WMJ_4_2021_WEB

vol. 67
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 4, December 2021
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Valedictory Speech by theWMA President,David O.Barbe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Presidential Inaugural address by Dr. Heidi Stensmyren. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
WMA 2021 Virtual General Assembly Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
WMA Declaration on Principles of Health Care in Sports Medicine . . . . . . . . . . . . . . . . . . . . 16
WMA Resolution in Support of Medical Personnel and Citizens of Myanmar. . . . . . . . . . . . 17
WMA Resolution in Support of Taiwan’s Participation in all WHO Health Programs and
Inclusion in the International Health Regulations (IHR) Mechanism. . . . . . . . . . . . . . . . . . . 18
WMA Resolution in Support of the Countries Worst Affected by the Covid-19 Crisis . . . . . 19
WMA Resolution on Covid-19 Vaccines and International Travel Requirements . . . . . . . . . 19
WMA Resolution on the Repression of Nicaraguan Doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . 20
WMA Resolution Supporting the Rights of Patients and Physicians in the Islamic
Republic of Iran. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
WMA Statement in Support of Ensuring the Availability, the Quality and the Safety
of Medicines Worldwide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
WMA Statement on Access of Women and Children to Health Care . . . . . . . . . . . . . . . . . . . . 24
WMA Statement on Essential Surgical Care as a Part of Access to Healthcare. . . . . . . . . . . . 25
WMA Statement on Family Violence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
WMA Statement on Medical Care for Migrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
WMA Statement on Medical Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
WMA Statement on Solar Radiation and Photoprotection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
WMA Statement on Trade Agreements and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
WMA Statement on Women’s Rights to Health Care and How that Relates to the
Prevention of Mother-to-Child HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
London Scientific Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
International Roundtable Webinar on Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Cordoba Scientific Session. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Focus on COVID-19 Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Embryo: Are Researchers Working to Protect It? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
The Environment & Healthcare: Do Our Choices Matter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
A commentary on “Health is a Creative Adaptive Process”, C.R. Cloninger et Al. . . . . . . . . . 57
Report from COP 26, Glasgow, Scotland, UK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Obituary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Editor in Chief
Dr. med. h. c. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Advisor
Helena Chapman, MD, MPH, PhD
Assistant Editor
Mg. Health. sc. Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
Medicīnas apgāds, Ltd
Skolas street 3, Riga, Latvia.
ISSN: 0049-8122
Dr. Heidi STENSMYREN
WMA President
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE-114 86 Stockholm
Sweden
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Jung Yul PARK
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
Samgu B/D 7F 8F 40 Cheongpa-ro,
Yongsan-gu
04373 Seoul
Korea, Rep.
Dr. Osahon ENABULELE
WMA President-Elect
Nigerian Medical Association
8 Benghazi Street, Off Addis Ababa
Crescent Wuse Zone 4, FCT,
P.O. Box 8829 Wuse Abuja, Nigeria
Dr. Kenji MATSUBARA
WMA Vice-Chairperson of Council
Japan Medical Association
113-8621 Bunkyo-ku,Tokyo
Japan
Dr. Joseph HEYMAN
WMA Chairperson of the Associate
Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. David BARBE
WMA Immediate Past-President
American Medical Association
AMA Plaza, 330 N. Wabash, Suite
39300 60611-5885 Chicago, Illinois
United States
Dr. Ravindra Sitaram
WANKHEDKAR
WMA Treasurer
Indian Medical Association
Indraprastha Marg 110 002
New Delhi
India
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Marit HERMANSEN
WMA Chair of the Medical Ethics
Committee
Norwegian Medical Association
P.O. Box 1152 sentrum
107 Oslo
Norway
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
1
Editorial
Editorial
Severe morbidity and mortality from Covid-19 have reached huge
numbers worldwide, and each country is fighting the pandemic dif-
ferently. In autumn 2021, researchers and doctors had already a lot
of information both on the coronavirus SARS-CoV-2 and on the
pathogenesis, the course of disease as well as changes in the body
caused by the virus.
Critical and important are lessons learned that the coronavirus
SARS-CoV-2 causes more severe disease and higher mortality in
people who have a sedentary lifestyle, overweight, hyperlipidaemia,
high arterial blood pressure, carbohydrate disorder and high sugar
level as well as other chronic diseases.The currently available infor-
mation also shows a higher incidence of severe disease and higher
mortality from Covid-19 not only among somatic patients, but also
among mental patients.
We have information that mortality is lower among those patients
with hypertension, dyslipidaemia and diabetes who are meticulous
and compliant in the treatment of their chronic diseases during the
pandemic compared to patients who are noncompliant with medi-
cation, who have medication non-adherence. Several studies have
shown that in patients who have regularly used cholesterol-lower-
ing drugs during the pandemic, including statins, severe disease and
death rates are lower than in patients who stopped taking statins
before or during the illness.
The difference between the rates of the severity of disease and
mortality in different age groups depending on the treatment/non-
treatment of chronic diseases is high, up to 3–5 times. This makes
us reasonably concerned about the need to treat chronic diseases
during the pandemic.
Now, when politicians in all countries of the world place emphasis
on vaccination and various restrictive measures, it is the time for
doctors to stress the extreme importance of prevention and treat-
ment of chronic diseases. The reduction of low-density cholesterol,
adjustment of blood pressure and control of sugar level are very im-
portant areas in decreasing the Covid-19 severity and reduction of
mortality rate. Governments that limit the volume of medical ser-
vices to treating Covid-19 patients make a very big mistake, since it
might increase severe morbidity and mortality.
Increasing the volume of physical activities,particularly in the elderly
with chronic diseases and risk factors for cardiovascular diseases, is
very important in circumstances where,very likely,we are to live with
SARS-CoV-2 for a long time. It is the doctor’s responsibility to pro-
mote healthy lifestyles, at least half an hour of physical activity daily,
optimally aspiring to each person taking 10,000 steps a day.
So, let us encourage vaccination, take care of restrictions on disease
transfer, and at the same time actively promote sports and physical
activities as well the treatment of chronic somatic and mental dis-
eases. No one else will explain this to governments and the media if
it is not done by the leaders of the World Medical Association and
national medical associations.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal
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2
WMA News
Thank you, Dr. Montgomery. Dr. Kloiber,
officers, Council and Assembly members
and our JDN and Associate members. Let
me start by thanking you again for the great
privilege of serving as your president for
this past year. It has been one of the most
unusual and challenging years the WMA
and our profession has ever faced. Due to
the pandemic, this is now the second Gen-
eral Assembly we have found necessary to
hold virtually and the fourth Committee
and Council sessions.
Although conducting our WMA business
virtually is bad enough, the pandemic has
kept us apart for many more NMA meet-
ings, scientific conferences, and from many
opportunities to be together to share a time
of friendship and productive discussions
outside of the formal business sessions.
I  know we all hope we will able to start
meeting together again soon – both to con-
duct our business and to keep our relation-
ships with one another strong. In my inau-
gural remarks a year ago, I stated that “It is
in times like these that our fellow physicians
and our patients need our leadership more
than ever.” I went on to say that “We need
strong physician organizations at every lev-
el: the WMA, our NMAs and state and lo-
cal medical societies.”This year, I have been
proud to see that strong leadership in action
in the work that you have done. I’ve seen
the Indian Medical Association raise funds
for their colleagues impacted by COVID,
speak out against violence directed at health
care workers, and resist expansion medical
practice by persons without medical train-
ing. I  have seen the Turkish Medical As-
sociation advocate for members wrongfully
imprisoned and fight to retain recognition
of their Association. I have seen the Ko-
rean Medical Association speak out against
intrusion of the government into the op-
erating theater. I’ve seen physician leaders
in Nicaragua and Egypt speak out against
oppression and threats against physicians in
their countries.
These are but a few of the many examples
of NMAs advocating for their members
and for their patients. In all of these situa-
tions, the WMA was right there with these
NMAs and physicians supporting them in
their struggle to protect physicians and de-
liver high quality care to their patients.That
is leadership … and that shows the impor-
tance of our professional organizations and
the WMA.
In spite of the pandemic, many association
meetings, scientific meetings and advocacy
meetings were held virtually,and the WMA
participated in many of them. In addition
to NMA meetings, the WMA participat-
ed in multiple meetings related to various
aspects of the pandemic including the re-
cently completed meeting sponsored by the
Pontifical Academy for Life at the Vatican
in Rome at which we were invited to give
the physician’s perspective on the impact
of the pandemic. We participated in sev-
eral conferences on equitable distribution
of vaccines and on the need to improve our
ongoing response to this pandemic and our
planning for the next.
WMA leadership participated in other con-
ferences including ones on the contempo-
rary relevance of bioethics, medical ethics
and professionalism, person centered medi-
cine, violence against physicians and health
care, and on the role of health professionals
in encouraging adherence to the Treaty on
the Prohibition of Nuclear Weapons. So,
in spite of the limitations of the pandemic,
the WMA has continued to be a strong and
recognized voice for physicians around the
world.
The Scientific Sessions associated with our
General Assembly meetings continue to be
important forums for international discus-
sion of key issues facing medicine. The ses-
sion in September on the ethical challenges
of organ donation and transplantation pro-
cesses coordinated by the General Council
of Official Medical Colleges of Spain and
last week’s session on antimicrobial resis-
tance coordinated by the British Medical
Association were both excellent sessions
and brought together experts from around
the world to present and discuss these criti-
cal and timely topics.
We have a responsibility as a profession
to engage in scientific sessions like these
and the many others in which you and the
WMA are involved to address the chal-
lenges we face in many areas of science,
medicine, and ethics. I commend those
who organize such scientific session for
helping us fulfill that responsibility to our
physician colleagues, to our patients, and
to society.
Because the WMA is recognized as hav-
ing broad involvement in activities such as
those I have just mentioned and very spe-
cifically in recognition of physicians’ work
and sacrifice around the world during the
COVID-19 pandemic, the WMA received
the “Golden Arrow 2021” award last Janu-
Valedictory Speech by the WMA President, David O. Barbe, MD MHA.
WMA General Assembly London, UK (virtual), October 15, 2021
David O. Barbe
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3
WMA News
ary at the 18th
Vienna Congress co-hosted
by the Medical Doctor’s Association of
Austria. The WMA was the first organiza-
tion to receive that prestigious award previ-
ously awarded only to individuals.
In my remarks to that group, I told them
“there are many physicians around the
world who do not feel appreciated or sup-
ported for the risk they have taken or the
sacrifices they have made in caring for pa-
tients with ­
COVID. Many are demoralized.
Many feel their governments, and, in some
cases, their hospitals have let them down.
Some feel taken for granted or even taken
advantage of.
This Golden Arrow award proclaims to the
physicians of the world – You are appreci-
ated. We recognize all you have done and
thank you for the sacrifices you have made.”
I think physicians need to hear that. I think
you need to hear that. It is our job as lead-
ers to make sure our physicians know we
are proud of them and that their efforts and
their sacrifice are appreciated.
I am also proud of the important work you
continue to do on the issues on our agenda
at this meeting… continued work on re-
vising the international code of medical
ethics… addressing racism in medicine…
emphasizing women’s right to healthcare…
advocating for access to medications and
vaccines… improving our principles on
end-of-life care… and multiple statements
related to improving patient safety and spe-
cific areas of medical care.Thank you for the
time and energy you devote to this work.
Before my closing comment, I want to sin-
cerely thank Dr. Kloiber, Sunny, Clarisse,
Magda and all our staff at the WMA for
the tremendous work they do on our behalf
and the support they give WMA leadership
as we represent the organization.Thank you.
I also thank the American Medical Associ-
ation again for their confidence and support
in nominating me for this position 2 years
ago. And finally, a loving thank-you to
my wife, Debbie, who has been a constant
source of support and encouragement dur-
ing the many years I have served in our pro-
fessional organizations.Thank you, Debbie.
In my inaugural speech a year ago, I in-
cluded a quote by American baseball leg-
end Babe Ruth. He said, “It’s hard to beat a
person who never gives up.” We must never
give up in our efforts to advance our poli-
cies and our work to achieve our common
goals. We must never fail to advocate on
behalf of patients and physicians. I know
that Drs. Stensmyren and Enabulele will
do that as your elected leaders. I know that
Drs. Montgomery and Kloiber will do that
in their respective roles. I am confident that
you will also leave our meeting this week
encouraged and inspired by the actions we
have taken, and that each of you will use the
WMA resolutions, statements, and declara-
tions in your countries to support your phy-
sicians and accomplish our common goal
and the WMA’s purpose of achieving “the
highest international standards in medi-
cine…and health care for all people in the
world.” Thank you very much.
