is 5,144 with the total of insured
persons being 94,248,000.
Currently there is a discussion to integrate
and reorganize the insurers in each prefec-
ture, and it is suggested firstly to integrate
those managed by municipalities and by
national government.
The Japan Medical Association is propos-
ing basic policies for the health care system
reform.
We firstly and strongly advocate for main-
taining the universal health insurance sys-
tem. We are also suggesting the creation of
new Medical Insurance System for the
Elderly to address public concerns. The
system with the national government as
insurer would cover only those aged 75
years and older. However, the system will
be managed by the local government after a
certain period of time. We are proposing for
the financial sources of this system special;
10% of the contribution from the patient,
10% from insurance premiums, with–con-
sideration for low-income earners, and 80%
from public expenses and national mutual
assistance such as consumption tax and cig-
arettes tax. If a health insurance system is
seen as a part of social security system, it is
necessary to increase public funding or tax
to meet its need for financial sources.
Compared to other in major countries, the
price of cigarettes is the lowest for Japan
and it is necessary to discuss various relat-
ed matters including a consumption tax
scheme and a proposal for an earmarked tax
for health car.
A rise in cigarette prices may be the most
efficient measures to cut the number of
smokers. We are proposing to utilize the
increased tax for financial resources for
health care.
Health care should not be regulated by age.
This is natural when you think about char-
acteristics of the elderly and their potential
diseases. The Medical Insurance System for
the Elderly will be based on self-help, and
mutual and public assistance. The health
insurance system in Japan provides benefits
in kind sufficiently to meet people’s needs
for health care. In Japan, the Long-term
Care Insurance System was established for
those aged over 40 years of age in 2000,
which provides cash benefits to support
long-term or nursing care. The fund comes
from the premiums and public spending.
The level of nursing care required is divid-
ed into 5 levels, each having a set quota. We
distinguish between a long-term or nursing
care and medical care. And necessary
arrangements are being made between the
two areas of care. Therefore, the Long-term
Care Insurance System, which provides
cash benefits, and the health insurance sys-
tem cannot be integrated. Control of the
growth rate of health costs based on the
economic indicators such as GDP should
not be permitted because it disturbs neces-
sary and safe health care.
To enhance the level of health services for
the elderly, it is important to promote pre-
ventative measures against lifestyle-related
diseases to keep the elderly healthy. Co-pay-
ment by patients should be decreased and
should not exceed the current level. The
government should extend the retirement
age of workers to 65 years of age. All retired
employees should join the National Health
Insurance which provides benefits which
will be covered by patients’ co-payment,
premiums and mutual assistance between
employee’s health insurance systems.
The government managed health insurance
system has been enlarged by the Social
Insurance Agency and been establishing
and managing hospitals. Retired bureau-
crats of the Health, Labour and Welfare
Ministry have been obtaining jobs at these
hospitals. A reform is going to abolish these
hospitals.
As for the health care delivery system, in a
comparison of the average number of visits
per person per year in major countries, it is
Medical Science, Professional Practice and Education
89
21 higher times in Japan, the highest figure.
However, health cost per one visit in Japan
compared with other countries in 63 US dol-
lars, which is very low. To sum it up, it can
be said that health cost in Japan is very low.
In an international comparison of the health
care delivery system in 1998, the number of
beds per 1,000 people was high at 13.1 in
Japan, while the number of physicians per
100 beds was low at 12.5. Furthermore, the
number of nursing staff per 100 beds was
also low at 43.5, with the longest average
number of hospital stays being 31.8. The
rate of outpatient visits stand at 16.0. This
reveals the facts that in Japan the people
have many opportunities to visit any kind
of medical institutions under the universal
health insurance, the period of hospital stay
is long, and a patient is attended by a small
number of physicians and nursing staff.
To shorten the hospital stay, we are trying
to review the organizational problems relat-
ed to the inpatient settings, health care
delivery system, and the revision of the
medical fees. The Japan Medical Asso-
ciation is making its utmost efforts to main-
tain the universal health insurance which
Japan is proud of, to provide necessary and
safer health care services for all the nation
of Japan. ■
Medical Science, Professional Practice and Education
90
I am delighted to be here today on behalf of
the American Medical Association. My
visit with you continues a decades-long tra-
dition of mutual friendship and support.
And our friendship, now and in the future,
is even more vital than it has been in the
past. Together, we face potential pandemics
and terrorist threats. Public health chal-
lenges from tsunamis, hurricanes, earth-
quakes and floods. We are subject to eco-
nomic and political decisions made far
away that have immediate impact in our
communities – that affect access to care and
quality of care for our patients. More than
others, perhaps, we recognize that disease
and discord, that epidemics and terrorists,
alike, respect no boundaries.
We also know that knowledge and our
mutual caring for our patients know no
boundaries, either. No boundaries and no
limits. In such a world, cooperation among
our associations and within the WMA is
more important that ever. I shines like a bea-
con – a model for ethical behavior for all
other professions and associations. Today,
as we discuss the strenghts and weaknesses
of our nations’ health care systems, we can
learn from each other. Identify the best prac-
tices – and the worst pitfalls. And steer our-
selves toward a better, healthier world
tomorrow.
The Uninsured
This is something the American Medical
Association is trying to deal with in my
homeland, the United States.
There, medical care is financed and deliv-
ered through both public and private
means. Persons over the age of 65 are cov-
ered under the Medicare program, adminis-
tered by our national federal government.
The economically disadvantaged are eligi-
ble for Medicaid, administered on the state
level with partial federal funding.
Most American workers get their health
insurance through their employers, a prac-
tice that started during World War II, when
wages were controlled. Health insurance
emerged as a way to enhance benefits for
workers who couldn’t get salary increases.
For some people, this patchwork system
works well. For those with access, the U.S.
offers what I believe is the highest quality
care in the world, despite our significant
delivery and systems problems.
But for others, it barely functions, if at all.
For instance, there are almost 46 million
Americans who have no health insurance.
That’s about 15 percent of our population –
a national disgrace.
The employer-based system of health
insurance is showing signs of weakness.
More than 80 percent of the uninsured – 36
million of them – work or are members of
working families. They hold down jobs and
draw a paycheck. For them, living without
health insurance has terrible consequences
for health and economic well-being. They
live sicker and die younger. Often, they
delay seeking help until they are suffering
from a more advanced stage of disease –
when treatment is often more expensive –
and less effective.
But it takes a toll on more than the individ-
ual. It extracts a heavy cost on our society
in terms of reduced employment and pro-
ductivity, and the flood of uninsured into
emergency departments and free clinics has
a price tag, too.
In 2004, American taxpayers spent 35 bil-
lion U.S. dollars from uncompensated,
publicly-funded care. That’s $4 million per
hour every day. And this number doesn’t
take into account the additional billions of
dollars spent on privately given care,
including uncompensated care by physi-
cians.
Managed Care Concentration
So the question is, how do we in the United
States repair our system? It is flawed, and
fails to give coverage to enough people.
One of the most severe issues, not only
with those who have no health insurance,
but for all American patients, is continuity
of care – the patient-physician relationship.
That relationship has been under siege in
recent decades in the U.S.
In my practice, I’ve seen some of my
patients for many years. I know their med-
ical histories. I can follow up on old prob-
lems or see subtle changes that a stranger
The U.S. Health System:
A Question of Access
Presented at the World Medical Association Scientific Session, Santiago
J. Edward Hill, MD, President American Medical Association
Medical Science, Professional Practice and Education
91
might not. In these circumstances, a patient
feels comfortable – and is better able to ask
questions and communicate.
This patient-physician relationship is the
cornerstone of medicine. A healthy and
continuous relationship with a physician
can lower costs by getting a patient access
to the health care system at an earlier stage
of a disease.
But with the spread of privately run man-
aged care in the U.S., this continuity has
been disrupted. Patients often move from
physician to physician – when their
employers change health plans – or when
their physician decides not to contract with
a given insurer.
Perhaps it is because with some of the more
abusive insurers – physicians are paid less
to see more patients and work longer hours.
It is clear that a more competitive insurance
landscape would help protect the quality of
medical care – and ultimately lower costs
for consumers.
What we have structured is a cost-based
care system – while we should be offering a
care-based cost system. We need to put
decisions about health care coverage – back
where they belong: in the hands of patients
– and their physicians.
In the United States, a handful of giant
health insurance companies dominate the
market. It makes it difficult for an individ-
ual physician to negotiate patient care
issues with what are essentially monopo-
lies.
Managed care organizations have consoli-
dated at a record pace in the United States,
with more than 350 mergers and acquisi-
tions in one five-year span.
The AMA is working to redress this imbal-
ance.
We believe regulators should start looking
more closely at the behavior of the health
insurance industry. Also that physicians
should be able to negotiate more effective-
ly with large health insurance companies.
Because when the health care market land-
scape is dominated by just a few giant com-
panies, it forces physicians to accept unfair
contracts which can have serious implica-
tions for patient care.
Single-Payer Not the Answer
Some would argue that the solution to the
problem of the uninsured would be to adopt
a single-payer national health insurance
plan. Most of you in this room practice
under such a system, in one form or anoth-
er.
Proponents of such a system are passionate
and vocal. But we at the American Medical
Association respectfully disagree. We
believe a single-payer system in the United
States would:
• Require physicians to negotiate a bind-
ing fee schedule;
• Discourage hospital expansions and
capital purchases;
• Eliminate the health insurance industry,
eliminating institutional memory and
hundreds of thousands of jobs;
• Force employers to transfer money ear-
marked for health benefits to a national
health insurance program.
• And discourage the innovation that has
driven medical advances and innova-
tions in the United States over the past
century.
To us, this runs counter to freedom, choice,
and private enterprise, qualities ingrained in
the American psyche, and which fuel
American society.
Such a system would be exponentially
more difficult to manage in the United
States than it is almost elsewhere, because
we have a “melting pot” society with a
remarkably diverse and diffuse character. It
makes our country especially resistant to
one-size-fits-all solutions imposed from
above.
The AMA believes that by implementing a
single-payer system, the United States
would be trading one set of problems for
another.
• We would see long, detrimental waits
for care and the rationing of care.
• We would be slow to adopt new tech-
nology and maintain facilities.
• We would be bound by price controls,
which eventually drive up costs;
• And it would create a gigantic bureau-
cracy that interferes with clinical deci-
sion making.
Would a single-payer system save us
money? We don’t think so. We believe that
such a conclusion is rooted in faulty and
incomplete comparisons of administrative
costs between the United States and coun-
tries that offer a single-payer system.
It has long been recognized that public
insurance imposes a variety of costs on
patients, including excessive wait times, a
proliferation of short visits, and lack of
access to certain services and procedures.
In June 2003, the Chairman of the British
Medical Association characterized the
U.K.’s single-payer health care system as:
“The stifling of innovation by excessive,
intrusive audit … the shackling of doctors
by prescribing guidelines, referral guide-
lines and protocols … the suffocation of
professional responsibility by target-setting
and production-line values that leave little
room for the professional judgment of indi-
vidual doctors or the needs of individual
patients.” So say a physician with long,
first-hand experience with a single-payer
health system.
We have to recognize that nothing worth-
while – comes without a price. The fact is
that effective prices play a role in the provi-
sion of, and access to, services in any health
care system, not just market-based systems.
In the final analysis, consumers clearly pay,
in one way or another – regardless of the
system.
Any system that offers access to care with-
out direct charges to consumers generates
demand for care that exceeds what can be
delivered. Ultimately, there is no guarantee
that even medically urgent services will be
available when needed.
The AMA has a viable solution – one that
does not limit the universe of choices and
that does not dictate a single-payer system
as the only path toward universal health
coverage.
Medical Science, Professional Practice and Education
92
AMA Plan for the Uninsured
The AMA has long advocated that every
American should have health insurance and
thus access to medical care. We’ve been
working with other major players on the
American health care scene to raise the pro-
file of this issue – and to remind the public
of its urgency. We believe the country will
seriously address this issue eventually.
As Winston Churchill once said,
“Americans can always be counted on to do
the right thing … after they have exhausted
all other possibilities”.
The American Medical Association believe
we have a plan that would expand health
insurance coverage in our country. We think
it’s the right thing to do.
The plan is simple:
• Give people money to buy their own
health care coverage.
• Give wealthy people less money. Give
more to poor people.
The AMA plan has three pillars – tax cred-
its, individual ownership and selection of
plans, and regulatory reform.
The most central point to understand – is
the system of tax credits. Under the AMA
plan, all workers would get a tax credit
large enough to ensure they could purchase
affordable coverage. The tax credit would
be inversely related to income. This means
that the people with the lowest incomes –
those most likely to be uninsured – would
get the biggest subsidy. The tax credits
would be refundable, so families that owe
little or no taxes would still get a credit.
Finally, the credits would be available in
advance, so that families who can’t afford
monthly premiums don’t have to wait for a
year-end refund to bye coverage.
What’s more, Americans could choose and
purchase a health care plan that fits their
needs.
At present, of those companies that offer
health care coverage only one in six offers
a choice of more than one plan. Under the
AMA insurance proposal, employees could
choose to get coverage through their
employers or not.
This would empower people. Allow them to
do what federal government employees,
including members of our U.S. Congress,
can do today. That is to choose from a wide
array of plans. This in turn, would create
competition and vibrant health insurance
markets.
Finally, our plans for regulatory reform
would also bring sanity and reason to the
current maze of market regulations for
health insurance.
Currently, some regulations aimed at pro-
tecting high-risk individuals have the unin-
tended consequence of a driving up the
number of people who are insured.
We aim to create a more sensible regulato-
ry system. A system that gives incentives to
patients to purchase coverage before they
get sick. And that gives incentives to insur-
ers to cover high-risk individuals. Overall,
our plan to expand health care coverage and
choice – would get 94 percent of Americans
covered. This is just one example of how
we could improve market regulations for
health insurance and get more people cov-
ered in the process.