Presidential Inaugural address by Dr. Heidi Stensmyren.
WMA General Assembly London, UK (virtual), October 15, 2021
Honored colleagues, dear friends,
Humbled by the distinguished work of my
predecessors let me first express my grati-
tude to Dr. Barbe, for your excellent work
as president during the past year.It has been
a challenging year of office, but you have
managed to be present despite the lack of in
person meetings. I want to thank the Swed-
ish Medical Association, for putting your
trust in me and supporting my candidacy.
This is the effort of many, but I especially
thank the board and President Sofia Ry-
dgren Stale and CEO Hans Dahlgren  –
keeping the organization on top to the
benefit of all of us engaging in organized
medicine. A special thank to our interna-
tional secretary Tomas Hedmark; always on
track and on time. Thank you all for good
teamwork and for true friendship. Thank
also to Björn Zoega for including me in the
leadership of Karolinska University Hospi-
tal where I now serve.
My deepest gratitude to my family; My two
wonderful children Nora and Fröja. You
have spent many hours underneath board-
room tables, on a coach in the office or in
the back of a conference room waiting for
me. My dear parents who have supported
me in every way and who are the most won-
derful grandparents. I could not have made
it without you.Thank you! Colleges, friends,
and family are important, especially in
times like this. ….over 230 million COVID
cases since the start of the pandemic…and
over 4.7 million deaths. But we are fight-
ing back…. With almost 6 billion vaccines
given worldwide.
All of us have faced personal and profes-
sional challenges during the pandemic,
and a virulent virus still ravages our world.
Healthcare has been pushed to the limit.
Physicians have toiled on the frontlines,
risking self and family to provide care to
countless patients that have fallen ill to Co-
vid-19. The working conditions are beyond
challenging. Many physicians have become
victims of the virus, and some of us have
died while caring for others.
The pandemic has shown that we share a
very small world.What happens in one cor-
ner of our planet affects us all; the “Butterfly
Effect” has never been demonstrated more
poignantly. Physicians everywhere strive
for that same effect, hoping that providing
good medical care to patients in their corner
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4
WMA News
of the world will translate into a “global de-
fense.”Viruses know no borders,but neither
do medicine or the ethics that guide us.
The pandemic has raised difficult questions
and some grim ethical and moral quandaries
• How do we prioritize care?
• What are the best vaccines and vaccina-
tion programs?
• What is the fairest method to distribute
resources?
Patients, populations, and governments
look to us for guidance when health is at
stake, and these difficult questions about
the ethical practice of medicine must be
addressed. The WMA must lead the way –
providing a firm foundation to respond to
these challenges that remain critical to ev-
ery man, woman, and child on our planet.
Let us not forget that ‘ethics’ is the core of
the WMA. “The health and well-being of
my patient will be my first consideration”
and “I will share my medical knowledge for
the benefit of the patient and the advance-
ment of healthcare.”Words we promote and
the pledge by which we live.
The WMA policies are frameworks and
guidelines implemented by physicians and
institutions every day all over the world.The
vision of my Hospital is “We will cure and
relieve tomorrow what no one can cure or
relieve today”.
A vision that has come through recently
is the advancement to produce a vaccine
against malaria. This is fruits of years and
years of hard work by vital organizations on
a global level. Next to the vaccine, global
cooperation is the most crucial compo-
nent to fight disease and this virus in par-
ticular. No other physician organization has
the inclusiveness and reach of the WMA;
therefore, we need to help bridge govern-
ments and borders. As the most important
international organization for physicians,
we should foster even more robust coopera-
tion between international organizations. It
is important to continue to engage in, and
deepen our relations and cooperation with
the WHO on issues of common interest.
Efficient and effective initiatives, such as
CEPI, Coalition of Epidemic Preparedness
Innovations, or GAVI, co-leading COVAX
distributing covid-19 vaccines, has a better
chance to succeed when global agreements
are in place. I urge all of our national mem-
bers to promote your countries to support
the global institutions.
The pandemic has also highlighted the
importance of medical research and devel-
opment. Vaccines, their development, and
distribution have been at the center of the
pandemic. And the speed with which vac-
cines have been developed is awe-inspiring
and demonstrates what can be achieved in a
global emergency.
Medical research always raises ethical ques-
tions,even more so in situations where there
is intense pressure to achieve results quickly.
The pandemic has put us under extreme
pressure; with demands for revolutionary
research results leading to new therapies
and vaccines to be provided to patients
quicker than ever. Under such conditions
ethical guidelines are crucial. The WMA
Declaration of Helsinki guiding in ethical
issues related to medical research involving
human subjects. I take office highly aware
of the necessity that this core WMA dec-
laration must continue to be well-known. It
must remain a relevant touchstone of ethics
in medical research. At the core of good re-
search and good medical practice is a solid
basis in evidence-based medicine. There
has been and continues to be, fearmonger-
ing, misinformation, and false claims. Some
of these claims are highly concerning and
present potentially serious health risks to
global health. We have a responsibility to
speak out against fraudulent claims, to rep-
resent science. We are also responsible for
explaining this science in ways the general
public can grasp and comprehend. Moving
forward, this will be an increasingly impor-
tant task for the WMA. As president of the
WMA I will add “vaccinate!” to the quote
“test, test, test” made by Thedros, Director-
General of the WHO.
Many physicians and researchers have
worked tirelessly to get us back to a more
normal life. Thinking about a “normal” life
again, we should remind ourselves of the
necessity to ensure a sustainable life for all
of us on our planet. Nature continues to be
an essential source for developing new pa-
tient treatments. The new vaccines are such
examples, partly founded upon research in
biology. If the loss of biodiversity continues,
we will be less resilient.The WMA has vital
policies on environmental issues. As presi-
dent, I stress the importance to highlight
the value of protecting our environment to
achieve sustainability. Our future patients´
health depends on it.
As physicians, our colleagues worldwide
stand at the center of health,and the WMA
should be the global guiding light for all
of us. Please help me continue to build a
strong international voice for the WMA,
a voice that speaks for every Physician on
our small planet. Thank you for electing me
as your president. The honor humbles me.
I will do my best to represent you and the
WMA.
Heidi Stensmyren
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5
WMA News
Monday October 11
For the second year in succession, the
WMA’s annual General Assembly had to
be organised as a virtual event. London was
due to host a week of meetings. But instead,
the Scientific Session, the Council, com-
mittee meetings and General Assembly
were all held online over a period of seven
days.Two days were set aside for the Scien-
tific Session (see separate report) in the first
week,with the Council meeting starting the
second week.
Council
More than a hundred National Medical
Association (NMAs) delegates from more
than 20 different time zones logged on to
hear the Chair of Council, Dr. Frank Ulrich
Montgomery, welcome them and express
his hope, once again, that they would soon
be meeting face to face.The Secretary Gen-
eral, Dr. Otmar Kloiber, welcomed two new
Council members, Dr. Jack Resnik (Ameri-
can Medical Association) and Dr.  Jian
Wang (China).
President’s Report
Dr. David Barbe, in his written report, said
that despite the Covid-19 pandemic the
WMA leadership had participated in many
conferences addressing various aspects of
the pandemic. Their emphasis had been on
protecting physicians and other healthcare
workers, recognizing the personal risk they
took in carrying out their task of caring for
patients with Covid-19 under very difficult
circumstances. They had also participated
in conferences on equitable distribution of
Covid-19 vaccine,overcoming vaccine hesi-
tancy, and improving vaccination rates.
Dr. Barbe said he had been especially proud
to speak out about violence against physi-
cians and other health care providers and to
provide support and advocacy for NMAs
and individual physicians who had been
targets of violence, governmental oppres-
sion, or punishment simply for advocating
for their patients, providing medical care to
political protesters, or advocating for im-
proved management of the Covid pandemic
and vaccinations in their countries.
Two specific events had highlighted his
presidential year – the WMA’s receipt of the
Golden Arrow Award for the medical pro-
fession’s service during the pandemic and
the Vatican workshop on Covid-19.
Chair of Council’s Report
Dr.  Montgomery said the last year had
changed all their lives dramatically. Cov-
id-19 had taken its toll. Among many other
colleagues and friends they had to mourn
was their esteemed colleague and friend
K.K. Aggarwal from India who had passed
away from the disease in May. He listed
some of the many activities the WMA had
engaged in about the pandemic and vaccine
equity.He said it was true that national gov-
ernments had an obligation to service their
own population, but “vaccine nationalism”
was not the road to freedom. They had to
share wisdom, knowledge and vaccines.
The Chinese Medical Association again
raised a protest about the WMA’s policy
seeking observer status at the World Health
Organisation for Taiwan. It said it was im-
possible for China to accept this policy, as
Taiwan was an inseparable part of China.
The protest was noted.
Urgent Items
Two emergency issues were raised. The first
related to Covid-19 and the fact that citi-
zens of some countries were experiencing
serious complications in travelling, as their
vaccinations were not accepted as proof of
full protection. Many countries accepted
only a certain set of vaccines considered
as suitable protection, while other vaccines
were not recognized. The Council proposed
an emergency resolution calling for an end
to this discrimination.
Dr. Kloiber said that many of the countries
had installed vaccine requirements for travel,
social events and leisure. Usually this was
shown by having compliance with vaccination.
For travel, it was necessary to have a full vac-
cination defined by each country in a different
way. But the vaccines being authorised were
very different from country to country. Even
people fully vaccinated might not be able to
travel because they had been vaccinated with
the assumed wrong vaccine. The emergency
resolution was saying that it should be the ef-
fectiveness of the vaccine which counted, not
the authorisation of the vaccine.Governments
needed to reconsider their current rules to al-
low international meetings to be held. There
had been a lot of concern from colleagues in
Asia and Africa who were having big prob-
lems in travelling to Europe.
WMA 2021 Virtual General Assembly Report
October 11–15, 2021
Nigel Duncan
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WMA News
The meeting approved the Resolution.
The second urgent item related to the situ-
ation in Nicaragua. It was agreed to discuss
this later in the week.
The Council meeting was adjourned until
Friday.
Finance and Planning Committee
The committee was called to order by the
Chair, Dr. Jung Yul Park (South Korea).
Audited Financial Statement for 2020
The committee considered the Audited Fi-
nancial Statement for 2020. The Treasurer,
Dr. Ravindra Sitaram Wankhedkar, stated
that the WMA’s finances in 2020 were very
solid, with cost savings due to the effects of
Covid-19 and restrictions on meeting and
travel expenses.
The committee agreed that the Audited Fi-
nancial Statement for 2020 be approved by
the Council and forwarded to the General
Assembly for adoption
Membership Dues
Delegates also heard a report on the Budget
and Membership Dues Payments for 2021
and Membership Dues Arrears and Dues
Categories 2022.
It agreed that the proposed Budget for 2022
be approved by the Council and forwarded
to the General Assembly for adoption. It
also agreed that the Dues Categories 2022
be forwarded to the General Assembly for
information.
Strategic Plan
Dr. Kloiber gave an oral report, saying that
ambitions to enlarge the membership of the
Association had been interrupted by Co-
vid-19.They still had a lot of targets to deal
with. He also said that the Secretariat had
been exploring options for hybrid meetings.
Statutory Meetings
The committee considered the planning for
future meetings and two invitations from
the Sindicato Médico del Uruguay and the
Ordem dos Médicos (Portugal) to host the
Council Session in 2024 or 2025,or the Gen-
eral Assembly in 2025.The two organisations
agreed to discuss the matter between them-
selves and return with co-ordinated dates.
Special Meetings
Dr. Kloiber reported that the WMA con-
tinued to play an active role in a series of
webinars as a member of the World Health
Professionals Alliance, which were focused
on Covid-19 related issues of mental health
and institutional changes.
Participation in meetings to discuss the In-
ternational Code of Medical Ethics at the
international level were planned next year at
the 14th
World Conference on Bioethics in
March in Porto and at the 16th
World Con-
gress of Bioethics in July in Basel.
Associate Membership
The committee received a report of the As-
sociate Membership and the report from
the Chair of Associate Members Dr. Joseph
Heyman. He said that the total number of
associate members who were in good stand-
ing was 1,487. The regional breakdown was
Japan 605 members in good standing and in
all other countries 882 members. Two suc-
cessful webinars had been held, the first on
‘How Healers became Killers: Nazi Doctors
and Modern Medical Ethics’, and the sec-
ond ‘The Frustrating Hydra of Municipal
Social Fabric Weaknesses Revealed by the
Pandemic’.Task forces had been established
to consider revising the Declaration on The
Protection and Integrity of Healthcare Per-
sonnel in Armed Conflicts and on revising
the Statement on Guiding Principles for
the Use of Telehealth for the Provision of
Health Care. Work was also under way on
eHealth and Medical Technology and on
Advocacy and Communication.
Junior Doctors Network
An oral report on the activities of the Ju-
nior Doctors Network was given by the
Chair of the JDN, Dr.  Yassen Tcholakov.
He said a new team had now been elected.
Despite the challenges and adaptations
forced on them by Covid-19, they had had
many new members and had managed to
maintain strong member engagement dur-
ing these unusual times. The Network had
maintained virtual activities and had seen
continued membership requests from ju-
nior doctors from diverse backgrounds
globally. The leadership had worked on
streamlining the membership onboarding
process and were looking forward to roll-
ing out the new system as soon as the IT
changes took place.
Past Presidents and Chairs of Council Net-
work
The committee received a report on the ac-
tivities of the Past Presidents and Chairs of
Council Network. Dr. Yoram Blachar had
been playing an active role to set the official
relationship with the International Chair
of Bioethics as a WMA Cooperating Cen-
ter and continued to be liaised to the 14th
World conference on Bioethics, Medical
Ethics and Health Law for the conference.
This was originally planned in Porto, Portu-
gal, May 2020, and was now postponed till
March 7–10 2022.
Drs Ardis Hoven, Cecil Wilson, Kati Myl-
lymaki, Jón Snaedal and Dana Hanson had
continued to join the Steering Committee
of the Associate Members and had been
actively participating in the discussion on
ideas of how to improve the membership
activities and engagement. They had also
contributed to the proposed new rules for
Associate Membership.
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Bylaws Amendments
The committee considered a report and rec-
ommendation from the workgroup on Bylaws
Amendments proposing additional commit-
tee members and the issue of voting rights.
The committee agreed the proposed revi-
sions should be sent to the Council and
forwarded to the General Assembly for
adoption.
Legal Seat of the WMA
The Secretary General reported that he had
been working on how to proceed with the
transition of moving the legal seat of the
WMA from the USA to France, as ap-
proved by the Council in April 2021. He
informed the committee about the timeline
and next steps, which would be presented
for the consideration of the Council and
General Assembly, with the aim of com-
pleting the transition by 2022.
Rules Applicable to WMA Associate Member-
ship
The committee considered a proposed revi-
sion of the rules applying to WMA Associ-
ate Membership. Members were told that
the changes would not alter the relationship
between the Associate Members and the
WMA Council or Assembly, but were de-
signed to make the rules more democratic.
The Japan Medical Association proposed
setting up a workgroup to consider the ideas
and it was agreed that the proposals needed
more discussion.
The committee agreed to recommend that a
workgroup be set up.
Procedures of conducting virtual meetings
A proposal from the Chinese Medical As-
sociation for developing procedures for con-
ducting virtual meetings was presented to
the committee. It was argued that it was rea-
sonable to expect that virtual meetings would
still be widely used in the post-pandemic era.
It was therefore imperative for the WMA
to develop written procedures regarding the
adoption and conducting of virtual meetings,
including the quorum, communication, and
voting rules. Developing such procedures
would help to clarify responsibilities of dif-
ferent entities of the WMA, streamline the
meeting procedures, and most importantly,
improve the efficiency, as well as transparen-
cy among constituent member associations.
The committee recommended that a work-
group should be set up to prepare a draft
proposal on procedures.
LGBTQ Equity in Venues Hosting WMA
Meetings and Functions
A proposed Resolution on LGBTQ Eq-
uity in Venues Hosting WMA Meetings
and Functions was considered. It set out
proposals for host nations’ policies to be
considered when venues were proposed
for WMA meetings. After several speakers
raised points of concern, it was agreed that
the matter required further discussion in a
workgroup.
The committee agreed to postpone the issue
until the next meeting.
Green Guidelines for WMA Meetings
The committee considered a set of proposals
to ensure that WMA meetings were eco-
neutral events. It was argued that this was
a process that required a change in event
culture. The proposals included guidelines
for greening transport, food and beverage
and event material and merchandise. The
suggestion was that the proposals should be
phased in by either creating a green policy
or guidelines for event organizers and par-
ticipants and then incorporating them pro-
gressively at a small scale.
The committee recommended that the
proposed guidelines should be circulated
among members for comment.
World Medical Journal
A written and oral report were received from
the Editor of the World Medical Journal,
Dr. Peteris Apinis. He said this had been
one of the strangest years of our lives. The
pandemic had caused fear, not only in gov-
ernments, health ministries, medical lead-
ers, doctors, nurses, but even more in their
patients – and the media had given them
only one message, fear. Governments had
succumbed to this mass psychosis and did
unthinkable things, far from related to epi-
demiology and infection prevention. Medi-
cal journals were full of contentious views as
different nations chose different methods to
reduce the spread of the infection and vac-
cinate the population.
In 2020, four WMJ magazines were issued,
both paper and digital. This year, three is-
sues had come out. Dr.  Apinis ended by
saying that it was time for him to stand
down as editor in chief to allow someone
younger to take over.
The committee thanked Dr. Apinis for all
his hard work.
Tuesday October 12
Socio-Medical Affairs Committee
The committee was called to order by the
Chair, Dr. Osahon Enabulele (Nigeria).
Health and Environment
The committee received an oral report from
Dr.  Peter Orris (Associate Member), Co-
Chair of the Environment Caucus.The Cau-
cus had discussed an update of My Green
Doctor,about greening physician’s offices and
Guidelines on healthcare practice towards
clinic sustainable environmental choices,
by Todd L Sack, Executive Director of My
Green Doctor Foundation. It had discussed
a suggestion for a new oath for medical and
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WMA News
health professionals, incorporating planetary
health, and these discussions were continu-
ing. And it had discussed the WMA’s in-
volvement in the UN Climate Change Con-
ference (COP26) in Glasgow in November.
Protection and Integrity of Medical Person-
nel in Armed Conflicts and Other Situations
of Violence
A revised Statement on the Protection and
Integrity of Medical Personnel in Armed
Conflicts was presented to the commit-
tee, updating the existing Declaration and
merging it with other Declarations and
statements. The revised Statement made it
clear that healthcare personnel must be pro-
tected, and this was confirmed by a number
of international agreements. It noted with
concern that attacks on health personnel
were on the rise, but even in armed con-
flict health care personnel had to stick to
medical ethics. The Statement made several
recommendations to governments and all
other parties involved in armed conflicts. It
stressed the importance of bringing to jus-
tice culprits of violence against health per-
sonnel and the need for data to do this. And
finally, it called on governments and NMAs
to raise awareness about this problem.
Speakers welcomed the document, but it
was suggested that it could be improved,
and might benefit from being circulated for
further comments. There was insufficient
emphasis on medical neutrality as a guiding
principle. There was also no mention that
serious violence was likely to amount to war
crimes, and there was lack of reference to
the International Criminal Court.
The committee agreed to recommend that
the document be circulated again among
members for comment.
Medical Technology
The committee received an oral report from
the workgroup on Medical Technology. It
was told that the workgroup had discussed
the definition of medical technology and
had worked on an inventory of WMA poli-
cies related to medical technology to iden-
tify missing and/or overlapping policies. It
would return in April 2022 with new ideas.
Trade Agreements and Public Health
A proposed revision of the Council Reso-
lution on Trade Agreements and Public
Health was presented to the committee.
This emphasised that negotiations should
take into account that the right to health
and to a healthy natural and social environ-
ment were well-prioritized. Trade agree-
ments should be directed at contributing to
global health and equity.
The committee heard that conflicting
views had been expressed by NMAs and a
compromise was now being proposed. Af-
ter a brief debate the following sentence
was approved without a vote: ‘The WMA
considers that patenting on medicines on
medicines/vaccines must be regulated in
accordance with the ethical principles and
values of the medical profession in order to
ensure effective and global action for public
health and therefore recognizes that it may
be necessary to temporarily waive patents in
times of public health emergencies’.
Following further debate, the committee
recommended that the document be sent to
the Council for forwarding to the General
Assembly for adoption.
Use of Telehealth for the Provision of Health
Care
A proposed major 10-year revision of the
Statement on Guiding Principles for the
Use of Telehealth for the Provision of
Health Care was presented to the com-
mittee. It was explained that three WMA
policies had been merged into one single E-
Health statement.
In a brief discussion, there was opposition
to the phrase in the document that ‘At pres-
ent, face-to-face consultation should re-
main the gold standard of clinical care’.This
was described as simplistic, and an amend-
ment was proposed that ‘The gold standard
of the delivery of clinical care is whichever
provides the patient with the optimal care
in the specific circumstances’. The amend-
ment was supported.
Other speakers questioned whether the
document captured the differences between
digital health and mhealth, and it was sug-
gested that further consideration should be
given to the issue.
A proposal to recirculate the document was
approved.
Supporting the Rights of Patients and Physi-
cians in the Islamic Republic of Iran
An oral report was given to the commit-
tee that physicians in the Islamic Republic
of Iran had reported a deliberate denial of
medical care in detention, withholding of
essential and readily available medications
by physicians and other health profession-
als. There was widespread use of torture
and ill-treatments in detention and concern
about the veracity of documentation related
to the death of patients,as well as physicians
being forced to produce clinically distorted
documentation.
The document was approved by the commit-
tee to be sent to the Council for forwarding
to the General Assembly for adoption.
Health Hazards of Tobacco Products and To-
bacco-Derived Products
A proposed major revision of the Statement
on Health Hazards of Tobacco Products
and Tobacco-Derived Products was pre-
sented and it was explained that it had been
updated to include the many novel forms of
tobacco use.
The committee agreed that the document
should be circulated for comment.
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WMA News
Global Burden of Chronic Disease
An oral report was given to the committee on
revising the Statement on the Global Burden
of Chronic Disease. This declared that the
world should pay more attention to chronic
non-communicable diseases. These were the
leading cause of mortality and disability in
both the developed and developing world,
the four main NCDs being cancers, cardio-
vascular diseases, chronic respiratory diseas-
es, and diabetes.Together they accounted for
seven of every ten deaths worldwide.
The committee recommended that the re-
vised Statement should be circulated to
members for comment.
Minor revisions were agreed to three poli-
cies:
• WMA Declaration on Leprosy Control
around the World and Elimination of
Discrimination against persons affected
by Leprosy
• North Korean Nuclear Testing
• Protection of Health Care Facilities and
Personnel in Syria
Implementation of the WHO Framework
Convention on Tobacco Control
The committee was presented with a minor
revision to the WMA Convention on To-
bacco Control.
Several amendments were proposed. The
Danish Medical Association proposed a
new paragraph which read: ‘In line with its
Statement on Electronic Cigarettes, calls on
Member States to include e-cigarettes and
other electronic nicotine delivery systems
in the scope of application of the WHO
Framework Convention and to ensure that
that these products be subjected to local reg-
ulatory approval and be entrenched in smoke
free laws’.The amendment was approved.
The American Medical Association pro-
posed two new sentences which were also
approved. The first referred to governments
combatting ‘the tobacco industry’s preda-
tory marketing tactics by adopting compre-
hensive bans on advertising, promotion and
sponsorship’ and the second urged govern-
ments ‘to introduce initiatives that break
brand recognition,including plain packaging
of cigarettes and other smoking products’.
The amendments were agreed and the
committee agreed that the Resolution, as
amended, should be sent to the Council for
forwarding to the Assembly for adoption.
Child Safety in Air Travel
A minor amendment was submitted to the
Resolution on Child Safety in Air Travel,
which expressed concern that adequate air
safety systems for infants and children had
not been generally implemented. It called
for a ban on the use of inappropriate “loop
belts” frequently used to secure infants and
children in passenger aircraft and urged all
airline companies to take immediate steps
to introduce safe, thoroughly tested and
standardized child restraint systems.
The American Medical Association pro-
posed an amendment to strengthen the
wording on loop belts to read ‘However, the
practice of holding an infant or child in a
lap or using a “loop belt” continues and is
not a sufficient safety measure’. It was ar-
gued that the WMA should clearly state
that the practice of using a “loop” or “lap”
belt was no longer recommended because it
was unsafe. The amendment was approved. 
The committee agreed that the Resolution,
as amended, should be sent to the Council
for forwarding to the Assembly for adop-
tion.
Occupational and Environmental Health and
Safety
A major revision to the 2016 Resolution on
Occupational and Environmental Health
and Safety was submitted by the Kuwait
Medical Association.