These kind of market-based approaches for
reform in the United States are already
showing promise. The removal of some
mandates, for example, has made possible a
new kind of plan that combines high
deductible insurance with health savings
accounts – HSAs. These accounts allow
consumers to use tax free dollars to pay for
out of pocket health care costs, or to roll
those dollars over. Nationwide, more than
one million people have already signed up
for HSAs. And the best part is that the sta-
tistics show that about one-third of them
were previously uninsured. [U.S. Chamber
of Commerce].
Can groups like families of the develop-
mentally and mentally disabled benefit
from these kinds of market-driven reforms,
too? We think so. That’s why we endorse
the concept of a tax-exempt medical trust to
provide for the long-term health care needs
of disabled family members. And we think
this concept should be linked to our overall
plan to finance health care for all
Americans. [H-165.893]
There’s no reason that anyone should be left
out of the picture (when it comes to creat-
ing a system driven by choice), that has the
potential to increase quality of life and
reduce costs for all patients.
The AMA’s plan of action is a good one. If
enacted nationally, it could give more than
94 percent of Americans health coverage.
It is an idea with powerful support. During
the most recent U.S. presidential campaign,
the candidates from both major political
parties endorsed the general concept of
using tax credits for individuals to purchase
health care coverage. However, given cur-
rent government budget challenges, we
know it’s unlikely that our plan will be
enacted nationally soon. That’s way we are
willing to support an incremental approach.
For example, we would like to see pilot
programs on local government levels to try
out our reforms. Such pilot programs could
focus on particularly vulnerable popula-
tions such as a low-income people, chil-
dren, or the chronically ill. Pilot programs
have the added benefit of allowing policy-
makers to guide future decisions through
actual data an experience and letting them
see how the AMA plan could work on a
national scale.
An editorial from one of America’s leading
newspaper, The Detroit News said, “The
AMA is offering a credible blueprint for
fundamental health care reform. It deserves
a hearing in Congress.” We agree.
But we know that this won’t be easy. That’s
why our leadership is bringing our ideas to
a group called the Search for Common
Ground. This group has all the major play-
ers and associations in health care –
employers, health plans, physicians and
many more. The one thing we have in com-
mon is that we’re all frustrated that 45 mil-
lion Americans are uninsured and 10 to 15
million more are underinsured. The mission
of this group? To cover as many people as
possible as soon as possible through non-
governmental solutions. Together, we can
get coverage for the millions of Americans
who lack it and we can maintain the integri-
ty and quality of American medicine in the
process.
WMA
93
Conclusion
One thing is certain – whatever insurance
plan we arrive at will be a uniquely
American system, with uniquely American
characteristics. Yet perhaps we can show
the world a different approach to providing
health coverage to everyone in our commu-
nities – and our countries.
We have a motto in the American Medical
Association that goes like this:
“Together we are stronger.”
It sounds self-evident, but it is a powerful
idea.
Working together – in meetings just like
this – we all become stronger.
Our profession becomes stronger. We learn
from each other. We find out more about what
works in medicine – and what doesn’t. And
we reinforce the foundation of science, ethics,
caring and compassion that supports all we
do. Through our work our patients are better
off. No matter what our health care system.
No matter what our country. The commitment
of the world’s physician to their patients is
one thing that doesn’t need reform. ■
The ceremony was opened by the President,
Dr. Yank D. Coble Jr., who warmly thanked
the Chilean Medical Association and its
leaders for the excellent arrangements and
the warmth and hospitality which had been
shown to the participants. He then called on
Dr. Juan Luis Castro, President of the
Chilean Medical Association, to address the
Assembly.
Dr. Castro in welcoming the Assembly, said
that the Chilean Medical Association was a
voluntary organisation with 20000 mem-
bers. Speaking about the problems of the
profession in Chile, he referred both to the
need to improve salaries (stating that on
qualification earnings were about $ 300
and after five years might reach $30000),
but stressed that a major problem was that
of lawsuits and liability He mentioned that
these resulted in about 180 trials a year and
spoke of the pioneering experience in Latin
America of creating the Foundation for
Legal Assistance (FALMED) to manage
lawsuits against the physicians and avoid
increases in insurance costs. Another
important achievement was the restoration
of ethical defence for the Association. At a
time when many countries were undergoing
processes of health reform, Chile was no
exception. There, physicians are witnessing
changes which will impact greatly on the
medical profession and its relations with
patients.
Thanking him Dr. Coble then introduced Dr.
Pedro Garcia, the Chilean Minister of
Health, who addressed the Assembly. He
welcomed delegates and referred to the
importance of the profession meeting to dis-
cuss problems. As a doctor himself and as a
politician he was, of course, interested in the
challenges facing society. Referring to the
complexity of the geography of Chile he
said this posed many problems for health
care, but there was a long history of health
care in the country and they still looked to
physicians to keep up with new develop-
ments in scientific knowledge and health
care. In his view it was there was need for
politicians and physicians to work together
to solve these problems and he was there-
fore particularly delighted that the WMA
had chosen to meet in Chile. He congratulat-
ed all the bodies responsible for the organi-
sation of the meeting, in particular, the
Chilean Medical Association. He pointed
out that 80% of Chilean doctors were mem-
bers of the CMA, of which he had been one
for many years. He hoped that delegates
would be able to get some idea of the
Chilean Health Reforms and also that they
would see something of the country during
their visit. He would be happy to respond to
any questions and he closed by wishing the
WMA a very successful conference.
Dr. Blachar, the Chair of Council, paid a
tribute to Dr. Yank Coble for his outstand-
ing services during his Presidential term of
office and invested him with the Past
President’s medal following which Dr.
Coble gave his valedictory address (This
will appear in WMJ 52 (1))
Dr. Blachar then introduced the new
President Dr. Kgosi Letlape and invited him
to take the oath of office. Following this,
Dr. Blachar invested him with the
President’s Badge of Office and invited him
to address the meeting (see Inaugural
Presidential Address p. 94).
Dr. Blachar after thanking the speakers for
their addresses and once again the members
of the Chilean Medical Association for invit-
ing the WMA to hold its General Assembly
in Santiago, adjourned the meeting. ■
WMA
WMA Assembly Ceremonial Session, Santiago 2005
WMA
94
Honourable Minister of Health Dr. Pedro
Garcia, Dr. Castro, the President of the
Chilean Medical Association, Honoured
Guests, Ladies and Gentlemen
Thank you for the privilege you have given
me to serve as President of the World
Medical Association. I assume this role on
behalf of all physicians on earth, but please
indulge me as I single out particularly my
brothers and sisters of Africa.
I would firstly like to congratulate Dr. Yank
Coble on an extraordinary Presidency.
Through his Presidential initiative of
“Caring Physicians of the World”, he has
managed to re-establish the fundamental
values of medicine–caring, ethics and sci-
ence. Together with the book on caring
physicians, he has succeeded in making us
feel good about being doctors again–so
Yank, thank you again for your leadership,
dedication and commitment to our profes-
sion. I find it a humbling experience to fol-
low him as President and hope that I will be
able to rise to the occasion.
An old Israeli saying states that you have to
look back to where you have come from, to
better see where you are heading. Looking
back over the last few years, it is gratifying
to note that the WMA has unquestionably
grown into the representative voice of
physicians. The World Health Organi-
zation, World Bank and other UN agencies
turn to the WMA if they need to hear the
views of physicians. Through our alliance
with the International Council of Nurses,
International Pharmaceutical Federation
and the World Dental Federation we have
also been able to make major break-
throughs in the field of public health.
Within the WMA there have also been very
positive developments. Our role as the cus-
todians of medical ethics has been rein-
forces by the successful revision of the
Declaration of Helsinki and the launch of
the WMA Ethics Manual. The impact of
the manual has been immediate and very
front line physicians. In addition, the
WMA called for Taiwan to be included in
the WHO surveillance and response net-
work, as they are a separate health entity,
not receiving any funding or assistance
from China. Here we are in 2005, with
avian flu posing as a possible disaster of a
proportion we have not seen since the
Spanish Flu epidemic in 1918, when mil-
lions died. Yet we do not have a fully func-
tional network where the physicians and
medical associations are directly linked to
WHO. The gab in the global public health
network, Taiwan, a country with 23 million
citizens, has not been yet addressed. If
avian flu is transmitted from China to
Taiwan, as had happened with SARS, there
are still no formal channels open between
WHO and Taiwan to exchange technical
data and provide help. Clearly we need to
be more vocal and active as social leaders
to make sure that all measures can be taken
to include all the peoples of the world in
preparing for health disasters.
The UN Commanding Officer in Rwanda
General Dallaire said that after shaking
hands with the devil in Rwanda he knows
there is a God. Noting that SARS never
came to Africa in 2003 I have also come to
know fully that God is there for all of us.
I offer you another story from my own con-
tinent. Last year the fundamentalist gover-
nor of Nigeria’s Kano State halted all polio
immunisation efforts because of alleged
and unsubstantiated claims that it was part
of a plot to sterilize Muslim girls. By the
time he relented, polio hat spread to 12
African countries that had previously been
freed of the disease, thereby dramatically
setting back global eradication efforts and
forcing the rest of the world to continue
vaccination programmes–another classic
example of where politics ruled over health
imperatives. Where were we, the physi-
cians of the world, in preventing this kind
of disaster? We can and should prevent this
from happening again!
In Northern Europe over the last year,
physicians have expressed their severe dis-
satisfaction with the new trend of rationing
of care, ever increasing paper work, work
hours and diminishing remuneration. This
led to protest actions in France, Germany
WMA General Assembly, Santiago 2005
Inaugural Presidential Address
Dr. T. K. S. Letlape
significant. From its publication in January
this year, it has now already been distrib-
uted worldwide and translated into at least
12 languages.
The WMA’s recent contributions in health
related human rights have also been wel-
comed by my compatriots from Africa. We
cannot encourage the WMA enough to help
physicians to be involved as the advocates
and protectors of patients and the vulnera-
ble groups in society. It will be part of my
Presidential plan to help push forward our
health-related human rights agenda.
I see the future role of the WMA as more
and more that of social leaders, in addition
to our role as the leaders of the health care
teams. I would like to tell you three stories
from the North, South and East to illustrate
this point.
In the East we currently have an outbreak
of avian flu. You will remember that in
2003 the world endured the SARS epidem-
ic, where hundreds of patients died in
China, Taiwan, Singapore and Canada. At
the Time the WMA argued strongly for the
establishment of a global surveillance and
response network which would include
WMA
95
and Belgium. As governments find it diffi-
cult to fund health care services (from the
patients’ own money), rationing has
increasingly been used to balance accounts.
This has placed great pressure on the
patient-physician relationship and physi-
cian autonomy. In September Belgian doc-
tors protested against a proposed new gov-
ernment policy, whereby the Ministry of
Health could intervene whenever the coun-
try’s health insurance budget goes into
deficit, effectively being able to exclude
financial benefits for certain types of diag-
nosis or treatment. What is in fact happen-
ing is that health care is being dumped
down to the lowest common denominator
of cost. Even more importantly, rationing is
slowly destroying the art and professional
practice of medicine, the patient-physician
relationship and patient access to all treat-
ment options. Physicians are expected to
act as administrative clerks and accoun-
tants and their professional role downgrad-
ed to select the least expensive, not the best
available, treatment for their patients.
This trend of political considerations deny-
ing our patients the best possible health
care services is unacceptable. We cannot
allow politics to stand in the way of effec-
tive handling of epidemics or disasters
affecting both national and international
levels. It highlights the fact that physicians
need to become more effective in shaping
the health policy environment, rather than
be shaped by it.
As I mentioned before, the last WMA
Presidency very effectively re-affirmed the
fundamental values of medicine. During
my term as President, I would like to place
the focus on patient-centred medical care.
As physicians we can draw encouragement
from the fact that patients still regard us as
the most trusted source of health informa-
tion, but as communicators we can do
much better. Patients are overawed with the
information they can now source from the
internet, but recent reports show that physi-
cians still don’t communicate effectively
enough with their patients. During my term
I hope that we can revisit out policy on
patient information and communication
and develop a training manual on the sub-
ject, as we have done so successfully for
ethics and human rights. We must remem-
ber always that our responsibilities come
before our rights.
We have two themes in the vision of the
World Medical Association, these are ethics
and access. Whilst we have been in the
forefront on ethics, there is still a lot to be
done on access. We have collective respon-
sibility globally to ensure access to basic
healthcare for all citizens of the word. The
Millennium Development Goals are being
rolled back and those that are needing help
are not necessarily receiving it. Globally,
healthcare is being under-funded and physi-
cian autonomy is interfered with, thus
undermining patients` rights. Doctors need
to work together with civil society to create
a safer world that can fund health care
appropriately.
I come from South Africa, the epicentre of
the HIV and AIDS epidemic. Therefore I
would like to close with an impassioned
plea for the WMA and all its members to
fully taken on the responsibility of combat-
ing HIV. This is still a growing disease,
where the role physicians can and should
play has not been optimized. This is espe-
cially true for our role in prevention. So far
only a limited number of full scale preven-
tion efforts have been developed with effec-
tively target “at risk” populations, the infra-
structure of health systems, societal atti-
tudes and individual beliefs and motiva-
tions.
Remember, prevention in HIV and AIDS is
ABCD, the four letters of the alphabet col-
lectively and in the proper sequence; selec-
tive application of the alphabet is hazardous
to the health of the people.
We need to ensure that our doctors are
trained appropriately to fulfil the role that
they play as leaders and healers. Medical
schools train them to be great healers; we
need to find a way to appropriately train
them to be great leaders too. We need a pro-
gramme to assist National Medical
Associations to get doctors to be good lead-
ers as well. I will dedicate my years as pres-
ident to realise this objective as a follow-on
to caring physicians, so that we can emulate
those caring physicians and truly put our
patients first.