The committee was told that during the
Covid-19 pandemic, an increased number
of workers worked outside the employer’s
premises using digital information and
communication technologies either full-
time or part-time. Such digital working en-
vironment could offer a flexible work sched-
ule, and reduce commuting time. But it also
had its own risks, as it isolated employees,
particularly individuals living alone, and re-
sulted in increased level of stress and anxi-
ety. A healthy digital working environment
needed to be in place to ensure employee
health and safety. This had been taken into
account in the new revised document.
The committee recommended that the re-
vised Resolution be circulated to members
for comment.
Racism in Medicine
The German Medical Association submit-
ted a proposed new Declaration on Racism
in Medicine.
The committee agreed to circulate this doc-
ument for comment.
Patient Safety and Professional Regulation
The committee considered the proposed
Statement on improving patient safety.
The British Medical Association said this
was a really important issue. Patient safety
was directly related to resources, infrastruc-
ture and workforce restraints. They needed
to be clear that if governments wanted to
ensure patient safety, they must address re-
sources,otherwise physicians became targets.
They had to recognise that systemic factors
were the largest contributor to safety issues.
Workforce culture affected every nation.
They knew that negative cultures affected
patient safety. Targeting doctors meant they
would not be open and would not learn.
When it came to physician wellbeing, they
knew that when doctors were under stress,
feeling harassed, the risks of errors went up.
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WMA News
On medical regulation, the biggest omis-
sion in WMA policies was that they were
always reinforcing the idea of regulating
individuals rather than regulating systems.
But if they were to regulate medical pro-
fessionals, the regulator should at all times
consider the wider context of resource con-
straints, infrastructure, culture, and wellbe-
ing.The entire system should be considered.
The BMA said the proposed Statement had
clear recommendations.
The committee agreed to recommend that
the proposed Statement be circulated for
comment.
Discrimination against Elderly Individuals
within Healthcare Settings
The Spanish Medical Council proposed
a Declaration on Discrimination against
Elderly Individuals within Healthcare Set-
tings,which declared that elderly individuals
experienced all kinds of discrimination and
were often perceived as a burden on health-
care systems and their financial sustainabil-
ity.The Spanish said the aim of the proposed
Declaration was to strengthen the health of
elderly people.The Covid-19 pandemic had
affected elderly people very seriously.
The committee agreed to recommend that
the proposed Declaration be circulated for
comment.
Providing Covid-19 Vaccines for All
The Turkish Medical Association submit-
ted a proposed Resolution for Providing
Covid-19 Vaccines for All, which proposed
measures for the access and equity of vac-
cines.
The committee recommended that the pro-
posed Resolution be circulated for comment.
WFME Standards for Distributed and Dis-
tance Learning in Medical Education1
1  This document is available in English only
The Secretary General gave an oral report
on a document from the World Federa-
tion for Medical Education ‘Standards for
Distance Learning for Medical Education’.
During the pandemic, this had become an
extremely important issue with the need for
online learning. These standards had now
been published.
The document was endorsed by the com-
mittee.
The Repression of Nicaraguan Doctors
An emergency Resolution on the situation
in Nicaragua was presented to the commit-
tee. Members were told that this was a very
urgent issue because doctors in the country
were facing threats of imprisonment for
speaking out about the state of the country’s
health care system.
The committee agreed that the Resolution
should be forwarded to the Council for
adoption by the General Assembly.
Wednesday October 13
Medical Ethics Committee
The committee was called to order by the
Chair, Dr. Marit Hermanson (Norway)
International Code of Medical Ethics
The committee heard an oral report on the
progress being made in revising the Inter-
national Code of Medical Ethics. Mem-
bers were told that a revised draft version
had been sent out for public consultation in
May, attracting a tremendous response from
physicians and ethics experts throughout the
world.Three productive virtual meetings had
been held to review these comments in detail
and the result of these discussions was the re-
vised draft now presented to the committee. 
The committee was told that the paragraph
on conscientious objection would be han-
dled separately, as the workgroup was still
reviewing the vast feedback this paragraph
had received from the public consultation.
Further conferences would be held early
next year and it was hoped to have two more
regional conferences in Asia and Africa. A
small expert meeting was planned for some
time in August next year.
The Spanish Medical Council said it was
disappointed that points raised at a Latin
American Spanish regional meeting had
not been included in the draft. But it was
told that the workgroup wanted to keep the
document to a certain length and did not
want it to go into too much detail.
The committee agreed that the proposed
draft could be used for further conferences
next year.
After a brief debate on conscientious objec-
tion, the committee agreed to recommend
to Council that the proposed draft para-
graph be used as a basis for discussion at a
dedicated conference later next year.
Assisted Reproductive Technologies
As part of the annual 10-year policy review
process, a major revision of the Statement
on Assisted Reproductive Technologies was
submitted to the committee. A workgroup
under the South African Medical Asso-
ciation had been set up to coordinate with
the workgroup on Genetics and Medicine,
given the number of cross-cutting issues,
and the document had undergone much
discussion. The document’s opening words
stated ‘Assisted reproductive technologies
may raise profound issues. Views and be-
liefs on assisted reproductive technologies,
which vary both within and among coun-
tries. Assisted conception is also regulated
differently in various countries’.
The committee was given an outline of the
document’s recommendations. It was pro-
posed that the document should be circu-
lated for comment.
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WMA News
The committee agreed to recommend this
approach to the Council.
Physicians Treating Relatives
A proposed Statement on Physicians Treat-
ing Relatives was presented to the commit-
tee. This declared that physicians should
generally avoid treating relatives, except
in an emergency, or for minor short-term
health problems or where there was no oth-
er qualified physician available.
The committee heard that this document
had already been circulated for comments
and changes had been made, including
omitting ‘friends’from the title of the docu-
ment. It was proposed that the document
should now be approved.
However, the Japan Medical Association
objected to such a Statement being issued
by the WMA. It argued that physicians had
an obligation to treat anyone in an emer-
gency, and therefore this Statement was not
necessary. Other speakers also expressed
their doubts about the document, some
arguing that it was too long, others that it
contained inconsistencies.
The committee eventually agreed by 10
votes to six to recommend that the docu-
ment, as amended, be sent to Council for
forwarding to the Assembly for adoption.
Organ Donation in China
The committee received an oral report on
talks that had been held between the Ger-
man Medical Association and the Chinese
Medical Association about the Resolution
on Organ Donation in China, which the
Chinese asked to be rescinded. The Chi-
nese said it would like to see the whole is-
sue being discussed more comprehensively
within the WMA. It had suggested setting
up a workgroup to review existing WMA
policy relating to coerced organ transplants,
including the use the use of death penalty
prisoners’ organs. The Chinese said it had
no problem in condemning the practice of
coerced transplants, but pointed out that
there were other countries still carrying out
the practice. But there had been no criti-
cism from WMA about these countries and
it urged the WMA to correct this.
The committee agreed to recommend that
a workgroup be installed with the mandate
to discuss and review existing WMA poli-
cies related to the fight against coerced or-
gan procurement,including the use of death
penalty prisoners’ organs.
Declaration of Venice and End of Life Care
A proposed 10-year revision of the Dec-
laration of Venice on Terminal Illness was
presented to the committee. The American
Medical Association,which was tasked with
merging the Declaration of Venice with the
Declaration on End-of-Life Medical Care,
explained that this was a major update. The
workgroup had decided that the Declara-
tion of Venice should remain the base docu-
ment. The draft contained new content on
palliative care and sedation and it was sug-
gested that when the proposed revision was
adopted, the Declaration on End-of-Life
Medical Care should be rescinded and ar-
chived. The AMA proposed circulating the
document for comment.
The British Medical Association informed
the committee that the BMA had moved
from a position of opposition to all forms
of physician assisted dying and euthanasia
to neutrality on the issue. This meant they
were neither opposed nor in favour of as-
sisted dying,but that if there were legislative
proposals brought forward in Parliament,
they would comment on those proposals in
order to address doctors’ interests and con-
cerns and in particular to provide for con-
scientious objection.
The committee heard some criticism that
merging the two Declarations was con-
fusing, since the two policies had much
in common but also several differences. A
motion was proposed to split the two docu-
ments again, but on a vote the proposal was
defeated by nine votes to five.
The committee recommended that the draft
Declaration of Venice on Terminal Illness
should be circulated to constituent mem-
bers for comment and the Declaration on
End of Life Medical Care be rescinded and
archived.
Medical Ethics in the Event of Disasters
A proposed Statement on Medical Ethics
during Public Health Emergencies was pre-
sented to the committee, setting out revised
guidance to physicians on the ethical stan-
dards and principles required to confront
public health emergencies.
The committee was told that the Statement
took into account two existing policy state-
ments and the recommendation was to set
up a workgroup.
The committee agreed to recommend that a
workgroup be established.
Professional and Ethical Use of Social Media
The Junior Doctors Network submitted
a proposed major revision of the State-
ment on the Professional and Ethical Use
of Social Media. It was explained that the
policy had been updated to address the im-
portance of evidence-based information on
social media, the role of doctors standing
against misinformation and to examine the
professional and ethical challenges facing
physicians and patients.
The committee agreed to recommend that
the document be circulated for comment.
Monitoring of the Declaration of Tokyo
The committee considered a proposed mi-
nor revision to the Recommendation on the
Development of a Monitoring and Report-
ing Mechanism to Permit Audit of Adher-
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WMA News
ence of States to the Declaration of Tokyo.
The Declaration establishes guidelines for
physicians concerning torture and other
cruel, inhuman or degrading treatment or
punishment in relation to detention and
imprisonment.
A new paragraph was proposed to provide
support to WMA constituent members
and their individual physicians members
to resist such violations, and as far as real-
istically possible, stand firm in their ethi-
cal convictions. After further amendments
were proposed,the committee agreed word-
ing, stating that the medical profession and
governments should also protect physicians
endangered because they adhered to their
professional and ethical obligations.
The revision was agreed and the commit-
tee recommended that the document, as
amended, be sent to Council for forwarding
to the General Assembly for adoption.
Human Rights
The committee received an activity report
on human rights.
Thursday October 14
Resumed Council Session
The reconvened Council meeting was
opened by the Chair, Dr.  Frank Ulrich
Montgomery. It considered reports from its
three committees.
Medical Ethics Committee
Physicians Treating Relatives
The Japan Medical Association reopened
the debate on the proposed Statement on
Physicians Treating Relatives by saying that
the policy as currently worded contained
several inconsistencies. It was not against
the policy, but believed that further discus-
sion should be had about the possible prob-
lems of treating relatives. The Statement
did not take into account patients’ wishes.
It proposed that the document should be
circulated to members once again.
Other speakers also raised issues of concern,
and it was decided by 16 votes to eight to
recirculate the document.
The remainder of the Medical Ethics Com-
mittee’s report was approved without debate.
Finance and Planning Committee
Statutory Meetings
It was reported that the medical associations
of Portugal and Uruguay had agreed dates
on future meetings and it had been agreed
that the Council meeting in the Spring of
2025 should be held in Montevideo and the
Assembly that year should be held in Porto.
The Council agreed to recommend the
dates to the General Assembly.
Legal Seat
The Secretary General updated the Coun-
cil on plans to change the legal seat of the
WMA from the USA to France. He ex-
plained the constraints of the current situ-
ation because of being legally domiciled
in the US. He said the change was purely
technical and would have no bearing on the
purpose of the Association.
The Council approved the report.
Public Relations
The Council received an oral report on pub-
lic relations. Members were told that the
WMA had maintained a very high pro-
file over the past 18 months with its views
about how the Covid-19 pandemic was be-
ing dealt with. The President, the Chair of
Council and the Secretary General had all
conducted many media interviews to put
across the WMA’s various messages about
the pandemic, vaccine equity and vaccine
hesitancy.
Press releases from the Assembly would
highlight new policy documents on the
availability of medicines, women’s access to
health care and the situation in Nicaragua.
NMAs were asked to ensure that their me-
dia outlets received these.
The remainder of the Finance and Planning
Committee’s report was approved without
debate.
Socio-Medical Affairs Committee
Finally, the Council considered the report
of the Socio-Medical Affairs Committee
and approved it without debate.
Advocacy and Communication
An oral report was given by the workgroup,
including activity on social media, Wikipe-
dia and assistance to smaller NMAs on ac-
cessing WMA communications. The report
was received by the Council.
World Health Organisation
The Secretary General reported on discus-
sions that were going on within the WHO
on developing a pandemic treaty. He urged
NMAs to assist with information about
these talks, as it was important for NGOs
and civil society to be involved.