There are three things to remember:
1. Health is political even for doctors but
we will be non-partisan and engage
others, as opposed to confronting them.
2. Health is a foundation for peace not a
bridge, for as we saw in the aftermath of
Katrina, bridges were swept away but
the foundations remained.
3. A quote from Nelson Mandela: “After
climbing a great hill, one finds that
there are many more hills to climb.”
Having seen the hills and mountains of
Chile, I wonder if Mr. Mandela ever lived
in Chile!
I would like to end by thanking our hosts,
the Chilean Medical Association for their
unforgettable warmth and hospitality dur-
ing this Assembly. We are inviting you all
to our Assembly in South Africa next year
where we will try to emulate them. ■
(We are particularly indebted to Dr.
Appleyard for his background notes on this
meeting. Ed.)
The 171th Council meeting took place in
Santiago, Chile on 14th October 2005.
The meeting was opened by the Chairman,
Dr. Blachar who called on the Secretary
General to give his report.
Secretary General’s Report
Dr. Otmar Kloiber thanked the President,
Dr. Yank Coble, for his dedication and for
the ‘added value’ he had given to the Asso-
ciation through the “Caring Physicians of
the World” initiative. The resulting book
provides insight into how our physician
171th WMA Council Session
WMA
96
colleagues throughout the world serve their
patients under conditions that are often hard
to accept. The initiative had also supported
conferences in different parts of the world.
Dr. Kloiber also thanked all NMAs for their
response to the disaster caused by the
Tsunami and mentioned that money was
still being collected. He expressed his grat-
itude to specific NMAs for their support, in
particular for the staff time provided by the
AMA, in particular to Sharon Ostrowski
and Robin Menes, to the BMA, which
through Dr. Vivienne Nathanson provided
support for Work Groups, the Canadian
Medical Association and Dr. Bill Thould
for the Business Development Group, the
German Medical Association especially for
Dr. Parsa-Parsi’s secondment, Ms Leah
Wapner and the Israeli Medical Asso-
ciation, also to the Norwegian Medical
Association for the online courses.
Turning to restructuring of WMA Office
Team, he reported that since the last meeting
of Council Ms. Emma Viaud, a member of
Staff, had left the office. Dr. Parsi had been
seconded to the office for three months and
had, among other items, worked on the
development of the TB Course, Outreach to
Arab Countries, and on the Regional Office
for Africa in SAMA.
The Prison Medical Course had now been
translated into Spanish and is available on a
CD-Rom.
Dr. Kloiber appealed to all NMAs to assist
the Office in Ferney Voltaire by making
available secondments for one of their staff
to work at the WMA for three months until
another member of staff has been employed
It was felt that this could provide a valuable
educational opportunity for NMAs’ junior
medical staff.
Dr. Kloiber thanked Johnson and Johnson
for their continuing support of the Ethics
Unit and the production of the Ethics
Manual and to the South African, Australian
and Norwegian MA’s for their work on the
TB project.
Following the successful completion of the
implementation of the Istanbul Project in
five nations with the ICRT, the work will be
extended to other countries through a fur-
ther grant from the European Commission.
Dr. Kloiber reported that the FDI had now
joined the World Health Professions Alli-
ance. At a very successful WHPA Reception
on Patient Safety held at the same time as
the World Health Assembly. Sir Liam
Donaldson, Chairman of the World Alliance
for Patient Safety, gave the keynote address.
A joint seminar will be held next year on
three topics, the Reporting of Medical
Errors, Counterfeit Medicines and on
Human Resources for Health.
Turning to finance and organisation, Dr.
Kloiber told Council that his first priority
following his appointment was to ensure
sound financial governance. In this he had
had great support from Mr Adi Hällmayr
and Dr. Karsten Vilmar, the Treasurer
Emeritus. He had had to apply the brakes to
give an emergency stop to expenditure.
Stating that his main concern was to know
how much of the WMA could be used for
advocacy he commented that the WMA had
established a high reputation internationally
and its opinion was increasingly being
sought for its professional expertise.
Concerning Forced Sterilizations, since the
last Council meeting Dr. Kloiber had been
in correspondence with the Slovak Medical
Association about allegations that some
Physicians in Slovakia had been involved
in forced sterilisations (an illegal practice in
that country). The Slovak Medical Asso-
ciation had investigated these allegations
with the Slovakian Government. The Board
of the Slovakian Medical Association had
written, stating that the allegations could
not be confirmed and that none of the mem-
bers of the Slovakian Medical Association
had been involved.
Dr. Kloiber reported that since the last
Council Session he had attended meetings
of the AMA, BMA, Norwegian MA and
Cuban Medical Association. He valued
these personal contacts and by participating
in the meetings had a greater understanding
of local issues. Further visits to other NMAs
will be undertaken next year.
Dues
The Revision of the Dues system as proposed
by the Treasure Emeritus was considered.
Dr. Plested (AMA) asked if the full implica-
tions of the proposed changes had been
explored and whether some NMAs would
use this schedule as an opportunity to reduce
their dues. Dr. Kloiber replied that he antici-
pated that the changes would be cost neutral.
The NMA’s from poorer nations would be
able to receive more votes in proportion to
their subscriptions and become more
involved in the activities of the WMA. The
lower cost would encourage non members
from poorer nations to join. He emphasised
that there would be no change in the dues
paid by the larger and richer NMA’s, who
provide 85% of the WMAs dues revenue.
After Dr. Johnson (BMA) agreed that the
recommendations had to be taken as a ‘pack-
age’, the revised dues system wasAGREED.
Sponsorship
Dr. Plested (AMA) proposed that the speci-
fication for new Sponsorship projects should
be reassessed to ensure robust projections for
anticipated Income and Expenditure. He
moved a motion, seconded by Dr. Nelson
(USA),‘that the Secretary General work
within the existing guidelines to maximise
non-dues income“. This was AGREED.
Medical Ethics Committee
Report
This was presented by the Chairman, Dr.
Bagenholm.
Minor Revisions of Declarations etc.
The Declaration of Lisbon, as revised, was
approved.
It was agreed that a work group be convened
by the AMA with the BMA to integrate
NMA comments on the ‘Statement of
Ethical Issues concerning patients with
Mental Illness’, which was re-classified as
requiring major revision.
Major Revisions of Declarations etc.
It was resolved that all the Documents clas-
sified as requiring major revisions be
referred to NMA’s for comment.
Concerning the Policy Review of the
Declarations of Geneva, of Tokyo, and the
Regulations in Times of Armed Conflict, Dr.
Nathanson gave an oral report on her pro-
WMA
97
posals to amend these statements. It was
AGREED that the proposals of the BMAs
convened Work Group be circulated to
NMA’s.
Sponsorship Guidelines
Dr. Bagenholm reported on the discussion
within her committee on the principle of
accepting sponsorship It was AGREED that
Council establish a Working Group of the
Chairs of Ethics and of Finance and
Planning Committees, to review the WMA’s
Corporate relationship Guidelines (see page
86 for fuller account of the discussion).
Socio-Medical Affairs
Committee Report
Dr. Haddad in presenting his report, intro-
duced for the first time a Consent Calendar
for the Recommendations of his Committee.
This procedure involves the presentation of
all the Recommendations from the
Committee together as one recommenda-
tion, with the option that any member of
Council could request the withdrawal of any
specific recommendation, for further debate.
The report was for the first time presented
as a consent calendar, which meant that all
recommendations that were not challenged
(extracted) were then voted for en bloc and
approved.
Dr. Plested suggested the extraction of para
2.2.1, the Proposed Statement on Reducing
the Global impact of Alcohol. This enabled
him to speak in favour of the document
emphasising the point made within it of the
necessity for a Strategic Framework similar
to the one on Tobacco, following this the
statement was agreed unanimously (the
Alcohol Statement will appear in the next
issue of WMJ).
Skills Drain
The BMA had prepared two background
papers on the Healthcare Skills Drain from
Developing Countries.These will be distrib-
uted to NMA’s for information.
Finance and Planning
Committee
Dr. John Nelson presented his report of the
meeting of the committee. All the recom-
mendations were adopted without further
debate including the revised dues structure.
(see also Dues above)
Other Business
Recommendations on Business Develop-
ment and on Non-dues income were agreed
(see above!).
Disaster Planning
It was AGREED that a Work Group be
established to consider the preventive mea-
sures and contingencies necessary for
Disaster Planning including the possible
Asian Flu pandemic. The Canadian, South
African, German and American MA’s will
contribute to this.
Preventing Chronic Diseases
Dr. Appleyard (IPP) referred to his report to
Council in May concerning the WHO initia-
tive on Preventing Chronic Diseases and
stressed the importance of the major finan-
cial burden this would place on developing
countries. WHO was launching the initia-
tive at the end of October and it would be
appropriate for the WMA to identify itself
with this important preventive venture. In
view of the time constraints he suggested a
special Council Resolution:
„The WMA (Council) welcomes the
WHO Report on “Preventing Chronic
Diseases, a vital investment, and recom-
mends that all NMA’s work with health
professional organisations, interested
stakeholders and their Governments, to
prevent and relieve the increasing burden
of chronic disease.
This was formally proposed by Dr. Haddad
and seconded by Dr. Wu.
Dr. Kloiber raised concerns about the finan-
cial impact saying that he had no capacity to
attend the launch later in the month.
After further debate to which Dr. Appleyard
replied, reading out for translation purposes
a brief background paper he had prepared,
the Council Resolution was AGREED nem
con, with the caveat that there would be no
additional cost incurred.
(full WHO report is accessible at
www.who.int/chp/chronic_disease_report/
overview_en.pdf)
Executive Committee
Dr. John Nelson raised a question about the
composition of the Executive Committee,
expressing concern at the exclusion of the
three Presidents as non-voting members.
Presidents were elected from the General
Assembly representing all the NMAs, not
just those larger NMA’s who had ‘bought’
seats on the Council with their larger
declared membership. Dr. Kloiber said that
he was bound by the last decision of Council
that only the voting members of Council
would be included on the executive. These
had been specified as the Chair of Council,
Deputy Chair, and the Chair of the three
Committees. The Executive committee had
already decided to revisit the issue again. ■
The World Medical Association recog-
nizes the potential global morbidity and
mortality as a result of the H5N1 strain of
avian flu. This possibility increases with
every passing day as more countries find
infected birds in their territories. The
WMA will work with member NMAs, the
WHO and other stakeholders to track the
progress of the disease and propose the
necessary measures to minimize its
impact on the global human population.
The WMA also urges governments to
engage with NMAs to prepare for the pos-
sibility of a pandemic.
The World Medical Association Resolution on
Avian Influenza
Adopted by the WMA General Assembly, Santiago 2005
WMA
98
Preamble
1. In recent years, the field of genetics has
undergone rapid change and development.
The areas of gene therapy and genetic
engineering and the development of new
technology have presented possibilities
inconceivable only decades ago.
2. The Human Genome Project opened new
spheres of research. Its applications also
proved useful to clinical care by allowing
physicians to utilize knowledge of the
human genome in order to diagnose future
disease, as well as to individualize drug
therapy (pharmacogenomics).
3. Because of this, genetics has become an
integral part of primary care medicine.
Whereas at one time, medical genetics
was devoted to the study of relatively rare
genetic disorders, the Human Genome
Project has established a genetic contribu-
tion to a variety of common diseases. It is
therefore incumbent upon all physicians
to have a working knowledge of the field.
4. Genetics is an area of medicine with enor-
mous medical, social, ethical and legal
implications. The WMA has developed
this statement in order to address some of
these concerns and provide guidance to
physicians. These guidelines should be
updated in accordance with developments
in the field of genetics.
Major Issues:
Genetic Testing
5. The identification of disease-related genes
has led to an increase in the number of
available genetic tests that detect disease
or an individual’s risk of disease. As the
number and types of such tests and the
diseases they detect increases, there is
concern about the reliability and limita-
tions of such tests, as well as the implica-
tions of testing and disclosure. The ability
of physicians to interpret test results and
counsel their patients has also been chal-
lenged by the proliferation of knowledge.
6. Genetic testing may be undergone prior to
marriage or childbearing to detect the
presence of carrier genes that might affect
the health of future offspring. Physicians
should actively inform those from popula-
tions with high incidence of certain genet-
ic diseases about the possibility of pre-
marital and pre-pregnancy testing, and
genetic counseling should be made avail-
able to those individuals or couples who
are considering such testing.
7. Genetic counseling and testing during
pregnancy should be offered as an option.
In cases where no medical intervention is
possible following diagnosis, this should
be explained to the couple prior to their
decision to test.
8. In recent years, with the advent of IVF,
genetic testing has been extended to pre-
implantation genetic diagnosis of embryos
(PGD). This can be a useful tool in cases
where a couple has a high chance of con-
ceiving a child with genetic disease.
9. Since the purpose of medicine is to treat,
in cases where no sickness or disability is
involved genetic screening should not be
employed as a means of producing chil-
dren with pre-determined characteristics.
For example, genetic screening should not
be used to enable sex selection unless
there is a gender-based illness involved.
Similarly, physicians should not counte-
nance the use of such screening to pro-
mote non-health related personal attribut-
es.
10. Genetic testing should be done only with
informed consent of the individual or
his/her legal guardian. Genetic testing for
predisposition to disease should be per-
formed only on consenting adults, unless
there is treatment available for the condi-
tion and the test results would facilitate
earlier instigation of this treatment.