Friday October 15
GENERAL ASSEMBLY
Ceremonial Session
WMA President Dr.  David Barbe called
the session to order and welcomed everyone
to the second online General Assembly.
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Dr.  Chaand Nagpaul, Chair of the host
British Medical Association, welcomed
delegates and reminded them that it was in
BMA House that the idea of creating the
WMA was first born in 1945 in a meet-
ing between leaders of medical associations
from different nations.
He went on: ‘Throughout the pandem-
ic doctors from around the world have
worked day in day out in the most chal-
lenging of circumstances with selflessness
and dedication. Many risked their own
health and lives as they exposed themselves
to this deadly virus.We accepted wholesale
change overnight to our lives. Many doc-
tors moved from their usual specialty to
learn new skills to care for Covid patients.
Working above and beyond, we showed
determination and courage. We have done
our duty. While fighting the virus, it is a
tragedy that too many doctors around the
world have lost their lives in the course of
their duties. They will be remembered and
never be forgotten.
‘However, within the past year we have also
witnessed a breakthrough in medical science
in the development of Covid vaccines anew
within 10 months in what normally takes
up to 10 years. It just shows what can be
achieved with the collective efforts of medi-
cal researchers and scientists working across
the globe and which has brought hope to
the world that there is a way through this
pandemic. The pandemic also reminded us
we are one global community and that no
one safe until everyone is safe’.
He spoke about the need to prioritise sup-
port and aid to those nations worst affected
by the pandemic. It was also a time to rec-
ognise the central importance of a universal
doctrine. The Declaration of Geneva com-
mitted them to recognise the dignity of
every human being, irrespective of nation
or border. These principles reminded them
that the pandemic would not end until they
tackled Covid in every nation, ensuring eq-
uitable access to vaccines in all parts of the
world. The unique strength of the WMA
was more important now than ever before,
bringing together medical leaders from
across the world to connect and collaborate
and to share information about best prac-
tice, to speak out to protect human rights
and the independence of doctors, including
those threatened by their own governments.
It was a crucial moment that required coop-
eration, solidarity and support.
He concluded by saying: ‘It is a time for all
of us to hold our countries to account and
inspire them to act together as one in ser-
vice to the benefit of all nations, to finally
pull through the pandemic together. All na-
tions must recognise the efforts of doctors
and the toll it has taken on their lives. This
has been an emergency that most govern-
ments were unprepared for, so it was left to
health care workers to tend to a crisis that
many of us never could have imagined.This
has led to a new wave of physical exhaustion
and mental health issues for doctors, whose
wellbeing must now be properly supported
if health services are to deal with the con-
tinuing scale of challenges ahead.’
The honoured guest, Professor Chris Whit-
ty, Chief Medical Officer for England and
Chief Medical Adviser to the UK Govern-
ment, expressed his deep respect and per-
sonal gratitude to the millions of physicians
represented by WMA leaders. The profes-
sionalism and compassion they had, and
continued to demonstrate, was remarkable.
He also praised the communication and
collaboration within the medical commu-
nity in responding to the global emergency.
He had valued the support and advice he
had received from public health colleagues
all over the world.The international knowl-
edge and data sharing had played an essen-
tial role in their understanding of Covid-19.
In addition, they had also seen countries
provide essential resources to others in
need and this international network would
continue to be important as they recovered
from this pandemic and faced other global
health issues in the future. He said he was
hopeful that together as a medical commu-
nity they could respond effectively to these
challenges.
Physician delegates logged onto the meet-
ing were then invited to recite the Declara-
tion of Geneva, also known as the Physi-
cian’s Pledge.
Dr.  Barbe paid tribute to physicians who
had died in service during the pandemic,in-
cluding Dr. K.K. Aggarwal from India and
Dr. Mykola Tyshchuk.from the Ukraine.
The Chair of Council, Dr.  Montgomery,
paid tribute to Dr. Barbe’s Presidency, say-
ing he had tirelessly promoted the messages
for Covid-19 testing and vaccination.
Dr.  David Barbe delivered his valedictory
address and was presented with a Past Pres-
ident’s medal by Dr. Montgomery.
Dr.  Montgomery then installed President
Elect, Dr.  Heidi Stensmyren as President
for 2021/22. Dr. Stensmyren took the oath
of the office of President and was presented
with the Presidential Medal. She then de-
livered her inaugural address.
Plenary Session
Dr. Montgomery opened the plenary ses-
sion of the General Assembly.
Minutes of the last Meeting
The Chinese Medical Association expressed
its opposition to paragraph in the minutes
reporting the Resolution adopted at last
year’s General Assembly on Human Rights
Violations against Uighur people in China.
It said this contained serious procedural
flaws and ignored facts and evidence. Its
allegations about the health of the Uighur
people were completely groundless.
In a vote on whether to accept the Uighur
paragraph in the minutes, 98 votes were in
favour and 15 against.
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WMA News
In a further vote on whether to accept the
minutes as a whole, 101 votes were cast in
favour and 13 against.
Election of President for 2022/23
The Secretary General reported the results
of the election for President-elect. There
were two candidates, Dr.  Osahon Enab-
ulele (Nigeria) and Dr. Muhammad Ashraf
Nizami (Pakistan). A total of 49 member
associations participated in the vote with
a total of 144 votes. The result was that
Dr. Enabulele was elected with a majority
of votes to become President in 2022–23.
In his acceptance speech, Dr. Enabulele said
this was the first time since the establishment
of the WMA in 1947 that a physician from
Nigeria,the most populous country in Africa
with a population of well over 200 million
people, had been elected to lead the WMA.
‘Coming from an underserved, under-repre-
sented, and poorly understood region of the
world, deprived of quality healthcare – the
African region with 54 countries – I had in
the run up to the Presidential election, em-
phasized the need to give fair consideration
and opportunities to physicians from the
African region, to lead the organization, in
a way that highlights the fact that everyone
counts in the WMA,and that we can all learn
and benefit from each other’s experiences’.
He added: ‘I consider it an important affir-
mation of the fact that every member and
every region counts in the WMA, and that
at different moments, the various members
and regions of the organization will have
the opportunity to lead at different levels
of the WMA. On behalf of the Nigerian
Medical Association, my country Nigeria,
the African region, and indeed my family,
I wish to express profound gratitude to all
National Medical Associations from all re-
gions of the world, and to physicians across
the globe, for reposing huge confidence in
me and the African region, and for finding
me worthy to be elected to serve the WMA
in the high office of President for the 2022–
2023.’
Dr. Enabulele concluded by saying: ’The is-
sues of health disparities and inequities,made
worse by the Covid-19 pandemic, the issue
of quality patient care, physician wellbeing,
rights and autonomy, remain critical issues
for engagement. We must therefore continue
to make our contributions to the manage-
ment of the Covid-19 pandemic that has
devastated the health system, lives and liveli-
hoods, including the lives of physicians and
other health professionals.I cannot end these
remarks without paying special tribute to our
colleagues who lost their lives in the course of
duty, in this Covid-19 pandemic era’.
Report of the Council
The reports of the three committees were
presented to the Assembly from Council.
The Assembly adopted the following policies:
• Resolution on Covid-19 Vaccines and In-
ternational Travel Requirements
• Resolution in support of Myanmar
Health Personnel and Citizens
• Resolution in support of the Countries
worst affected by the Covid-19 Crisis
• Revised Declaration on Principles of
Health Care for Sports
• Revised Statement on Access of Women
and Children to Health Care
• Revised Statement on Women’s Right
to Health Care and How that Relates to
the Prevention of Mother-to-Child HIV
Infection
• Statement on Photoprotection
• Statement in Support of Ensuring the
Availability, Quality and Safety of All
Medicines
• Revised Statement on Medical Liability
• Statement on Access to Surgery and An-
esthesia Care
• Revised Resolution on Trade Agreements
and Public Health
• Revised Resolution Supporting the
Rights of Patients and Physicians in the
Islamic Republic of Iran
• Resolution on the Repression of Nicara-
guan Doctors
Minor revisions were agreed to the follow-
ing policies:
• Declaration on Leprosy Control around
the World and Elimination of Discrimi-
nation against persons affected by Lep-
rosy
• North Korean Nuclear Testing
• Protection of Health Care Facilities and
Personnel in Syria
• Resolution on Child Safety in Air Travel
• Implementation of the WHO Frame-
work Convention on Tobacco Control
• Revised Recommendation on the Devel-
opment of a Monitoring and Reporting
Mechanism to Permit Audit of Adher-
ence of States to the Declaration of Tokyo
• Revised Resolution on Plain Packaging
of Cigarettes
Taiwan
The Chinese Medical Association proposed
rescinding the proposed Resolution calling
for observer status for Taiwan at the World
Health Organisation. It argued that the
Resolution was factually and legally wrong.
There was only one China and Taiwan was
an inalienable part of China. This principle
was universally recognised in the interna-
tional community and the WMA had al-
ways claimed it did not hold any political
position on the issue of national sovereignty.
It was also inconsistent with the principles
and practices upheld by the United Nations
and the World Health Organisation. The
proposed Resolution violated both the UN
Charter and the WMA’s statement not to
take any political stance.There was no barri-
er whatsoever for the Taiwan medical com-
munity to communicate with the WHO.
However, the delegate from Taiwan.,
Dr. Tai-Yuan Chiu said that Taiwan had not
been invited to the World Health Assembly
as an observer since 2017. From 2009 to the
end of 2020 Taiwan had applied to attend
199 technical meetings held by the WHO.
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WMA News
It was allowed to attend only 64, a 70 per
cent rejection rate. The WHO had failed to
fulfil the principles of universality, equality
and its ethical aspirations.
On a vote, the motion to rescind the Reso-
lution was lost by 99 votes to 19.
On a second vote, the proposed Resolution
was adopted by 91 votes to 16.
Proposed revision of Statement on Medical
Care for Refugees, including Asylum Seekers,
Refused Asylum Seekers and Undocumented
Migrants, and Internally Displaced Persons
The Assembly was asked to adopt the pro-
posed revision of the Statement on Medical
Care for Refugees, which sets out physi-
cians’ duty to provide migrants with appro-
priate medical care, based solely on clinical
need, regardless of the civil or political sta-
tus of the patient.
The delegate from Bangladesh referred to
the paragraph urging governments to en-
sure access to safe and adequate living con-
ditions and essential services for all.He pro-
posed adding to the end of the sentence the
words ‘migrants even with the support from
the donor agencies and/or philanthropists if
needed’. He argued that if countries, where
the displaced people migrated, could not af-
ford to bear by itself the economic burden
created due to influx of migrants, external
support from the donors and philanthro-
pists was needed to support the healthcare
services effectively.
His amendment received support from
Pakistan and the Assembly agreed to in-
clude the new words in the Statement.
The whole document, as amended, was then
adopted without a vote.
Family Violence
A proposed revision of the Statement on
Family Violence was submitted for adoption.
Dr.  René Héman (Royal Dutch Medical
Association) proposed several amendments.
The first was to delete the word ‘often’ from
the sentence ‘Victims often become perpe-
trators of family violence and violent acts
against non-intimates’ and replace it with
the word ‘can’. He argued that to say that
victims of family violence often become per-
petrators themselves was too strong. Inter-
generational transmission of violence was a
known phenomenon, but did not necessar-
ily happen to victims of this violence.
After a brief debate, the deletion of the
word ‘often’ was agreed without a vote.
Dr. Héman also said he was not in favour
of making the reporting of family violence
compulsory. Reporting should be consid-
ered on a case-to-case base and should be
seen as a final step in a series of possible in-
terventions, such as providing. He proposed
several amendments to make this clear. On
a vote, these were agreed.
The Assembly then adopted the Statement,
as amended.
Treasurer
The Treasurer, Dr.  Ravindra Sitaram
Wankhedkar, gave a brief report on the As-
sociation’s financial situation. He referred
to the Association’s net income, the mem-
bership dues which had been paid, the fi-
nancial earnings which continued to be low
and the substantial cost savings because of
Covid-19. He reported on the budget for
2022 and said the Association’s finances
were very solid.
His reports were approved by the Assembly.
Future Meetings
The Assembly was informed that the 2025
Council session would be held in Monte-
video, Uruguay from April 24–26 and the
General Assembly that year would be held
in Porto, Portugal from October 8–11.
A request had been received from the Royal
Dutch Medical for the 2026 General As-
sembly to be held in the Netherlands
The Assembly approved the reports.
It was reported that the theme at the sci-
entific session in Berlin on October 6 2022
would be ‘Medical Ethics in a Globalised
World’. The General Assembly from Octo-
ber 5–8 would coincide with the 75th
anni-
versary of the German Medical Association.
This was approved by the Assembly.
Bylaws Amendments
The Assembly approved amendments to
the bylaws proposing additional committee
members and the issue of voting rights.
Associate Members
Dr. Ankush Bansal presented a report from
the Associate Members. He said Dr. Joseph
Heyman had been re-elected to the chair
and proposals to amend the group’s rules
had been discussed and would now be cir-
culated to members for comment.
The report was accepted.
International Day of the Medical Profession
Dr. Huerta (Spain) reminded the Assem-
bly of the Resolution, adopted at last year’s
General Assembly, for October 30th
to be
the International Day of the Medical Pro-
fession. He asked the WMA and its mem-
bers to promote activities to celebrate this
day, the first time that it had been celebrat-
ed.The Spanish Medical Council was going
to send out letters and posters in Madrid
and meet with the chairs of societies all over
Spain to ask them to promote this day and
the profile of the medical profession.
The Assembly ended with the showing of a
film on Berlin, the venue for the next Gen-
eral Assembly in October 2022.
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WMA Declaration on
Principles of Health Care in
Sports Medicine
Adopted by the 34th
World Medical Association General Assembly, Lis-
bon, Portugal, September/October 1981, amended by the 39th
World
Medical Association General Assembly, Madrid, Spain, October 1987,
by the 45th
World Medical Association General Assembly, Budapest,
Hungary, October 1993, by the 51st
World Medical Association General
Assembly, Tel Aviv, Israel, October 1999, reaffirmed by the 185th
WMA
Council Session, Evian-les-Bains, France, May 2010, and amended by
the 72nd
WMA General Assembly (online), London, United Kingdom,
October 2021
Preamble
Sports medicine physicians are physicians concerned with the
prevention and treatment of injuries and disorders that are relat-
ed to participation in sports. In some countries, sports medicine
physicians are recognized as medical specialists. They are trained
to address issues associated with nutrition, sports psychology and
substance misuse, and may also counsel athletes on injury preven-
tion.
Considering the involvement of physicians in sports medicine, the
World Medical Association (WMA) recommends ethical guide-
lines for sports medicine physicians, recognizing the special cir-
cumstances in which their medical care and health guidance is
given.
Anabolic Agents and Performance
Enhancing Drugs and Methods
The use of anabolic agents, performance enhancing drugs, pain kill-
ers and performance enhancing methods by athletes is contrary to
the rules and ethical principles of athletic competition as set forth
by most sports governing bodies. Performance enhancing drugs and
methods have been associated with adverse health effects.
The sports medicine physician should be aware that methods, drugs
or interventions which artificially modify blood constituents, bio-
chemistry, genome sequence, gene expression or hormone levels and
do not benefit patients, violate the basic principles of the WMA’s
Declaration of Geneva, which states: “the health and wellbeing of my
patient will be my first consideration.”
The WMA believes that the use of anabolic agents and performance
enhancing drugs and methods is a threat to the health of athletes
and is in conflict with the principles of medical ethics. The physi-
cian must oppose and refuse to administer or condone any means
or method which is not in accordance with medical ethics, or which
might be harmful to the athlete using it. The physician must also
inform athletes of potential health risks.
Examples of these drugs and methods include,but are not limited to:
• The use of drugs or other substances whatever their nature and
route of administration, including central-nervous-system stim-
ulants or depressants and procedures which artificially modify
reflexes, alter a sense of well-being and/or general mental out-
look.
• Procedures or therapeutics to mask pain or other protective
symptoms if used to enable the athlete to take part in events or
training activities when clinical signs make his or her participa-
tion inadvisable. This includes allowing participation in athletic
activity when doing so would be dangerous to the athlete.
• Procedures or therapeutics used to mask the presence of other
performance enhancing drugs or to induce rapid water or weight
loss.
• Measures aimed at an unnatural improvement in or maintenance
of endurance or oxygen carrying capacity during competition.
This includes the manipulation of blood and/or blood compo-
nents defined as the administration or reintroduction of blood or
red blood cell products of any origin into the circulatory system,
artificially enhancing the uptake, transport, or delivery of oxygen
using chemicals such as erythropoietin, or other forms of intra-
vascular manipulation to artificially increase red blood cell mass,
unless medically indicated for the treatment of a documented dis-
ease or medical condition. Blood doping also exposes the athlete
to unwarranted and potentially serious health risks.
• Use of anabolic agents including “designer steroids”, which are
substances that are undetectable through the use of standard test-
ing methods.
• Use of anabolic steroid precursors, including dietary supplements,
that claim to provide “safe” steroid equivalents, but that metabo-
lize in the body into anabolic steroids.
• Use of non-approved substances which have no current approv-
al by any governmental regulatory health authority for human
therapeutic use, for example, drugs under pre-clinical or clinical
development, discontinued drugs, designer drugs or substances
approved only for veterinary use.
• Use of peptide hormones, growth factors and related substances
to increase red blood cell count, blood oxygenation or oxygen-
carrying capacity.
• Use of hormone and metabolic modulators, which are substances
to modify hormone activity by blocking the action or increasing
the activity of a hormone.
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WMA News
Of special concern is the use of anabolic agents and steroid precur-
sors in adolescents. Young users are considered particularly suscep-
tible to potentially serious health problems during this physically
and emotionally vulnerable period when their own hormonal cycles
are changing. In females, anabolic agents have been associated with
a number of adverse effects, some of which appear to be permanent
even when drug use is stopped. Physicians should strongly discour-
age using these products.
World Athletics Gender Rules for
Classifying Female Athletes
World Athletics 2018 Eligibility Regulations for Female Classifica-
tion [1] imposes an upper hormonal limit for athletes wishing to
compete in the female category in certain disciplines of interna-
tional athletics competitions.
The WMA opposes World Athletics’rules [2] requiring female ath-
letes with differences in sex development to take drugs to reduce
and maintain their natural level of blood testosterone in order to
compete. The mere existence of a condition caused by a difference
in sex development, in a person who has not expressed a desire to
change that condition, does not constitute a medical indication for
treatment. Medical treatment solely to alter athletic performance is
unethical.
Recommendations
1. Sports medicine physicians have an obligation and duty to re-
spect and comply with the ethical standards of the medical pro-
fession.
2. The sports medicine physician who cares for athletes has an eth-
ical responsibility to recognize the special physical and mental
demands placed upon athletes by their participation in athletic
activities.The physician’s duty is to preserve the athlete’s mental
and physical health and not solely to increase athletic perfor-
mance.
3. When the sports participant is a professional athlete and derives
livelihood from that activity, the physician should understand
the occupational health aspects involved.
4. The sports physician should give his or her objective opinion
about the athlete’s state of fitness clearly and precisely, leaving
no doubt as to his or her conclusions.
5. In all sporting events, it is the physician’s duty to decide
whether the athlete is medically fit to compete in an event.
This decision cannot be delegated to other non-physician pro-
fessionals.
6. In order to carry out his or her ethical obligations, the sports
medicine physician’s authority must be fully recognized and up-
held, particularly when it concerns the health and safety of the
athlete. Concern for the athlete’s health and safety must over-
ride the interests of any third party.
7. The sports medicine physician is obligated to uphold the ethical
principles of the medical profession. This includes the right to
privacy and respect for the confidential nature of the patient-
physician relationship. These principles and obligations should
be supported by an agreement between the sports medicine
physician and the athletic organization involved.
8. The sports medicine physician must oppose and refuse to ad-
minister any substance or condone any means or treatment
method which is not in accordance with medical ethics and/or
which might be harmful to the athlete using it. The physician
must also inform athletes of potential health risks.
9. The sports medicine physician should be invited to participate in
the design and modification of a sport’s rules and regulations in
order to protect the health and safety of athletes.
10. The sports medicine physician, with patient consent, should
work cooperatively with the patient’s personal physician, and
keep him or her fully informed of the patient’s current condi-
tion.
11. All physicians should recognize that the desire to enhance per-
formance, appearance, and/or well-being is not limited to elite
athletes. Amateur and recreational athletes, as well as adoles-
cents, are also at risk of and subject to sociocultural pressures to
misuse anabolic agents and performance enhancing drugs and
methods. A harm-reduction approach with discussions focused
on risks, harm minimization, prevention strategies, and health
promotion is recommended.
WMA Resolution in
Support of Medical
Personnel and Citizens of
Myanmar
Adopted by the 217th
WMA Council Session, Seoul (online), April 2021
and by the 72nd
WMA General Assembly (online), London, United
Kingdom, October 2021
The World Medical Association notes with increasing alarm, the
continuing actions of the current police and Myanmar security
forces including arbitrary arrests and detention of health personnel
and other citizens, attacks against physicians and other health per-
sonnel and facilities, and continuing harassment and intimidation
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WMA News
of protesters, human rights defenders and journalists. The WMA
and its members are seriously disturbed by their terrorizing, ar-
resting, kidnapping and murdering health care workers for treating
protesters.
With a collapsed health system, the Covid pandemic is devastat-
ing Myanmar with lack of medical equipment and personnel and
increasing deaths. Recent reports of forcing hundreds of physicians
to secretly treat Covid patients and ambushing and arresting physi-
cians after luring them to a non-existent Covid patient’s home, are
cause for further dismay.
These activities are in total opposition to the international recom-
mendations in the WMA Declaration on the Protection of Health Care
Workers in situation of Violence, the WMA Statement on the Protection
and Integrity of Medical Personnel in Armed Conflicts and Other Situ-
ations of Violence as well as the United Nations Declaration on Human
Rights Defenders.
Thus, the WMA and its members demand that the Myanmar secu-
rity forces take immediate action to:
• Guarantee, in all circumstances, the physical and psychological
integrity of protesters, including health personnel who are ar-
rested;
• Release protesters and personnel immediately and uncondition-
ally, and drop all charges against them since their detention is
arbitrary as it only aims at preventing freedom of expression and
their human rights activities;
• Put an urgent end to attacks against health personnel and facili-
ties and ensure their protection to provide adequate health care
provisions to all.
• Stop all acts of harassment, intimidation, and killing, against pro-
testers, human rights defenders and journalists and comply with
all the provisions of the United Nations Declaration on Human
Rights Defenders;
• Ensure in all circumstances respect for human rights and fun-
damental freedoms in accordance with international human
rights standards and international instruments, including the
International Covenant on Economic, Social and Cultural
Rights.
• Cooperate with international fact-finding commissions.
WMA Resolution in Support of
Taiwan’s Participation in all WHO
Health Programs and Inclusion
in the International Health
Regulations (IHR) Mechanism
Adopted by the 170th
WMA Council Session,Divonne-les-Bains,France,
May 2005 and revised and adopted as a Resolution by the 72nd
WMA
General Assembly (online), London, United Kingdom, October 2021
Preamble
In line with the Charter of the United Nations, Member States of
the WHO recognize the “enjoyment of the highest attainable standard
of health”as a fundamental right of every human being “without dis-
tinction of race, religion, political belief, economic or social condition”,
uphold that “the health of all peoples is fundamental to the attainment
of peace and security and is dependent upon the fullest co-operation of
individuals and States” (Preamble of WHO’s Constitution).
Taiwan, located at a key position in the Asia-Pacific region, has
long enjoyed close relationship with countries and areas of the re-
gion, with over 20 million regional and international travelers per
year. Thus, the devastating outbreak of the 2019 Novel Coronavirus
further highlights the urgency and importance of inclusiveness and
leaving no one behind in the global health network.By continuing to
refuse to grant Taiwan observer status to the WHA and full access to
its meetings, mechanisms and activities, the WHO fails to fulfill the
principles of universality and equality established in WHO’s consti-
tution as well as the ethical standards of the organization.
From 2009 to 2016,Taiwan was invited to participate in the World
Health Assembly (WHA) as an Observer, with very limited access
to WHO technical briefings,mechanisms and activities.Since 2017,
the WHO has not granted the Observer status to Taiwan anymore.
Although Taiwan has been officially included in the implementa-
tion framework of the International Health Regulations (IHR)
since 2009, its contact point information is not included on the
IHR Portal established by WHO, impeding timely exchange of in-
formation and communication to the detriment of Taiwan. Delayed
and/or incomplete medical information can impact adversely on the
Taiwanese population, causing a gap in Taiwan’s domestic disease
control network, with unavoidable implications for global health.
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WMA News
Allowing the participation of Taiwan to the World Health Assem-
bly and fostering its inclusion in all WHO’s health programmes and
in the International Health Regulations would benefit the people
in Taiwan, but also the WHO and its member states as well as all
related parties.