11. Valid consent to genetic testing should
include the following factors:
a. The limitations of genetic testing,
including the fact that the presence of a
specific gene may denote predisposi-
tion to disease rather than the disease
itself and does not definitively predict
the likelihood of developing a certain
disease, particularly in multi-factorial
disorders.
b. The fact that a disease may manifest
itself in one of several forms and in
varying degrees
c. Information about the nature and pre-
dictability of information received
from the tests.
d. The benefits of testing including the
relief of uncertainty and the ability to
make informed choices, including the
possible need to increase or reduce reg-
ular screenings and checkups, and to
implement risk reduction measures
e. The implications of a positive result
and the prevention, screening and/or
treatment possibilities.
f. The possible implications for the fami-
ly members of the patient involved.
12. In the case of a positive test result that
may have implications for third parties
such as close relatives, the individual test-
ed should be encouraged to discuss the
results of the test with such third parties.
In cases where not disclosing the results
involves a direct and imminent threat to
the life or health of an individual, the
physician may reveal the results to such
third parties, but should usually discuss
this with the patient first. If the physician
has access to an ethics committee, it is
The World Medical Association Statement on Genetics and Medicine
Adopted by the WMA General Assembly, Santiago 2005
WMA
99
preferable to consult such a committee
prior to revealing results to third parties.
Genetic Counseling
13. Genetic counseling is generally offered
prior to marriage or conception, in order
to predict the likelihood of conceiving an
affected child, during pregnancy, in order
to determine the condition of the fetus, or
to an adult, in order to determine suscepti-
bility to a certain disease.
14. Individuals at higher risk for conceiving a
child with a specific disease should be
offered genetic counseling prior to con-
ception or during pregnancy. In addition,
adults at higher risk for various diseases
such as cancer, mental illness or neuro-
degenerative diseases in which the risk
can be tested for, should be made aware of
the availability of genetic counseling.
15. Because of the scientific complexity
involved in genetic testing as well as the
practical and emotional implications of
the results, the WMA sees great impor-
tance in educating and training medical
students and physicians in genetic coun-
seling, particularly counseling related to
pre-symptomatic diagnosis of disease.
Independent genetic counselors also have
an important role to play. The WMA
acknowledges that there can be very com-
plex situations requiring the involvement
of medical genetics specialists.
16. In all cases where genetic counseling is
offered, it should be non-directive and
protect the individual’s right not to be test-
ed.
17. In cases of counseling prior to or during
pregnancy, the prospective parents should
be given information to provide the basis
for an informed decision regarding child-
bearing, but should not be influenced by
the physicians’ personal views in this mat-
ter and physicians should be careful not to
substitute their own moral judgment for
that of the prospective parents. In cases
where a physician is morally opposed to
contraception or abortion, he/she may
choose not to provide these services but
should alert prospective parents that a
potential genetic problem exists and make
note of the option of contraception or
abortion as well as treatment alternatives,
relevant genetic tests, and the availabili-
ty of genetic counseling.
Confidentiality of results
18. Like all medical records, the results of
genetic testing should be kept strictly con-
fidential, and should not be revealed to
outside parties without the consent of the
individual tested. Third parties to whom
results may in certain circumstances be
released are identified in paragraph 12.
19. Physicians should support the passage of
laws guaranteeing that no individual shall
be discriminated against on the basis of
genetic makeup in the fields of human
rights, employment and insurance.
Gene therapy and genetic research
20.Gene therapy represents a combination
of techniques used to correct defective
genes that cause disease, especially in the
fields of oncology, hematology and
immune disorders. Gene therapy is not
yet an active current therapy but is still in
a stage of clinical investigation.
However, with the continued develop-
ment of this field, it should proceed
according to the following guidelines:
a. Gene therapy performed in a research
context should conform to the require-
ments of the Declaration of Helsinki
while therapy performed in a treatment
context should conform to standards of
medical practice and professional
responsibility.
b. Informed consent should always be
obtained from the patient undergoing
the therapy. This informed consent
should include disclosure of the risks of
gene therapy, including the fact that the
patient may have to undergo multiple
rounds of gene therapy, the risk of an
immune response, and the potential
problems arising from the use of viral
vectors.
c. Gene therapy should only be undertak-
en after a careful analysis of the risks
and benefits involved and an evaluation
of the perceived effectiveness of the
therapy, as compared to the risks, side
effects, availability and effectiveness of
other treatments.
21. It is currently possible to undertake
screening of an embryo in order to pro-
vide stem cell or other therapies for an
existing sibling with a genetic disorder.
This may be considered acceptable med-
ical practice where no evidence exists that
the embryo is being created exclusively
for this purpose.
22. Genetic discoveries should be shared as
much as possible between countries, so as
to benefit humankind and reduce duplica-
tion of research and the risk inherent in
research in this area.
23. In the case of genetic research performed
on large, defined population groups,
efforts should be made to avoid potential
stigmatization.
Cloning
24. Recent developments in science have led
to the cloning of a mammal and raise the
possibility of such cloning techniques
being used in humans.
25. Cloning includes both therapeutic clon-
ing, namely the cloning of individual stem
cells in order to produce a healthy copy of
a diseased tissue or organ for transplant,
and reproductive cloning, namely the
cloning of an existing mammal to produce
a duplicate of such mammal. The WMA
currently opposes reproductive cloning,
and in many countries it is considered to
pose more of an ethical problem than ther-
apeutic cloning.
26. Physicians should act in accordance with
the codes of medical ethics in their coun-
tries regarding the use of cloning and be
mindful of the law governing this activity.
WMA
100
Introduction
1. The prescription of a drug represents
the culmination of a careful delibera-
tive process between physician and
patient aimed at the prevention, amelio-
ration or cure of a disease or problem.
This deliberative process requires that
the physician evaluate a variety of sci-
entific and other data including costs
and make an individualized choice of
therapy for the patient. Sometimes,
however, a pharmacist is required to
substitute a different drug for the one
prescribed by the physician. The World
Medical Association has serious con-
cerns about this practice.
2. Drug substitution can take two forms:
generic substitution and therapeutic
substitution.
3. In generic substitution, a generic drug
is substituted for a brand name drug.
However, both drugs have the same
active chemical ingredient, same
dosage strength, and same dosage
form.
4. Therapeutic substitution occurs when a
pharmacist substitutes a chemically dif-
ferent drug for the drug that the physi-
cian prescribed. The drug substituted
by the pharmacist belongs to the same
pharmacologic class and/or to the same
therapeutic class. However since the
two drugs have different chemical
structures, adverse outcomes for the
patient can occur.
5. The respective roles of physicians and
pharmacists in serving the patient’s
need for optimal drug therapy are out-
lined in the WMA Statement on the
Working Relationship between
Physicians and Pharmacists in
Medicinal Therapy.
6. The physician should be assured by
national regulatory authorities of the
bioequivalence and the chemical and
therapeutic equivalence of prescription
drug products from both multiple and
single sources. Quality assurance pro-
cedures should be in place to ensure
their lot-to-lot bioequivalence and their
chemical and therapeutic equivalence.
7. Many considerations should be
addressed before prescribing the drug
of choice for a particular indication in
any given patient. Drug therapy should
be individualized based on a complete
clinical patient history, current physical
findings, all relevant laboratory data,
and psychosocial factors. Once these
primary considerations are met, the
physician should then consider com-
parative costs of similar drug products
available to best serve the patient’s
needs. The physician should select the
type and quantity of drug product that
he or she considers to be in the best
medical and financial interest of the
patient.
8. Once the patient gives his or her con-
sent to the drug selected, that drug
should not be changed without the con-
sent of the patient and his or her physi-
cian. Failure to follow this principle
can result in harm to patients. On
behalf of patients and physicians alike,
National Medical Associations should
do everything possible to ensure the
implementation of the following rec-
ommendations:
Recommendations
9. Physicians should become familiar
with specific laws and/or regulations
governing drug substitution where they
practise.
10.Pharmacists should be required to dis-
pense the exact chemical, dose, and
dosage form prescribed by the physi-
cian. Once medication has been pre-
scribed and begun, no drug substitution
should be made without the prescribing
physician’s permission.
11.If substitution of a drug product occurs,
the physician should carefully monitor
and adjust the dose to ensure therapeu-
tic equivalence of the drug products.
12.If drug substitution leads to serious
adverse drug reaction or therapeutic
failure, the physician should document
this finding and report it to appropriate
drug regulatory authorities.
13.National Medical Associations should
regularly monitor drug substitution
issues and keep their members advised
on developments that have special rele-
vance for patient care. Collection and
evaluation of information reports on
significant developments in this area is
encouraged.
14.Appropriate drug regulatory bodies
should evaluate and ensure the bioe-
quivalence and the chemical and thera-
peutic equivalence of all similar drug
products, whether generic or brand-
name, in order to ensure safe and effec-
tive treatment.
15.National Medical Associations should
oppose any action to restrict the free-
dom and the responsibility of the physi-
cian to prescribe in the best medical
and financial interest of the patient.
16.National Medical Associations should
urge national regulatory authorities to
declare therapeutic substitution illegal,
unless such substitution has the imme-
diate prior consent of the prescribing
physician.
The World Medical Association Statement on Drug Substitution
Adopted by the WMA General Assembly, Santiago 2005
WMA
101
1. A culture of litigation is growing around
the world that is adversely affecting the
practice of medicine and eroding the
availability and quality of health care
services. Some National Medical
Associations report a medical liability
crisis whereby the lawsuit culture is
increasing health care costs, restraining
access to health care services, and hin-
dering efforts to improve patient safety
and quality. In other countries, medical
liability claims are less rampant, but
National Medical Associations in those
countries should be alert to the issues
and circumstances that could result in
an increase in the frequency and severi-
ty of medical liability claims brought
against physicians.
2. Medical liability claims have greatly
increased health care costs, diverting
scarce health care resources to the legal
system and away from direct patient
care, research, and physician training.
The lawsuit culture has also blurred the
distinction between negligence and
unavoidable adverse outcomes, often
resulting in a random determination of
the standard of care. This has led to the
broad perception that anyone can sue
for almost anything, betting on a chance
to win a big award. Such a culture
breeds cynicism and distrust in both the
medical and legal systems with damag-
ing consequences to the patient-physi-
cian relationship.
3. In adopting this Statement, the World
Medical Association makes an urgent
call to all National Medical
Associations to demand the establish-
ment of a reliable system of medical
justice in their respective countries.
Legal systems should ensure that
patients are protected against harmful
practices, physicians are protected
against unmeritorious lawsuits, and
“standard of care” determinations are
consistent and reliable, so that all par-
ties know where they stand.
4. In this Statement the World Medical
Association wishes to inform National
Medical Associations of some of the
facts and issues related to medical lia-
bility claims. The laws and legal sys-
tems in each country, as well as the
social traditions and the economic con-
ditions of the country, will affect the rel-
evance of some portions of this
Statement to each National Medical
Association but do not detract from the
fundamental importance of such a
Statement.
5. An increase in the frequency and sever-
ity of medical liability claims may
result, in part, from one or more of the
following circumstances:
a. Increases in medical knowledge and
medical technology that have
enabled physicians to accomplish
medical feats that were not possible
in the past, but that involve consider-
able risks in many instances.
b. Pressures on physicians by private
managed care organizations or gov-
ernment-managed health care sys-
tems to limit the costs of medical
care.
c. Confusing the right to access to
health care, which is attainable, with
the right to achieve and maintain
health, which cannot be guaranteed.
d. The role of the media in fostering
mistrust of physicians by questioning
their ability, knowledge, behaviour,
and management of patients, and by
prompting patients to submit com-
plaints against physicians.
6. A distinction must be made between
harm caused by medical negligence and
an untoward result occurring in the
course of medical care and treatment
that is not the fault of the physician.
a. Injury caused by negligence is the
direct result of the physician’s failure
to conform to the standard of care for
treatment of the patient’s condition,
or the physician’s lack of skill in pro-
viding care to the patient.
b. An untoward result is an injury
occurring in the course of medical
treatment that was not the result of
any lack of skill or knowledge on the
part of the treating physician, and for
which the physician should not bear
any liability.
7. Compensation for patients suffering a
medical injury should be determined
differently for medical liability claims
than for the untoward results that occur
during medical care and treatment,
unless there is an alternative system in
place such as a no-fault system or alter-
nate resolution system.
a. Where an untoward result occurs
without fault on the part of the physi-
cian, each country must determine if
the patient should be compensated
for the injuries suffered, and if so, the
source from which the funds will be
paid. The economic conditions of the
country will determine if such soli-
darity funds are available to compen-
sate the patient without being at the
expense of the physician.
b. The laws of each jurisdiction should
provide the procedures for deciding
The World Medical Association Statement on Medical Liability Reform
Adopted by the WMA General Assembly, Santiago 2005
WMA
102
liability for medical liability claims
and for determining the amount of
compensation owed to the patient in
those cases where negligence is
proven.