Recommendations
1. Considering the Sustainable Development Goal 3 aiming to
ensure healthy lives and promoting well-being for all at all ages
and WHO’s primary objective to “attain by all peoples the highest
possible level of health” (article 1 of WHO’s Constitution), both
aims requiring a true inclusive strategy comprising all popula-
tions worldwide,
2. Reminding the ethical core value of the medical profession
to serve humanity regardless of any other considerations than
people’s health and well-being, and firmly committed to the
safeguard and promotion of health-related human rights, the
WMA and its constituent members call on:
–
– WHO to grant Taiwan observer status to the World Health
Assembly and to ensure Taiwan’s participation in all its health
programs based on a substantive, timely and professional basis,
–
– WHO and its Member States to include Taiwan as a full rtici-
pating party to the International Health Regulations, allowing
its critical contribution to the global health protection network.
WMA Resolution in Support of
the Countries Worst Affected by
the Covid-19 Crisis
Adopted by the 217th
WMA Council Session, Seoul (online), April 2021
and adopted by the 72nd
WMA General Assembly (online), London,
United Kingdom, October 2021
The World Medical Association is deeply concerned to see the alarm-
ing and worsening Covid crisis in many countries worldwide.We rec-
ognise the huge challenges doctors and other healthcare professionals
are facing in maintaining healthcare systems in such harrowing con-
ditions.The WMA calls on the international community and govern-
ments to urgently prioritise support and aid to these the worst af-
fected nations,including oxygen,drugs,vaccines,Personnal Protective
Equipment (PPE) and other equipment as needed,and to strengthen
healthcare system resilience in the face of future pandemics.The pan-
demic will not end until we tackle Covid in every nation and this is
a time for global cooperation, solidarity and support for one another.
WMA Resolution on
Covid-19 Vaccines and
International Travel
Requirements
Adopted by the 72nd
WMA General Assembly (online), London, United
Kingdom, October 2021
While international travel has begun to normalize for many of those
who have been vaccinated against SARS-CoV 2, fully vaccinated
citizens of some countries are still subject to significant travel re-
strictions, as the vaccines they have received are not accepted as
proof of full protection in all countries. Many countries only con-
sider those who have received certain vaccines from specific coun-
tries to be fully vaccinated, while other vaccines are not recognized
or available.
These practices effectively lead to discriminatory border restric-
tions against travelers who have been fully vaccinated using vaccine
regimens approved in their home countries. This may restrict in-
ternational cooperation and business, mainly disadvantaging poorer
countries and regions. In some cases, it has even led fully vaccinated
individuals to request third and fourth vaccine doses in order to
provide proof of the required level of protection.
The WMA understands the reluctance of pharmaceutical authori-
ties to allow the market introduction of vaccines for which an au-
thorization has not been applied in their jurisdiction, or which are
still in the process of authorization,or which may have been rejected
because their ethical or technical standards of testing or production
do not meet the required standards.
However, the WMA considers it necessary to evaluate Covid-19
vaccines based solely on their effectiveness against infection and se-
vere illness when determining the reliability of their protection for
travel purposes. Presently, there are enough data available to assess
the protection offered by vaccines, independent of their marketing
authorization status. Should vaccines be deemed to be ineffective,
and therefore not acceptable as proof of protection, the reasons for
such decisions should be made public.
We call on national governments and the European Union to im-
mediately adopt fair, harmonized, and non-discriminatory rules to
enable safe and fair travel opportunities, and to inform the public
about any serious concerns that may hinder the acceptance of spe-
cific vaccines.
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WMA Resolution on the
Repression of Nicaraguan
Doctors
Adopted by the 72nd
WMA General Assembly (online), London, United
Kingdom, October 2021
Nicaragua is currently in a phase of accelerated expansion and com-
munity transmission of COVID-19. It is urgent for health authori-
ties to promote necessary and proportionate measures to contain the
progress of the pandemic.
The exponential increase in COVID-19 cases has caused a col-
lapse of Nicaragua’s public and private healthcare system. The lack
of basic medical devices has contributed to dozens of doctors and
healthcare professionals becoming infected and a large number
who have died.
The Nicaraguan medical profession, through more than 30 medi-
cal societies and the COVID-19 citizen observatory, has been de-
nouncing this situation for a long time. Nonetheless, the Special
Cybercrime Act approved by the Government of Nicaragua, in
force since 30 December 2020, establishes sentences of 1 to 10 years
in prison for all those who spread news that produces fear or anxiety
in the population.
This situation of persecution is compounded by the approach to the
COVID-19 pandemic,as doctors in the public sector who demand-
ed protective measures like masks,gloves or vaccines,were dismissed
under the accusation that they disrupted the public peace. Private-
sector physicians who cared for patients or guided the population
on self-protection measures against the pandemic were called to
stop those statements, under penalty of withdrawing their licence
to practice medicine or the imposition of criminal penalties, among
other terrorism-related charges.
The General Assembly of the World Medical Association
(WMA) hereby ratifies the letter from its president, Dr Barbe,
sent on 31 August to the president of the Republic of Nicaragua,
Mr Daniel Ortega, which outlines the dramatic situation suf-
fered by Nicaraguan medical professionals and offers its support
to the Declarations of 25 June 2018 and 23 August 2021 from
­
CONFEMEL (Latin American and Caribbean Medical Con-
federation).
The World Medical Association (WMA) opposes and observes
with extreme concern any governmental interference that threat-
ens the freedom of professional practice and freedom of expression
of any doctor. It also urges the government of Nicaragua and the
members of its National Assembly:
• to protect all health professionals;
• to avoid or modify any legal regulation that may harm the profes-
sional autonomy of physicians.
The World Medical Association (WMA) also wishes to highlight
the extraordinary role of Nicaraguan doctors, which is inherent to
our ancient profession. It actively supports and promotes the right
of everyone to receive information and medical care based solely on
their clinical needs.
WMA Resolution Supporting
the Rights of Patients and
Physicians in the Islamic
Republic of Iran
Adopted by the 60th
WMA General Assembly, New Delhi, India, October
2009, and amended by the 72nd
WMA General Assembly (online), Lon-
don, United Kingdom, October 2021
WHEREAS
Physicians in the Islamic Republic of Iran have reported:
• Deliberate denial of medical care in detention, withholding of es-
sential and readily available medications by physicians and other
health professionals;
• Widespread use of torture and ill-treatments in detention;
• Concern about the veracity of documentation related to the death
of patients and physicians being forced to produce clinically in-
correct documentation;
• Lack of essential functioning medical equipment and supplies
• Denial of the rights of hunger strikers; and
• Physicians’ complicity in facilitating the death penalty for juve-
niles in violation of children’s rights.
THEREFORE, the World Medical Association
1. Reaffirms its Declaration of Lisbon on the Rights of the Patient,
which states that whenever legislation, government action or
any other administration or institution denies patients the right
to medical care, physicians should pursue appropriate means to
assure or to restore it.
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2. Reaffirms its Declaration of Hamburg Concerning Support for
Medical Doctors Refusing to Participate in, or to Condone, the Use of
Torture or Other Forms of Cruel, Inhuman or Degrading Treatment,
which encourages doctors to honor their commitment as physi-
cians to serve humanity and to resist any pressure to act contrary
to the ethical principles governing their dedication to this task.
3. Reaffirms its Declaration of Tokyo – Guidelines for Physicians Con-
cerning Torture and other Cruel, Inhuman or Degrading Treatment
or Punishment in Relation to Detention and Imprisonment, which:
–
– Prohibits physicians from participating in, or even being pres-
ent during the practice of torture or other forms of cruel or
inhuman or degrading procedures;
–
– requires that physicians maintain utmost respect for human life
even under threat and prohibits them from using any medical
knowledge contrary to the laws of humanity.
4. Reaffirms its Resolution on the Responsibility of Physicians in the
Documentation and Denunciation of Acts of Torture or Cruel or
Inhuman or Degrading Treatment, which states that physicians
should attempt to:
–
– ensure that detainees or victims of torture or cruelty or mis-
treatment have access to immediate and independent health
care;
–
– ensure that physicians include assessment and documentation
of symptoms of torture or ill-treatment in the medical records
using the necessary procedural safeguards to prevent endanger-
ing detainees.
5. Refers to the WMA International Code of Medical Ethics, which
states that physicians shall be dedicated to providing competent
medical service in full professional and moral independence,
with compassion and respect for human dignity.
6. Reaffirms its Declaration of Malta on hunger strikers which pro-
hibits force-feeding of hunger strikers as “degrading and inhu-
man,” even when this is the only way to save their lives.
7. Refers to the United Nations Nelson Mandela Rules, which
emphasizes that the provision of health care for prisoners is a
State responsibility, and that the relationship between health-
care professionals and prisoners is governed by the same ethical
and professional standards as those applicable to patients in the
community.
8. Refers to the WMA Statement on Access of Women and Children
to Health Care, which categorically condemns violations of the
basic human right of women and children, including violations
stemming from social, political, religious, economic and cultural
practices.
9. Refers to the WMA Statement on Natural Variations of Human
Sexuality, which condemns all forms of stigmatization, crimi-
nalization and discrimination of people based on their sexual
orientation.
10. Urges the government of the Islamic Republic of Iran to respect
the International Code of Medical Ethics and the standards in-
cluded in the aforementioned declarations to which physicians
are committed.
11. Stresses that physicians who adhere to the professional and ethi-
cal obligations outlined in the entire WMA policy apparatus,
including the aforementioned declarations, must be protected
WMA Statement in Support
of Ensuring the Availability,
the Quality and the Safety of
Medicines Worldwide
Adopted by the 72nd
WMA General Assembly (online), London, United
Kingdom, October 2021
Introduction
Over the past decade,pressure on supply has led to shortages of cer-
tain medical products, including vaccines. In many situations, these
shortages result from putting economic objectives before public
heath. These shortages are detrimental to patient care, to maintain-
ing public health and to the organisation of healthcare systems.
The world is going through rapid change; technological progress,
radical progress in matters of communication and access to infor-
mation as well as the increasing power of multi-nationals are trans-
forming the global landscape, including the pharmaceutical indus-
try.Unfortunately,some of these developments have encouraged the
production and sale of medical products which do not meet the
required safety standards,whether due to the manufacturing process
or inappropriate storage, or due to the criminal manufacture and
fraudulent distribution of sub-standard or falsified medicines.
According to the WHO’s Global Surveillance and Monitoring
System (GSMS) for sub-standard and falsified medical products,
around one out of ten medicines is either of a sub-standard quality or
falsified in countries with low or medium income.This observation is
not limited to the most expensive medicines or the most well-known
brands, but also concerns patented and generic products. The medi-
cines most often flagged are the antimicrobials and antimalarials.
The WMA reiterates its position on biosimilar medicines, its reso-
lution on prescribing medicines, its position on the substitution of
medicines and resistance to antimicrobials.
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The rational use of medicines implies ensuring that research,regula-
tion, production, distribution, prescription, financing, delivery and
proper administration of these medicines comply with coherent and
rational scientific, professional, economic and social criteria.
From a healthcare point of view, a shortage of medicines is unac-
ceptable, as it has a negative impact on confidence for patients, doc-
tors, pharmacists and the healthcare system, it leads to insecurity
and uncertainty and compromises treatment continuity; with all the
risks that this implies.
With the objective of combatting the intolerable missed opportuni-
ties that such shortages represent for patients, undermining public
trust in the healthcare system, the WMA is calling for the imple-
mentation of the following recommendations:
Recommendations
Availability of medicines
1. As a public health issue and out of concerns for safety, the
WMA urges national governments to improve the availability
of medicines.
2. National governments and regulatory authorities should:
–
– Create a national entity responible for gathering and communi-
cating information relative to demand and offer for medicines
under their jurisdiction. Establish standards and mechanisms
guaranteeing the continuity and the supply of medicines and
thus avoid shortages.
–
– Improve the monitoring of medical product supply chains, as
the weakness of regulatory structures make the application of
good medical product distribution particularly difficult.
–
– Design contingency strategies to counter the dependence of
States on foreign medicine production due to the delocalisation
and centralisation of the majority of structures which produce
the main pharmaceutical components used in the composition
of major medicines.
–
– Encourage national healthcare authorities to maintain stocks of
essential medicines in order to minimise the risk of shortages.
Indeed, the Covid-19 health crisis has demonstrated the limits
of stocks held by States and has constrained them to reorganise
and restrict access to certain medicines.
–
– In the case of global epidemic, to pool scientific research and
clinical trials with the objective of accelerating the develop-
ment of vaccines and/or treatments to eradicate the pande­
mic.