8. National Medical Associations should
consider some or all of the following
activities in an effort to provide fair and
equitable treatment for both physicians
and patients:
a. Establish public education programs
on the risks inherent in some of the
new advances in treatment modali-
ties and surgery, and professional
education programs on the need for
obtaining the patient’s informed con-
sent to such treatment and surgery.
b. Implement public advocacy pro-
grams to demonstrate the problems
in medicine and health care delivery
resulting from strict cost contain-
ment limitations.
c. Enhance the level and quality of
medical education for all physicians,
including improved clinical training
experiences.
d. Develop and participate in programs
for physicians to improve the quality
of medical care and treatment.
e. Develop appropriate policy positions
on remedial training for physicians
found to be deficient in knowledge
or skills, including policy positions
on limiting the physician’s medical
practice until the deficiencies are
corrected.
f. Inform the public and government of
the dangers that various manifesta-
tions of defensive medicine may
pose (the multiplication of medical
acts or, on the contrary, the absten-
tion of the physicians, the disaffec-
tion of young physicians for certain
higher risk specialties or the reluc-
tance by physicians or hospitals to
treat higher-risk patients).
g. Educate the public on the possible
occurrence of injuries during med-
ical treatment that are not the result
of physician negligence, and estab-
lish simple procedures to allow
patients to receive explanations in
the case of adverse events and to be
informed of the steps that must be
taken to obtain compensation, if
available.
h. Advocate for legal protection for
physicians when patients are injured
by untoward results not caused by
any negligence, and participate in
decisions relating to the advisability
of providing compensation for
patients injured during medical treat-
ment without any negligence.
i. Participate in the development of the
laws and procedures applicable to
medical liability claims.
j. Develop active opposition to merit-
less or frivolous claims and to con-
tingency billing by lawyers.
k. Explore innovative alternative dis-
pute resolution procedures for han-
dling medical liability claims, such
as arbitration, rather than court pro-
ceedings.
l. Encourage self-insurance by physi-
cians against medical liability
claims, paid by the practitioners
themselves or by the employer if the
physician is employed.
m.Encourage the development of vol-
untary, confidential, and legally pro-
tected systems for reporting unto-
ward outcomes or medical errors for
the purpose of analysis and for mak-
ing recommendations on reducing
untoward outcomes and improving
patient safety and health care quality.
n. Advocate against the increasing
criminalization or penal liability of
medical acts by the courts.
Dr. G Dumont was re-elected Chair and the
minutes of the meeting in Tokyo 2004 were
approved.
Arising from the minutes, Dr. Kloiber, the
Secretary General, reported that, following
last year’s resolution in connection with
forced sterilisation of women in the Slovak
Republic, he had written to the Slovak
Medical Association. The Slovak Ministry
of Health had investigated the allegation
with the Medical Association. The allega-
tions were found to have no foundation.
The Slovak Medical Association had writ-
ten to WMA stating that no member of the
SMA had been involved in this practice
which was illegal in the Slovak Republic.
General Assembly Associates’ Meeting,
Santiago 2005
The Secretary General, reporting on the total
numbers of Associate Members commented
that he was reviewing the role of Associate
Members in the future, pointing out that the
International Dental Federation’s associate
members played a more proactive role.
Responding to a proposal by Dr. Mont-
gomery, the longest serving member present
at the meeting, that the meeting be disband-
ed, Dr. Appleyard opposing this ,said that
the Associate’s meeting had produced some
helpful statements, citing the two which
were on the agenda as examples. Junior doc-
tors were keen to form a group within WMA
WMA
103
and he referred to IFMSA members being
eligible for free associate membership of
WMA for three years after graduation. Dr.
Kloiber confirming this, pointed out that res-
olutions of theAssociates’meeting were sent
to the General Assembly, although Council
tended to consider them first.
After an extensive debate it was agreed that
the Secretary General would report back on
his deliberation.
Dr. Montgomery proposed, seconded by Dr.
Nelson, that Assembly business be consid-
ered next on the agenda. Although this was
opposed by Dr. Fransblau, the motion was
adopted by a large majority.
The meeting then elected Drs. Montgomery
and Smoak as representatives at the General
Assembly.
The meeting then considered a resolution on
Medical Assistance in Air Travel submitted
by the late Dr. Odenbach, presented on his
behalf by Dr. Kloiber. This was supported
by Dr. Montgomery. Dr. Appleyard felt that
the issue of liability in circumstances where
humanitarian help was offered was impor-
tant and proposed that the motion be
referred to Council in the first instance. The
proposal was seconded by Dr. Montgomery
and the Resolution was adopted.
A second proposed Resolution on Child
Safety in Air travel, was introduced by Dr.
Kloiber, expressing concern that adequate
safety systems for babies and small chil-
dren had not been implemented. After some
discussion the Resolution was passed unan-
imously. ■
The author of the following note spent three
months in the WMA Office this year and
writes about the experience and what it
offers.
The voice of the World Medical Association
is considered as the opinion of millions of
physicians from every region of the world.
Its function has always been to constitute a
free, open forum for the frank discussion of
matters related to medical ethics, medical
education, and socio-medical affairs. With
its declarations and statements it has con-
tributed significantly to national and inter-
national debates. Approved by its General
Assembly, WMA documents guide national
medical associations, health care, govern-
ments, non-governmental organisations and
United Nations agencies.
The World Medical Association has also,
however, always been involved in many
other activities beyond statements and reso-
lutions. A number of global projects and
programmes are continuously initiated,
supported or conducted by the WMA.
These activities might not be as visible and
well known to the health care community
and the general public.
Who is doing all the work?
People might assume that a few tens of
highly specialized staff members work
inexorably in the high-tech offices of a
large WMA headquarters. The WMA must
surely work with heavy administration and
staff budgets?
In truth, for reasons of economy, and in
order to operate within the vicinity of
Geneva-based international organizations
like the WHO and other UN agencies, the
International Red Cross and international
associations, the WMA Secretariat was
transferred in 1975 from New York to its
present location in Ferney-Voltaire, France
close to Geneva.
Membership of the World Medical
Association is voluntary and its budget is
funded from membership fees from nation-
al medical associations. Hence, funds are
limited and vary significantly. The WMA
has been a marvel in managing projects,
programmes and its meetings and assem-
blies with extremely small budgets. Its
Secretariat operates with a small permanent
staff only, but manages to accomplish an
impressive amount of work.
The WMA would certainly be interested to
commit itself to even more projects and
activities. However, more manpower
would be necessary. One way to increase
capacities at WMA is its programme for
health care professionals to spend three to
six months at the WMA Secretariat in
Ferney-Voltaire. National medical associa-
tions may use this opportunity to send a
staff-member for a short-term “training” at
the WMA Secretariat.
There is certainly no better way to get to
know the work of the WMA and experi-
ence the job environment of a truly interna-
tional organization.
It is a win-win-situation
Fellows are able to dive into „hands on“
work from the very first day. Apart from
some routine work which clearly helps to
understand the every-day work of an inter-
national organization, Fellows have the
chance to take on the management of indi-
vidual projects. Fellows routinely interact
with senior health care experts from the
various health care organisations and work
self-responsibly and independently.
For example, this summer the WMA start-
ed a project to develop an online course for
physicians on multi-drug-resistant tubercu-
Beyond statements and resolutions – Working
at the WMA Secretariat in Ferney-Voltaire
Dr. Ramin Parsa-Parsi, MD, MPH, German Medical Association
WMA
104
losis (MDR-TB). The WMA had previous-
ly developed a similar programme for
physicians in prisons. This training course
is being developed to train physicians to
more effectively diagnose, prevent and
treat MDR-TB. The WMA is collaborating
with the South African Medical
Association and its Foundation for
Professional Development on this project.
The WMA is also collaborating with the
WHO and several national medical associ-
ations in order to produce a state-of-the art
and universally accessible product. The
Norwegian Medical Association is trans-
forming the material into the online format
and the German Medical Association is
helping with logistic support. The manage-
ment and the coordination of the entire pro-
ject is performed by WMA staff. Although
the coordination of all stakeholders and
international experts can be challenging,
helping to make this project happen is a
truly exciting and rewarding task. The final
product will be an important contribution
to the global fight against MDR-TB.
For another project the WMA collaborates
with the International Rehabilitation
Council for Torture Victims (IRCT) on a
European Union sponsored project. Using
the “Istanbul Protocol” as a manual, physi-
cians are trained in effective investigation
and documentation of torture and other
cruel, inhuman or degrading treatment or
punishment. The training seminars were
completed in five pilot countries: Morocco,
Mexico, Uganda, Sri Lanka and Georgia.
WMA experts participated in coordination
and evaluation meetings and attended
preparatory missions and training semi-
nars. The WMA particularly fostered the
identification process with national med-
ical associations and used its special exper-
tise in medical ethics during seminars.
Also, the collaboration with other organiza-
tions, local authorities and consultants has
been helpful and important in the process.
The continuation of the project with a new
phase is projected to run over a three-year
period and will most probably start by
January 2006. The new project will include
a consolidation of activities in the five cur-
rent project countries and initiate activities
in five new countries. Furthermore it will
support capacity-building activities for
rehabilitation centres and strengthen the
collaboration between centres and local
human rights organizations. The IRCT and
the WMA have a formal partnership in this
project with shared responsibilities. The
collaboration has been extremely good.
Regular contact and discussions on key
issues helped ensuring a coordinated and
efficient process.
Applications are welcome
Being involved in the work of various dif-
ferent projects, fellows will experience the
entire spectrum of health care services and
systems. Furthermore, regular communica-
tion with representatives of national med-
ical associations, including new and future
WMA members, helps understanding the
differences and similarities of physician
organizations worldwide. Also helping to
prepare Council meetings and the Annual
General Assembly is indeed rewarding. In
short: Working at the WMA Secretariat is a
unique experience.
National Medical Associations who are
interested in the fellowship programme
may contact the WMA Secretariat in
Ferney-Voltaire. Interested parties may also
contact previous fellows for more detailed
information.
Please contact:
Dr. Ramin Parsa-Parsi
Phone: 030/ 4004 56-366
The World Medical Association
13, ch. du Levant
CIB – Bâtiment A
01210 Ferney-Voltaire
France
Phone: +33 4 50 40 75 75
Fax: +33 4 50 40 59 37
e-mail: wma@wma.net ■
While currently the whole world seems to
worry about the prisoners in Guantánamo
Bay those incarcerated in the other prisons
of Cuba seem to be forgotten. Men and
women asking for nothing but freedom,
who are not involved in terrorism, war or
oppression, are being held as prisoners of
conscience permanently or repeatedly,
some for decades. Many of them have not
survived the special treatment by the Cuban
government and others possibly will die.
While for many of us Cuba may be seen as
a cheap Caribbean holiday resort, for those
living there the paradise may have some
dark spots. For more than forty years Cuba
has been under communist dictatorship.
What has been overcome in most of the for-
mer communist countries in Europe, terror,
intimidation, oppression, and prosecution
of those who want freedom, still lives in
Cuba.
The “Cuban Spring 2003” stands for an
aggressive “cleaning-up” campaign which
the communists carried out in Cuba: As far
as it is known in the free world, 75 persons
were sentenced to long prison terms of up
to 28 years. The way they are treated is sim-
ilar for totalitarian regimes. Methods
include imprisonment far away from their
families, placment together with violent
criminals, intimidation of family members
and reduced allowances for visits. Left
without sufficient food some loose weight
rapidly, and food and medicine brought by
relatives has been taken away.
The World Medical Association has repeat-
edly remembered the fate of Cuban
Physicians. They are outstanding col-
From the Secretary General’s desk
“Don’t forget the others”
WHO
105
leagues fighting for the freedom of the
Cuban People and for the freedom of med-
icine in their country. What they currently
get is hell on earth. Six of them are known
to us, they and their families and friends
deserve our attention as examples of all
those who pay a high price in the struggle
for freedom. The following information has
been compiled from various sources:
Dr. OSCAR ELÍAS BISCET, 44 years old,
a specialist in internal medicine, is the pres-
ident of the unofficial Lawton Human
Rights Foundation. He has been detained
more than two dozen times, charged with
‘insult to the symbols of the homeland,’
‘public disorder,’ and ‘incitement to com-
mit an offence’. Dr. Biscet has been kept in
special punishment cells for refusing to
carry out disciplinary measures. Before
Spring 2003 when Dr. Biscet was arrested
last, he had already been in prison for 3
years. Now in December 2005 it adds up to
6 years.
To discourage visits by his family he was
temporarily imprisoned in Prison Kilo 8 in
the province of Pinar del Rio, sharing a cell
with twelve other prisoners. He has been
sentenced to 25 years in prison.
DR. MARCELO CANO RODRÍGUEZ, 41
years old, is National Coordinator of the
unofficial Cuban Independent Medical
Association, an association of medical pro-
fessionals around the island. For not
respecting the prison rules for criminals Dr.
Cano has not been allowed to see the sun
for 10 month. Dr. Cano has been sentenced
to 18 years in prison.
DR. JOSÉ LUIS GARCÍA PANEQUE,
aged 39, is a plastic surgeon and a member
of the Cuban Independent Medical
Association. He has worked as a journalist,
as director of the independent news agency
Libertad and member of the independent
Journalists’ Society. Dr. Paneque’s weight
has dropped from 86 to 48 kg and he is
presently in the infirmary of “Las Mangas”
Prison in Bayamo. His health continues to
be critical. His wife is currently being
threatened with imminent mob attacks
against their home Dr. Paneque was sen-
tenced to 24 years in prison.
DR. LUIS MILÁN FERNÁNDEZ, 36 year
old, is a member of the Cuban Medical
Association. In June 2001 he and his wife,
Lisandra Lafitta, also a doctor, signed a
document called ‘Manifiesto 2001,’ calling
among other measures for recognition of
fundamental freedoms in Cuba. Together
with other health professionals they carried
out a one-day hunger strike to call attention
to the medical situation of detainees and
other issues. Although without emotional or
mental problems, he is now confined with
mental patients in the psychiatric ward of
the Prison of Boniato, in the province of
Santiago de Cuba. Dr. Milán Fernández,
had been sentenced to 13 years in prison.
ALFREDO MANUEL PULIDO LÓPEZ,
aged 45, graduated in 1983 in the specialty
of Stomatology, and Dentistry. He practiced
until 1998, when he was fired from his job
for joining the Christian Liberation
Movement. In 2001 he joined the unofficial
news agency El Mayor in Camagüey for
which he worked as journalist. Incarcerated
in the Maximum Security Prison Kilo 7 his
health is rapidly deteriorating. He is not
only suffering from severe migraine, but
has also experienced several hypoglycemic
episodes. Instead of providing treatment he
has been threatened that he gets a psychi-
atric evaluation to find out the sources of
his headaches. Dr. Pulido López has been
sentenced to 14 years in prison.
RICARDO ENRIQUE SILVA GUAL, 32,
physician and member of the Christian
Liberation Movement like Dr. Pulido
López. Dr. Siva Gual suffering from glau-
coma. Dr. Silva Guall has been sentenced to
10 years in prison.
Sources:
Coalition of Cuban-American
Women/LAIDA CARRO.
Joseito76@aol.com.
Human rights first
http://action.humanrightsfirst.org/cam-
paign/Biscet
Amnesty International
http://web.amnesty.org/library/Index/ENG
AMR250022005
Internationale Gesellschaft für
Menschenrechte
http://www.igfm.de
Medicina Cubana
http://medicinacubana.blogspot.com/2005_
09_01_medicinacubana_archive.html
For further information monitor our web-
site: www.wma.net ■
Geneva, Switzerland, 9 November 2005.
“Thank you for making this a remarkable
and productive meeting. The world has
been watching and listening as, over these
three days, the scale of the challenges has
emerged. The international solidarity to
confront these threats is clear. The urgency
of acting now is felt by us all. Precise rec-
ommendations for action have emerged.
Equally, precise offers of help and support
have been put forward, by both developing
and industrialized countries.
I will now review the central points that
have come out of the meeting. Next I will
outline an integrated programme of action
which responds to the issues raised.
1. Minimizing the threat at source to both
animal and human populations through
rapid reduction of the viral burden of
WHO
FAO/OIE/WB/WHO Meeting on Avian
Influenza and Human Pandemic Influenza
Closing remarks of Dr. LEE Jong Wook, D.G., WHO
WHO
106
H5N1 is essential. This entails timely
notification of outbreaks in birds, poul-
try culling and vaccination as indicated,
including „backyard“ flocks, and provi-
sion of appropriate compensation for
farmers.
2. “Early warning” and surveillance sys-
tems for animal and human influenza are
critical to effective response. The current
window of opportunity to intervene is
measured in days. Transparent and
immediate reporting is essential.
3. The introduction of avian infection with
H5N1 to other countries is predicted,
following the patterns of migratory
birds, and as a result of production sys-
tems and market practices. Other strains
of avian flu are also an ongoing and
emerging threat and must be monitored.
Strengthened veterinary services are a
crucial aspect of detection and response.
Open sharing of virus samples is essen-
tial. Quality assured animal vaccines
produced to international standards
should be used in healthy poultry when
appropriate.
4. At present many governments are not
ready to cope with outbreaks, still less a
pandemic. Preparedness is vital in every
country, in every Region. Integrated
country plans will build on and strength-
en existing systems and mechanisms.
They will be comprehensive, costed, and
evaluated. Response mechanisms should
be rehearsed through simulation exercis-
es. These plans will include protection of
vulnerable groups such as children,
refugees and displaced populations.
5. Resources needed to slow down or con-
tain the emergence of a pandemic are
insufficient. Supplies of antiviral drugs
currently do not meet potential demand.
Issues remain of equitable access to
medicines and deployment of stockpiles.
6. A universal non-specific pandemic vac-
cine may be the ultimate protective solu-
tion for human influenza. „Smart“ solu-
tions are being investigated. Issues of
technology transfer, resolution of licens-
ing and regulatory obstacles, sustained
use of good manufacturing practices and
pre-qualification are under discussion.
Predictable, increased orders for season-
al flu vaccine will support greater manu-
facturing capacity, including in develop-
ing countries.
7. Communications. The recent series of
high-level meetings on avian influenza
and human pandemic influenza have
successfully created a shared agenda.
The public needs clear, regular, reliable
information. Civil society, nongovern-
mental organizations and other commu-
nity groups must be involved.
8. A rich array of resources is potentially
available to support government and
institutional efforts. Countries that have
successfully controlled outbreaks of
avian influenza are prepared to help oth-
ers.
9. Mechanisms for donor support are in
place. There is broad commitment to
minimize transaction costs of interna-
tional support through alignment and
harmonization. International support to
country plans should supplement nation-
al resources, as well as existing donor
resources, and should target resource-
poor countries.
10.Investments are urgently needed at
national level – potentially reaching 1
billion dollars over the next three years.
An additional 35 million dollars is need-
ed immediately to support high priority
actions by technical agencies at the glob-
al level over the next six months.
The 10 points I have outlined need detailed
and concrete actions. This meeting has
identified a series of integrated actions
that will start straight away.
1. Support the development of integrated
national plans for avian influenza con-
trol and human pandemic influenza pre-
paredness and response.
2. Assist countries in aggressive control of
avian influenza in birds, and deepen the
understanding of the role of wild birds in
virus transmission.
3. Nominate „rapid response“ teams of
experts to support epidemiological field
investigations.
4. Strengthen country and regional capacity
in surveillance, laboratory diagnosis,
and alert and response systems.
5. Expand the network of influenza labora-
tories, with regional collaborative sys-
tems for access to reference laboratories.
6. Establish and integrate multi-country
networks for the control or prevention of
animal trans-boundary diseases, and
regional support units as established in
the Global Framework for the
Progressive Control of Trans-boundary
Animal Diseases.
7. Expand the global antiviral stockpile,
and prepare standard operating practices
for its rapid deployment to achieve early
containment.
8. Assess the needs and strengthen veteri-
nary infrastructure in line with OIE stan-
dards.
9. Map out a global strategy and work plan
for coordinating antiviral and influenza
vaccine research and development, and
for increasing production capacity and
equitable access.
10.Put forward proposals to the WHO
Executive Board at its 117th meeting for
immediate voluntary compliance with
relevant articles of the International
Health Regulations 2005.
11.Finalize detailed costing of country
plans and the regional and global
requirements to support them, in prepa-
ration for the January pledging meeting
to be hosted by the Government of
China.
12.Finalize a coordination framework
building on existing mechanisms at the
country level, and at the global level,
building on international best practices.
This is a challenging agenda which will
require all our best efforts.” ■
WHO
107
Public health experts have confirmed that a
polio epidemic in ten countries in west and
central Africa – Benin, Burkina Faso,
Cameroon, Central African Republic, Chad,
Côte d’Ivoire, Ghana, Guinea, Mali and
Togo – has been successfully stopped. The
epidemic has paralysed nearly 200 children
for life since mid-2003, but no new cases
have been reported in these countries since
early June. At the same time, polio eradica-
tion efforts are intensifying in Nigeria,
where extensive disease transmission con-
tinues, as part of a mass polio campaign
across 28 African countries beginning today.
Emergency efforts to stop the epidemic had
been launched under the auspices of the
African Union (AU), and largely underwrit-
ten through US$ 135 million in emergency
funding from the European Commission
(EC), Canada and Sweden. The ten coun-
tries, which had previously been polio-free,
participated in a series of mass immunisation
drives across 23 countries, reaching as many
as 100 million children with multiple doses
of polio vaccine over the last 18 months.
Speaking on behalf of donors, European
Commissioner for Development and
Humanitarian Aid, Mr Louis Michel, said:
„The reversal of these epidemics is precise-
ly what EC development objectives are all
about. Such a rapid return on development
investment is good for Africa, good for
donors, and most importantly, good for the
children of Africa.“
Experts cautioned, however, that ongoing
disease transmission in remaining endemic
areas continues to pose a risk of more out-
breaks across the region. To minimise this
risk, 28 African countries – including the
ten countries which have stopped their epi-
demics – today launched the first element
of a ‘maintenance’ programme to sustain
this progress, with an additional series of
synchronized immunisation activities to
reach more than 100 million children with
polio vaccine in November and December.
The ‘maintenance’ programme is part of a
four-pronged strategy to protect the US$ 4
billion invested globally since the 1988
launch of the Global Polio Eradication
Initiative. The other elements of the strate-
gy include: strengthening routine immuni-
sation at country level in close collabora-
tion with the Global Alliance for Vaccines
and Immunisation (GAVI) and through the
new Global Immunisation Vision and
Strategy (GIVS); increasing surveillance
sensitivity and outbreak response capacity,
and increasing both the number and quality
of polio campaigns in the remaining
endemic areas, particularly in Nigeria.
The Nigerian government has signalled
strong commitments to further strengthen-
ing its polio eradication programme. With
virus now beaten back to the north of the
country, efforts are focusing on re-deploy-
ing support staff to the northern states dur-
ing the upcoming immunisation campaigns.
To succeed, however, Nigeria needs the
ongoing support of the international com-
munity to ensure every child is reached
throughout the country with polio vaccine.
Key to success is ensuring the necessary
funds continue to be made available. A US$
200 million funding gap for 2006 must
urgently be filled, US$ 75 million of which
is needed by December, to ensure activities
in the first quarter of next year can proceed.
Underlining the urgency of closing the
funding gap, late arrival of funds may com-
promise the quality of the immunisation
campaigns in some countries.
To support Nigeria and west and central
Africa in polio eradication efforts, Rotary
International is also gearing up its support
to the region. „Rotary club members from
across North America, Europe and Asia are
joining fellow Rotarians in Africa to partic-
ipate in the polio campaigns,“ commented
Carl-Wilhelm Stenhammar, President of
Rotary International. „At Rotary, we are
committed to doing everything we can to
support Africa in their polio eradication
efforts“.Rotary International and its 1.2
million volunteers worldwide have been
integral to the global eradicate of polio.
Collectively, Rotarians have committed
well over US$ 600 million to the effort, and
contributed countless volunteer hours dur-
ing immunization campaigns.
The polio eradication coalition includes
governments of countries affected by polio;
private sector foundations (e.g. United
Nations Foundation, Bill & Melinda Gates
Foundation); development banks (e.g. the
World Bank); donor governments (e.g.
Australia, Austria, Belgium, Canada, Den-
mark, Finland, France, Germany, Ireland,
Italy, Japan, Luxembourg, Malaysia,
Monaco, the Netherlands, New Zealand,
Norway, Oman, Portugal, Qatar, the Rus-
sian Federation, Spain, Sweden, United
Arab Emirates, the United Kingdom and
the United States of America); the
European Commission; humanitarian and
nongovernmental organizations (e.g. the
International Red Cross and Red Crescent
societies) and corporate partners (e.g.
Sanofi Pasteur, De Beers, Wyeth).
Volunteers in developing countries also
play a key role; 20 million have participat-
ed in mass immunization campaigns.
Since 1988, global eradication efforts have
reduced the number of polio cases by more
than 99%, from 350,000 annually to 1,469
cases in 2005 (as of 1 November). Six coun-
tries remain polio endemic (Nigeria, India,
Pakistan, Afghanistan, Niger and Egypt),
however poliovirus continues to spread to
previously polio-free countries. In total, 11
previously polio-free countries have been
re-infected in late 2004 and 2005 (Somalia,
Indonesia, Yemen, Angola, Ethiopia, Chad,
Sudan, Mali, Eritrea, Cameroon and Nepal).
For more information contact:
Sona Bari Oliver Rosenbauer
Telephone: +41 22 791 1476
Telephone: +41 22 791 383
Email: baris@who.int
int Email: rosenbauero@who.int
1
Benin, Burkina Faso, Cameroon, Cape Verde,
CentralAfrican Republic, Chad, Côte d’Ivoire,
the Democratic Republic of the Congo,
Djibouti, Equatorial Guinea, Eritrea, Ethiopia,
Gabon, Gambia, Ghana, Guinea, Guinea-
Bissau, Kenya, Liberia, Mali, Mauritania,
Niger, Nigeria, Senegal, Sierra Leone,
Somalia, Sudan and Togo. ■
Massive international effort stops polio epidemic
across 10 West and Central African countries
Regional and NMA News
108
These projects will be implemented by
ESA with the technical assistance of WHO.
Nowadays, the use of satellite-based Infor-
mation and Communications Technologies
(ICT) for telemedicine is progressing from
the scouting phase towards a more stable and
operational profile, where integration into
existing healthcare systems and the attain-
ment of self-sustainability is increasingly
becoming an essential condition for success.
In this frame, the European Space Agency
in line with the recommendations of the
Telemedicine Working Group (ref.
‘Opportunities and Challenges of eHealth
and Telemedicine via Satellite’, European
Journal of Medical Research, vol.10, 2005,
http://telecom.esa.int/telecom/media/docu-
ment/Scientific%5FPublication%5FESA%
5F Telemed.041222.final.pdf) is issuing
three invitations to tender to demonstrate
the exploitation of Satcom in Telemedicine
and validate the associated sustainability
through a user driven approach.
The ultimate goal of this action is to pave
the way for a European Telemedicine via
Satellite Programme of direct benefit for
the Health community and which will be
developed in close consultation with WHO.
The three invitations to tender are focused
on the following thematic areas:
Health Early Warning
The activity on Health Early Warning will
be aimed at the integration, deployment and
validation of a Satcom based system devot-
ed to gathering data from the field to predict
communicable disease diffusion patterns
and associated risks of outbreak. The sys-
tem will also provide a fast and resilient
way to distribute, over geographical areas
early warning and information to the popu-
lation to facilitate the establishment of ade-
quate protective measures to safeguard the
population’s health. The system will be con-
ceived, in particular, to face healthcare con-
sequences of catastrophic events.
Interconnectivity for Health-
care Services and
Professional Medical
Education bridging
Communities in Eastern and
Western Europe
The activity of Interconnectivity for
Healthcare Services and Professional
Medical Education bridging Communities
in Eastern and Western Europe will estab-
lish a pilot exploitation period and validate
the associated sustainability of the devel-
oped satellite based service supporting
remote medical consultation and healthcare
professional education and collaboration
between two medical systems, one in a
remote areas of Eastern Europe, and the
other in a Western European country.
Management of Medical
Emergency for Commercial
Aviation
The activity of Management of Medical
Emergency for Commercial Aviation will
be aimed to develop, integrate and validate
in an operational environment a telemedi-
cine service to support diagnosis from on-
board civil aircrafts. The system will pro-
vide interactive multimedia data exchange
between aircraft and ground based medical
centers to support decisions, in cases of
medical emergency, on whether to go for a
flight diversion and which actions to take
on board.
The details of these three invitations to
tender are available at the following URL
address: ftp://ftp.estec.esa.int/pub/telemedi ■
A number of meetings in the European re-
gion relating to health issues are of interest
at both regional and international levels. In
an interesting development in 1994 an ini-
tiative supported by the Catalan government
and the European Union in a conference
sought to explore health care and healthcare
problems in the Mediterranean region. Enti-
tled Euromed Health Forum (Euromed
Salud) the outcome was the Declaration of
Barcelona (1994) urging co-operation in the
healthcare field between all the countries
bordering on the Mediterranean Sea, includ-
ing those on the north coast of Africa, and at
the eastern end of the Sea. In November of
this year the tenth anniversary of this was
celebrated with a further highly successful
Forum in Barcelona. It explored such areas
as health policy development, the use of
telemedicine and the regulation and licens-
ing of healthcare physicians and other work-
ers. A further declaration was issued ex-
pressing the view of the Forum that these di-
alogues should continue and that a further
meeting take place in two years time. This
initiative to dialogue and explore positive
collaboration represents a potentially inter-
esting development in collaboration in the
Health sector between the northern side of
the Mediterranean (mostly European Union
countries), those at the eastern end, and on
the north African coast.
For more than 20 years there has been an an-
nual meeting under the title of Europe
Blanche under the aegis of the Institut des
Sciences de la Santé (Paris), to discuss a
specific major health or health professional
problem. These have included such topics as
Europe and Medicines, Continuing medical
education, The Therapeutic Revolution etc.
These meeting have provided an important
forum at which leading figures with an in-
terest in health including researchers, physi-
cians, healthcare providers and organisers,
economists, ministers and other politicians
Telemedicine via Satellite: An opportunity to
develop Satcom based sustainable services
Regional and NMA News
European Region
Regional and NMA News
109
and other relevant persons in society have
been able to meet and discuss issues during a
two day meeting. The enlargement of the
European Community to 25 has introduced
new considerations into the discussions.
This year the meeting was held in the Bu-
dapest, capital of one of the new members of
the EU, the topic for discussion was “Living
Longer but Healthier Lives” exploring how
to achieve health gains in the Elderly of the
European Union. At these meetings the Se-
nior and Junior Europe and Medicine Prizes
are awarded.
Finally, at a meeting organised by WMAand
the Caring Physicians of the World Net-
work, leaders of national medical associa-
tions in the European Region of the World
Medical Association met in Prague in No-
vember to discuss two major issues. Presen-
tations were given by WHO and other ex-
perts on the two topics of discussion. The
first was on the “Skills Drain” among physi-
cians and what actions NMAs can take. The
second topic was Human Avian Influenza
when the meeting considered what actions
can be done by NMAs in collaboration with
other institutions to prepare for a potential
pandemic. The presentations and discus-
sions were both lively and productive. ■
Under the aegis of the Caring Physicians of
the World Initiative, members of the General
Assembly of CONFERMEL met with repre-
sentatives of WMA to discuss issues of im-
portance to the medical profession, Health
Policy and reform of the Health Sector, the
new role of physicians in society and how
NMAs can meet the emerging needs of their
members at a meeting held on 10th October
prior to the WMA Assembly. A manifesto
was issued in the name of the 12 countries
present, Argentina, Bolivia, Brasil, Costa
Rica Ecuador, Honduras, Mexico, Nicaragua,
Panama, Peru, Venezuela and Uruguay. It re-
ferred to the difficult situation in these coun-
tries such as poverty and unfairness which
continue, despite some advances in growth
indices. In particular reference was made to
the consequent nutritional deficiencies, lack
of sanitation ,drinking water and the high
prevalence of malaria, dengue AIDS and tu-
berculosis. Concern was expressed that the
processes of reform and modernisation of the
health sector in these countries promoted pri-
vatisation of the public sector, deepening the
inequities without substantial improvement
in the quality of life and excluding large seg-
ments of the population from health care.
Pointing out that reform and modernisation
of the Health sector needs the participation
of representative organisations of health
professionals attention was drawn to the
“The 2nd KEMAT team arrived in Abbot-
tabad in the morning of October 22 and
took over all the tasks frorn the 1 team
without any reservatinn. As many yo physi-
cians have joined the 2nd team, mostly
composed by staff of Asian Medical Center
in Seoul, the camp was full of energy and
vibrancy. Lawrnaker Mr. Seok Hyun Lee,
the Chairperson of Health and Welfare
Committee of Korean National Assembly,
also joined this team and supported all the
commitment and hard work of all the Kore-
an medical teams and rescue teams dis-
patched to the quake-hit-areas taking a
field assessment from Abbottabad via Bal-
akot to Muzaffarabad. Over ten Korean
NGO`s are taking part in voluntary medical
work in Patika, Balakot, Muzaffarabad,
Batagram and Abbottabad.
Cases of scabies are continuously on the
rise and many people, especially children,
are still in need of long-term medical atten-
tion after being amputated. Dr. Irfan Khat-
tak, general surgeon of Ayub Medical Com-
plex and coordinator of voluntary medical
work said that they need medical equip-
ment such as DERMATOSE or MESHER
to take care of these patients. Drugs for
anesthesia are also needed. Moreover, men-
tal shocks they are going through also
should be brought under delicate treatment.
Operation Rooms of Ayub Medical Com-
plex, once shut down of additional collapse
are now functioning little by little. The 2nd
KEMAT conduction five major surgeries
including skin graft for open fractures, K-
Wire Reconstruction Operation and
PROSTALAC at operation rooms in coop-
eration of Pakistani doctors.
In Balakot mobile clinic, considerable
numbers of patients are suffering from diar-
rhea and de-hydration. Scabies is a major
concern here, too. The 2nd team has treated
total 2,810 patients (2,485 at Ayuh Medical
Center, and 325 in Balakot mobile clinic).
Latin America and the Caribbean lack of priority given by governments in re-
source allocation to the health care systems
which among others affects quality of care
and the rights of physicians and other
health personnel. The manifesto denounced
the indiscriminate creation of medical
schools without social necessity, and the
creation of non-medical careers permitting
the illegal practice of medicine.
Expressing concern about inequitable com-
mercial agreements relating to intellectual
property and pharmaceuticals which limit ac-
cess of citizens to drugs, and disregarding
WTO agreements, the manifesto ends by reit-
erating the professional organisations’ commit-
ment to the supervision of the quality of med-
ical care and the autoregulation of the profes-
sion through obligatory membership of a col-
lege in accordance with national legislation. ■
Korean Medical Association
Activity Report of the KMA Medical Team in to quake-affected
areas in Pakistan
(Extract from this interesting report. Ed.)
Letters
110
Replacing the tasks of the 2nd team, the 3rd
KEMAT team, composed of six doctors,
five nurses, one pharmacist, one policeman
and two administrative staff, arrived in Ab-
bottabad on October 29. The 3rd team spe-
cially is composed by the staff of National
Police Hospital.
Due to the huge difference of temperatures
between day and night, the number of pa-
tients coming down with the ART (Acute
Respiratory Infections) continues to inerease.
At Ayub Medical Complex, quake-related
emergency patients have decreased promi-
nently, compared to the situation of two
weeks ago and more and more patients with
chronic diseases come to see a doctor and
want to get medicines for their diseases.
However patients in need of minor surgery
dressing, cast and suturing still an average
70–80 people a day.
More equipment and efforts are necessary
to be put prevention of epidemics. Al-
though KEMAT is carrying out some pre-
vention steps using a smoke disinfector,
more organized projects should be urgently
arranged and carried out.
In Balakot mobile clinic, cases of diarrhea
skin diseases like scabies, and ARI are still
topping the list and many patients needing
to get their dressing renewed, or need to get
care after ampulation keep visiting the mo-
bile clinic.
The 3rd team has treated 3,395 patients all to-
gether (2,353 at Ayub Medical Complex and
1,040 at mobile clinic in Balakot), making
the total number of patients through the ac-
tivities of KEMAT is 7,505 approximately.
Ending its voluntary medical works, the
KEMAT donated medicines (anti-scabies
drugs, antibiotics, fluids, etc.) and medical
supplies left from their activities to the
Ayub Medical Complex and some medi-
cines to the Good Samaritan Hospital run
by Korean missionaries in Pakistan.
Contact info of Korean Medical Associa-
tion Medical Team (KEMAT; KMA Emer-
gency Medical Assistance Team):
Ms Yoonsun Park, Chief of Strategie Plan-
ning Team, KMA:
+822 794 2474 (ext. 120) (oftice) / +82 11
792 6908 (mobile phone) ■
Sir,
First let me introduce myself: I am a
Paediatric Surgeon, former Head of the
Department of Surgery of the main
Lisboa’s Children’s Hospital and also a for-
mer President of the WMA (more than 20
years ago – 1981/1983).
Secondly I would like to congratulate you
and your co-workers for the excellent qual-
ity of the “World Medical Journal”, which I
read always with great interest.
Finally I have to make a short comment on
your article “Saving the lives of Siamese
Twins” [WMJ 51(2) 30-31, 2005].
My experience started in 1978 and stems
from 7, fully and personally operated pairs,
with 9 survivors and 5 deaths (in one pair
one child was already dead on arrival,
another died of “malignant hyperthermia”
after separation had already been per-
formed, and the remaining one patient
dying 1 month post-operatively, with peri-
tonitis due to a leak in an intestinal anasto-
moses). Lisboa and its Hospital D.
Estefania, are not as fashionable and well-
known worldwide, as the Hospital for Sick
Children, (GOS), in London…!
My longest operation, with “total” recon-
struction of omphaloischiopagus twins
(boys, of which one had to remain a girl,
due to only one existing penis) took 13.30
hours, because, taking into account the
training I received in England (GOS and
Alder Hey), I was able to conduct the whole
operation, in both twins, from “top to bot-
tom” (and not having, at my side, several
sub-specialist, working in succession, in the
American Style). Also skin expanders
proved unnecessary, after adequate iliac
osteotomies.
The 7 survivors lead totally normal lives,
and the 2 latest ones have only minor prob-
lems and lead also, practically, normal
lives. The liver is usually the least problem,
with no significant haemorrhagic danger, as
normally a reasonable noticeable demarca-
tion exists between the 2 individual seg-
ments. The most difficult problem, for a
good functional and aesthetic outcome, is
associated with the urinary tract, followed
by the intestines. Osteotomies in the iliac
bones usually do away with the need to use
previously insert skin expanders.
In my opinion liver transplantation is not a
primary factor in the treatment of Siamese
twins, and its progress, no matter how
desirable it certainly is, will not benefit
these children (at least directly). Good
anaesthesia and intensive care (including
nurses), are the real issues, apart from
surgery itself. No matter how well a sur-
geon works, if anaesthesia and intensive
care are not also as good, the result may be
disastrous. In fact, the only really inopera-
ble Siamese twins are those with a “com-
mon heart”, and in which, the existing heart
and major vessels, cannot be useful for any
of them (so malformed they are…).
As Horsley once said, “A beautiful opera-
tion that ends with the death of the patient
is not satisfactory surgery”.
Finally I believe it is completely wrong and
a real pity, to abort Siamese twins, found at
routine echographies (as well as some
apparently major malformations), as mod-
ern Paediatric Surgery is able to correct
them (allowing those human beings, to lead
normal, useful and happy lives). That
should, I feel, be the main message to pro-
mote!
Unfortunately abortion is what we find in
the “so-called” developed countries. Most
operated Siamese twins come from devel-
oping countries, where echography is not
currently available and the diagnosis is
made only after birth!
Yours sincerely
Prof. Dr. Antonio Gentil Martins
Rua de Campolide 166-G
Lisbon 1070-096 PORTUGAL
Email: agentilmartins@netcabo.pt ■
Letters to the Editor
Saving the Lives of Siamese Twins
Review
111
Sir,
With regards to your article about ‘Spray-
on Skin Grafts’. I think this technique and
other similar techniques involving the cul-
ture of skin stem cells still has a long way
to go before they can be used for burns
involving the full thickness of the skin. I am
not familiar with the technology used at
East Grinstead but I suspect it may have
been rather over hyped. Just this week there
has been an article in the Lancet from a
French group using foetal skin cells which
grow rapidly and are incorporated into a
collagen matrix which have been used suc-
cessfully in a small number of patients but
it is really a biological dressing which is
replaced by host tissue. The use of cultured
skin cells obviously is attractive particular-
ly now that the stem cells of the skin can
now be identified and grown quite rapidly
but this still provided a very thin layer
which would not be adequate to replace a
full thickness burn following excision of
the scar.
However, this is an important area of devel-
opment and many groups around the world
are working on the culture of cells of the skin
and particularly the stem cells of the epider-
mis and without question in due course suc-
cessful clinical applications will be devel-
oped that would allow permanent replace-
ment without scarring. This then would be
perhaps suitable in reconstruction of the face.
Yours sincerely
Sir Peter Morris AC FRS FRCS
Head, Centre for Evidence in Transplan-
tation,
Emeritus Professor, University of Oxford,
Honorary Professor, University of London
The Royal College of Surgeons of England
35-43 Lincoln’s Inn Fields,
London WC2A 3PE
www.rcseng.ac.uk ■
Ethics of Research and Treatment in
Developing Countries
François and Emmanuel Hirsch, editors
Collection Espace éthique
Paris, Librairie Vuibert, 2005
14.50 Euro
ISBN 2 7117 7278 0
When the World Medical Association
undertook the latest revision of the
Declaration of Helsinki in 1997, it encoun-
tered issues in the application of ethics to
medical research in developing countries
that had not arisen previously. The most
controversial articles in the 2000 version of
the Declaration are precisely those that
address these issues, namely, paragraph 29
that deals with the comparator to be used in
a clinical trial, and paragraphs 19 and 30
that specify the obligations of researchers
and research sponsors to those who serve as
research subjects.
These same issues have been considered in
other international statements on research
ethics such as the 2001 National Bioethics
Advisory Commission (U.S.A.) report,
Ethical and Policy Issues in International
Research: Clinical Trials in Developing
Countries, the 2002 Council for International
Organizations of Medical Sciences (CIOMS)
International Ethical Guidelines for
Biomedical Research Involving Human
Subjects, the 2002 Nuffield Council (U.K.)
report, The Ethics of Research Related to
Healthcare in Developing Countries and its
2005 follow-up discussion paper with the
same title, and the 2003 European Group on
Ethics in Science and New Technologies
Opinion #17 on the Ethical Aspects of
Clinical Research in Developing Countries.
As the 2005 Nuffield Council discussion
paper explains, these documents do not agree
on many of the key issues in research in
developing countries.
In October 2002, a conference was held in
Paris to discuss these issues with particular
reference to the francophone countries of
Africa. The proceedings of this conference
are the subject of this review. Many of the
contributors areAfrican and they do not hes-
itate to criticise the dominant ‘Western’ par-
adigm of medical research as it is applied in
their countries.
Two sets of essays set out the context for
the presentations that follow. The first deals
with the principles of human rights and
medical research, and the second describes
the methodology of clinical trials and relat-
ed ethical issues.
The major part of the book consists of
seven substantial essays on African
approaches to biomedical research, each of
which points out shortcomings in the appli-
cation of ‘Western’ research methodology
in Africa. According to Godfrey B. Tangwa,
this methodology is based on a worldview
that is quite alien to Africans, for whom
“metaphysical concepts, ethics, customs,
laws and taboos form a unique ensem-
ble…” (p. 57). Whereas Western approach-
es display an excess of epistemological
confidence, bordering on arrogance and
often resulting in imprudence, “the princi-
pal value underlying African worldvisions
and concepts is its epistemological humility
and respectful prudence…” (p. 60). Certain
Advancing Surgical Standards – Stem Cells
Review
Éthique de la recherché et des soins dans les pays en développement
Review
112
ethical principles of great importance in
Western society, such as the confidentiality
of personal information, must be applied
differently in Africa where the family and
the community, not the autonomous indi-
vidual, are the fundamental social units.
The widespread suspicion of Western
researchers and the revelations of racist
medical research in apartheid-era South
Africa, have provided fertile ground for the
spread of conspiracy theories regarding the
origin and treatment of diseases such as
HIV/AIDS. The rationing of medical treat-
ment by ability to pay rather than by need is
contrary to the African view of healthcare
as a service, not a commodity. To illustrate
the Western attitude to Africa, Tangwa pro-
vides a case study of a medical researcher
in Cameroon who developed a promising
approach to a vaccine for HIV but was
unable to get funding from any of the
Western research agencies because it did
not fit their paradigm of medical research.
An important concept in both medical
research and medical treatment is ‘quality’.
In his article, Jean-Godefroy Bidima raises
many questions regarding how this concept
applies in Africa – quality of what, quality
for whom, and how should it be measured
(pp. 80-83). He goes on to discuss why the
Western concept of informed consent is
inapplicable in much of Africa: “In certain
African cultures one does not express a
refusal to someone in authority. One
expresses a refusal by not carrying out an
order that has been given, but formally one
agrees in order that the authority does not
lose face. The caregiver is an authority, and
when a sick African gives consent, what
does that signify? An agreement or simple
politeness?” (p. 85)
The African understanding of clinical trials
(‘essais thérapeutiques’) is explored by
Assétou Ismaëla Derme in relation to pro-
posed treatments for malaria. As with other
ailments, malaria is considered to be not
just a physical affliction but a result of
upsetting the relationships of natural and
supernatural forces. Healing therefore
requires spiritual as well as physical mea-
sures. Research on the prevention and treat-
ment of malaria is complicated by the mul-
tiple local terms used for the different phas-
es of this illness. Researchers must take all
these factors into account when undertak-
ing projects in Africa.
In the Ivory Coast, according to Lazare
Marcelin Poame, the concept of free and
informed consent to medical research or
treatment is largely unknown. Physicians
are the experts and the patient is expected,
and expects, to follow their orders.
Moreover, busy physicians simply do not
have the time required to present all their
patients with the information necessary for
informed consent. Where consent is sought,
it is usually from the family rather than the
individual patient. Despite all these obsta-
cles, Poame believes that the practice of
informed consent is achievable in the Ivory
Coast and offers concrete suggestions for
moving in this direction.
A French social scientist, Christophe
Perrey, reports on a research project on
informed consent conducted in the Ivory
Coast in which 57 women were interviewed
about their understanding of clinical trials,
including the meaning of placebo. Despite
explanations, it turned out that none of the
women could explain what a placebo is and
they all were convinced that they had
received the experimental drug. Other chal-
lenges to informed consent were different
understandings and terminology for the
symptoms and causes of diseases, the diffi-
culty of getting spousal consent for a
woman’s participation in the trial, and
rumours about toxicity of the proposed
intervention. If the principle of informed
consent is to be implemented in such set-
tings, much more work is needed on its
pedagogy.
In May 2002 the French National Agency
for AIDS Research published a Charter of
Ethics for Research in Developing
Countries that addresses many of the issues
raised at this conference. In presenting the
Charter, Brigitte Bazin noted some of the
difficulties in its implementation, including
the absence of ethics regulations and com-
mittees in many developing countries, the
lack of resources for those ethics commit-
tees that do exist, and the inability of non-
profit agencies to provide continuing care
to participants in research as required by the
Declaration of Helsinki.
In the final contribution from Africa,
Patrice Emmanuel Mbo Abenoyap provides
a perspective on these issues from African
theology. Africans live simultaneously in
two worlds: the visible one of humans and
finite creatures and the invisible one of
energies and powers. In the former, individ-
uals are subordinate to the community; in
the latter, they are subordinate to supernat-
ural forces. Both relationships challenge the
Western concept of individual autonomy
and the related principle of informed con-
sent. Moreover, the fact that one’s family is
often the only source of funds for one’s
medical treatment entails that the family
has a legitimate role to play in the consent
process.
To complete the list of issues that need to be
considered in relation to the ethics of
research in developing countries, the edi-
tors included as an annex a summary of dis-
cussions that took place in Paris in January
2001 and that presumably inspired the con-
ference that led to this book. The additional
issues mentioned include the following: the
right to health, global disparities, lack of
democracy in some developing countries,
the needs of migrants, corruption (a two-
way process, involving corrupters as well
as corruptees), taboos, and learning from
developing countries.
None of the issues, problems and chal-
lenges raised in this book admits of easy
answers. However, they must first be recog-
nized, and the authors have provided a
valuable service in pointing out both theo-
retical and practical difficulties in the appli-
cation of international standards of research
ethics in developing countries. The sugges-
tions they make for improving the situation
are worthy of further consideration, but as
the authors would be the first to admit,
much more needs to be done. All those
responsible for international research ethics
should follow the example of the editors of
this book in seeking meaningful involve-
ment of developing country representatives
in both the review of policies and in the
design and implementation of research
studies.
John R. Williams, Ph.D.
Director of Ethics
World Medical Association ■
CHINA E
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6524 9989
Fax: (86-10) 6512 3754
E-mail: suyumu@cma.org.cn
Website: www.chinamed.com.cn
COLOMBIA S
Federación Médica Colombiana
Calle 72 – N° 6-44, Piso 11
Santafé de Bogotá, D.E.
Tel: (57-1) 211 0208
Tel/Fax: (57-1) 212 6082
E-mail: federacionmedicacol@
hotmail.com
DEMOCRATIC REP. OF CONGO F
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (242-12) 24589/
Fax (Présidente): (242) 8846574
COSTA RICA S
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA E
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: orlic@mamef.mef.hr
CZECH REPUBLIC E
Czech Medical Association .
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201/202/203/204
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
CUBA S
Colegio Médico Cubano Libre
P.O. Box 141016
717 Ponce de Leon Boulevard
Coral Gables, FL 33114-1016
United States
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK E
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: er@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC S
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686/
533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR S
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fdmedec@andinanet.net
EGYPT E
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A S
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112
Fax: -0324
E-mail: comcolmed@telesal.net
marnuca@hotmail.com
ESTONIA E
Estonian Medical Association (EsMA)
Pepleri 32
51010 Tartu
Tel/Fax (372) 7420429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
ETHIOPIA E
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS E
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) 315388
Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fj
FINLAND E
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 826/Fax-794
Telex: 125336 sll sf
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE F
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel: (33) 1 53 89 32 41
Fax: (33) 1 53 89 33 44
E-mail: cnom-international@
cn.medecin.fr
GEORGIA E
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 398686 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY E
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
Tel: (49-30) 400-456 363/Fax: -384
E-mail: renate.vonhoff-winter@baek.de
Website: www.bundesaerztekammer.de
GHANA E
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I. F
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060
Fax: (509) 245-6323
E-mail: amh@amhhaiti.net
Website: www.amhhaiti.net
HONG KONG E
Hong Kong Medical Association, China
Duke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY E
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36
1443 Budapest, PO.Box 145
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND E
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 8640478
Fax: (354) 5644106
E-mail: icemed@icemed.is
INDIA E
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 337009/3378819/3378680
Fax: (91-11) 3379178/3379470
E-mail: inmedici@vsnl.com /
inmedici@ndb.vsnl.com
INDONESIA E
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND E
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273
Fax: (353-1) 6612758/6682168
Website: www.imo.ie
ISRAEL E
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: estish@ima.org.il
Website: www.ima.org.il
JAPAN E
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN F
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA E
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT E
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA E
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN E
Liechtensteinischer Ärztekammer
Postfach 52
9490 Vaduz
Tel: (423) 231-1690
Fax: (423) 231-1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
LITHUANIA E
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
LUXEMBOURG F
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Association and address/Officers
ii
Association and address/Officers
iii
MACEDONIA E
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
MALAYSIA E
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40418972/40411375
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA E
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO S
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. Cons. 410
Colonia Obispado C.P. 64060
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: fenacomemexico@usa.net
Website: www.fenacome.org
NEPAL E
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 225860, 231825
Fax: (977 1) 225300
E-mail: nma@healthnet.org.np
NETHERLANDS E
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
NEW ZEALAND E
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472-4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA E
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 480 1569,
Fax: (234-1) 493 6854
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
NORWAY E
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA S
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@sinfo.net
PERU S
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores, Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@colmedi.org.pe
Website: www.colmed.org.pe
PHILIPPINES E
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: pmasec1@edsamail.com.ph
POLAND E
Polish Medical Association
Al. Ujazdowskie 24, 00-478 Warszawa
Tel/Fax: (48-22) 628 86 99
PORTUGAL E
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: ordemmedicos@mail.telepac.pt
/ intl.omcne@omsul.com
Website: www.ordemdosmedicos.pt
ROMANIA F
Romanian Medical Association
Str. Ionel Perlea, nr 10
Sect. 1, Bucarest, cod 70754
Tel: (40-1) 6141071
Fax: (40-1) 3121357
E-mail: AMR@itcnet.ro
Website: www.cdi.pub.ro/CDI/
Parteneri/AMR_main.htm
RUSSIA E
Russian Medical Society
Udaltsova Street 85
121099 Moscow
Tel: (7-095)932-83-02
E-mail: rusmed@rusmed.rmt.ru
info@russmed.com
SINGAPORE E
Singapore Medical Association
Alumni Medical Centre, Level 2
2 College Road, 169850 Singapore
Tel: (65) 6223 1264
Fax: (65) 6224 7827
E-Mail: sma@sma.org.sg
SLOVAK REPUBLIC E
Slovak Medical Association
Legionarska 4
81322 Bratislava
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA E
Slovenian Medical Association
Komenskega 4, 61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOUTH AFRICA E
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/7
Fax: (27-12) 481 2058
E-mail: liliang@samedical.org
Website: www.samedical.org
SPAIN S
Consejo General de Colegios Médicos
Plaza de las Cortes 11, Madrid 28014
Tel: (34-91) 431 7780
Fax: (34-91) 431 9620
E-mail: internacional1@cgcom.es
SWEDEN E
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610, SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND F
Fédération des Médecins Suisses
Elfenstrasse 18 – POB 293
3000 Berne 16
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch
TAIWAN E
Taiwan Medical Association
9F No 29 Sec1
An-Ho Road
Taipei
Deputy Secretary General
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@med-assn.org.tw
THAILAND E
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: http://www.medassocthai.org/
index.htm.
TUNISIA F
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1082 Tunis Cité Jardins
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: ordremed.na@planet.tn
TURKEY E
Turkish Medical Association
GMK Bulvary,.
Pehit Danip Tunalygil Sok. N° 2 Kat 4
Maltepe
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
UGANDA E
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM E
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6710
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA E
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY S
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE F
Associazione Medica del Vaticano
Stato della Citta del Vaticano 00120
Tel: (39-06) 6983552
Fax: (39-06) 69885364
E-mail: servizi.sanitari@scv.va
VENEZUELA S
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org
E-mail: info@saludgmv.org
VIETNAM E
Vietnam General Association
of Medicine and Pharmacy (VGAMP)
68A Ba Trieu-Street
Hoau Kiem district
Hanoi
Tel: (84) 4 943 9323
Fax: (84) 4 943 9323
ZIMBABWE E
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791/553
Fax: (263-4) 791561
E-mail: zima@healthnet.zw