–
– Support legislative and regulatory initiatives which guarantee
an appropriate national capacity to produce pharmaceutical
products, in the interests of the well-being of the populace and
national security.
–
– Identify and create sustainable mechanisms which will guar-
antee sufficient stocks and sufficient access to necessary medi-
cines.
–
– Promote co-operation between governments in the prevention
and the management of medicine and vaccine shortages.
–
– Encourage governments to be more directive in their dealings
with the pharmaceutical industry, notably in terms of adjusting
quotas, of accelerating approvals and of importing substitute
medicines when pharmaceutical companies are not able to en-
sure a continuous and adequate supply of medicines.
–
– Consider demanding that medicine producers establish a con-
tinuity plan for the supply of vital and necessary medicines and
vaccines in order to avoid production shortages wherever pos-
sible.
–
– Ensure the transparancy, sharing and availability of quality in-
formation coming from reliable sources in order to establish a
trustworthy flow of communications between all stake-holders
and healthcare professionals and to the patients. In the case of
shortages, governments should divulge and detail the causes to
all stake-holders.
–
– Enable WMA member states to acquire, via common supply
contracts, healthcare and vaccine products in sufficient quanti-
ties during a pandemic and thus to have greater influence in
negotiations with laboratories.
–
– Avoid the ‘first come, first served’ approach, notably during a
pandemic, leading to counter productive competition acting
against the safeguarding of public health.
–
– Allow an industrial level of security of supply in line with the
deployment of Interpol’s programme combatting pharmaceuti-
cal criminality.
Safety of medicines
3. The objective is to set up active supply processes to ensure the
continuity of quality medical supplies while guaranteeing their
safety.
4. Elements of a high-quality, active supply process comprise:
–
– Improvements in quantification, including forecasting.
–
– Direct communication between supply agents and the manu-
facturers on the question of sustainable capacity.
–
– Deliberate and well-considered approaches to a specific situ-
ation for each product (long term, short term, split contracts,
etc.)
–
– Responsible pricing with the emphasis on quality
–
– Rational and necessary contracts.
–
– Establish frameworks which limit the excessive accumulation
of medicines and the useless scrapping of unused medicines
with the objective of preserving the quality of their pharma-
ceutical properties.
–
– Encourage governments to promote the sharing of public in-
formation on the real price of medicines. The authorities must
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regulate and limit the possibility of reaching agreements on
price and discounting confidentiality in the medicine evalua-
tion process. The system must be made more transparent in all
areas, including the evaluation of new medicines.
5. The WMA is clear on the fact that the quality of medicines is
a public health priority and is recommending national medical
associations and doctor members to:
–
– Increase awareness among the public and medical practitioners
of sub-standard and fake products.
–
– Create a list of ‘essential’medicines meeting a country’s health-
care needs.
–
– Create an early alert system, based around vital medicines and
those intended to treat a debilitating pathology, in particular
those for which no alternative therapeutic options are avail-
able. The activation of such a system would trigger a sequence
of measures for all the stake-holders (licensed manufacturers,
wholesalers, hospital pharmacists) alongside reporting obliga-
tions and a close monitoring of corrective actions.
–
– Create a scenario and emergency programmes, including a
stress test for manufacture and inspection systems at regular
intervals, with appropriate communication strategies adapted
to the different stake-holders.
–
– Persue efforts to harmonise regulatory standards between the
countries and beyond regions.
–
– Set up proactive and productive collaboration between all
the essential stake-holders in order to prevent medicine
shortages and mitigate the harmful effects these have on pa-
tient care.
–
– Work with healthcare user associations to fight against the
growing culture of ill-advised self-diagnosis, self-prescription
and self-medication, which could make the supply chain vul-
nerable to the introduction of non-approved or counterfeit
products.
–
– Restrict the prevalence of low quality medicines by implement-
ing and applying current good practices in manufactuting, stor-
age and distribution which respect the environment (cGMP)
and by preventing the deterioration of medicines.
–
– Encourage the pharmaceutical sector to undertake to guarantee
the continuity of supply of medicines, in order to avoid any
interruptions in treatment.
6. The WMA is insisting that national governments, in tandem
with healthcare user associations and other stake-holders, do
everything possible to ensure awareness of medicine safety for
all patients.
–
– At an international level and working together, Health Minis-
ters and Medical Regulators should recommend that national
medical associations actively oppose the illegal misappropria-
tion of medicines, the illegal sales of medicines on the internet,
the illegal importing of medicines and the counterfeiting of
medicines.
–
– Improve regulation and monitoring of the online pharmaceuti-
cal market through national regulation of e-commerce activities.
–
– Regulations and mechanisms should be adopted to immedi-
ately close all websites illegally offering medical products not
controlled by state authorities.
–
– Improve the identification and the revelation of counterfeit
medical products all over the world.
–
– Launch international campaigns warning of the health risks
linked to the use of counterfeit medical products, informing
people about the dangers of buying medicines, or products of-
fered as such, on the internet (counterfeit or fake medicines,
etc.).
–
– Improvement in detecting falsified and sub-standard medi-
cines, including vaccines and other medical products, and their
reporting worldwide. Falsified and sub-standard medicines,
including vaccines and other other medical products, should
be reported to the appropriate authorities whenever they are
discovered. Pharmacies, hospital pharmacies and patients must
be prevented by whatever means from being supplied with fal-
sified or sub-standard medicines. All adverse side-effects of a
falsified or sub-standard medicine must be immediately high-
lighted via an efficient and adapted reporting system.
–
– Strengthen and align international rules against conterfeit
medical products, allowing an efficient fight against the grow-
ing challenges of the systems of governance caused by the glo-
balisation of manufacturing processes and supply chains.
Covid-19 health crisis
7. The Covid-19 health crisis has highlighted the fundamental
problems of availability, quality and safety of medicines.
8. The already significant problems of availability, quality and
safety of medicines have been starkly brought to light by the
Covid-19 health crisis. The importance of these questions is
even bigger, on a global scale, and the Covid-19 pandemic has
created unprecedented challenges for the authorities of every
State. A pandemic leads to a sharp increase in demand for cer-
tain medicines and major expectations of specific medicines and
vaccines, creating the conditions for multiple tensions.
9. The problem of medicine availability is particularly apparent
for anesthetics and curares in life support, which are subject to
closely monitored delivery in order to avoid any break in supply.
The prescription and delivery of certain other medicines have
been closely supervised in order to maintain supply for chronic
illnesses.
10. As a response to the unequal access to vaccinations, the imple-
mentation of the COVAX mechanism must be developed in the
future so as to promote access to and distribution of vaccines,
with the objective of protecting the people of all countries.
11. The WHO warns and cautions consumers, healthcare pro-
fessionals and health authorities about medicine safety: the
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growing offer of falsified medical products in the context of
the ­
Covid-19 pandemic is aided by the possibility of short-
ages.
12. Concerning the quality of medicine, the health crisis has high-
lighted the risks of self-medication and the need for the States
to set up information systems aimed at the general population.
False hopes of possible cures for or prevention of Covid-19 by
scientifically unproven methods have been known to have seri-
ous consequences for the health of the individual.
13. Economic and/or political interests must not be in competition
with the health of the public. Pooling of public health interests
must be developed in order that economic and/or political inter-
ests are not the cause of failure to manage the situation, of stock
shortages or of anti-competitive behaviour.
14. The evolution of the current health crisis and notably the arrival
of new variants show that States must be able to respond sci-
entifically to this evolution without being hampered by overly-
restrictive international regulations.
WMA Statement on Access of
Women and Children to Health
Care
Adopted by the 49th
WMA General Assembly, Hamburg, Germany, No-
vember 1997 and amended by the 59th
WMA General Assembly, Seoul,
Korea, October 2008, by the 70th
WMA General Assembly,Tbilisi, Geor-
gia, October 2019 and by the 72nd
WMA General Assembly (online),
London, United Kingdom, October 2021
Preamble
For centuries, women and girls worldwide have suffered from gen-
der inequality and an uneven balance of power between men and
women. Historically based gender bias has led to women and girls
being restricted in their access to, inter alia, employment, education
and health care.
Gender inequality creates dangers in medical treatment. When
both genders are not offered equal quality treatment and care for
the same medical complaints or when different manifestations of
disease are not considered based on sex,patient outcomes will suffer.
In addition, in some countries, female healthcare providers have
been prevented from, or face barriers to practicing their profession
or being promoted to leadership positions due to religious and/or
cultural convictions, or discrimination based on the intersecting
grounds of sex and religion/ethnicity. A lack of gender representa-
tion and diversity within the medical profession may lead to female
patients and their children not having equitable access to health
care.
Discrimination against girls and women damages their health ex-
pectation. It serves as a barrier to accessing health services, affects
the quality of health services provided, and reinforces exclusion
from society for women and girls. For example, the education of
girls positively affects their health and well-being as adults. Educa-
tion also improves the chances of their children surviving infancy
and contributes to the overall well-being of their families. Con-
versely,secondary discrimination due to social,religious and cultural
practices – which diminishes women’s freedom to make decisions
for themselves and to access employment and healthcare opportuni-
ties – has a negative impact on health expectation.
National laws, policies and practices can also foster and perpetuate
discrimination in health care settings, prohibiting or discouraging
women and girls from seeking the broad range of health care ser-
vices they may need. Evidence demonstrates the harmful health and
human rights impacts of such laws. For example, in some countries
and due to national laws, legislations or social norms, women and
girls lack decision-making power about their own medical treat-
ment, surgery, childbearing or contraception.
Addressing discrimination in health care settings will contribute to
the achievement of many of the United Nations Sustainable Devel-
opment Goads (SDGs), ensuring that no woman or girl is left be-
hind. It is fundamental to securing progress towards SDG 3, Good
health and wellbeing, including achieving universal health coverage
and ending the AIDS and tuberculosis epidemics; SDG 4, Quality
education; SDG 5, Gender equality and women’s empowerment;
SDG 8, Decent work and inclusive economic growth; SDG 10, Re-
duced inequalities; and SDG 16, Peace, justice and strong institu-
tions.
Gender is a social determinant of health and health problems may
manifest themselves differently in men and women.There is a need
to address the differences in health and unequal health care between
men and women, including both the biological and socio-cultural
dimensions.
Access to healthcare, including both therapeutic and preventative
strategies, is a fundamental human right.This imposes an obligation
on government to ensure that these human rights are fully respected
and protected. Gender inequalities must be addressed and eradi-
cated in all aspects of healthcare.
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Machine learning, predictive algorithms and artificial intelli-
gence (AI) in healthcare are expected to drastically change the
way healthcare is practiced and managed. For example, AI could
change the way in which diseases such as cancer are diagnosed
and treated. However, even with the introduction of AI in health-
care, resource limitations may prevent most women globally from
accessing such healthcare. In order not to amplify any gender
inequalities, information being programmed into artificial intel-
ligence algorithms being created to inform medical diagnoses and
management must take into account the specific health consider-
ations of women, for example women may present with different
symptoms to men.
The WMA Declaration of Geneva establishes the physician’s re-
spect for human dignity and that it should not allow considerations
of gender to come between “my duties and my patients.”
Recommendations
Therefore, the World Medical Association urges its constituent
members to:
1. Promote the equal human right of health for women and chil-
dren;
2. Categorically condemn violations of the basic human rights of
women and children,including violations stemming from social,
political, religious, economic and cultural practices;
3. Insist on the rights of all women and children to full and ad-
equate medical care, especially where religious, social, and cul-
tural restrictions or discrimination may hinder access to such
medical care, and promote women’s and children’s health and
access to health as human rights;
4. Advocate for parity of health insurance premiums and coverage
to ensure that women’s access to care is not impeded by prohibi-
tively high expenses;
5. Governments have an obligation to ensure that the information
being programmed into artificial intelligence algorithms being
created to inform medical diagnoses and management must in-
clude a representative sample of data from women to ensure the
gender inequality gap is not amplified further.
6. Ensure universal access to sexual and reproductive health-
care;
7. Promote the provision of pre-conception, prenatal and maternal
care, and post-natal care including immunization, nutrition for
proper growth and healthcare development for children.
8. Advocate for educational, employment and economic oppor-
tunities for women and for their access to information about
healthcare and health services.
9. Work towards the achievement of the human right to gender
equality of opportunity and gender equality of treatment.
WMA Statement on Essential
Surgical Care as a Part of Access
to Healthcare
Adopted by the 72nd
WMA General Assembly (online), London, United
Kingdom, October 2021
Preamble
Surgery and anesthesia care encompass all clinical fields and all
health care providers dealing with surgical disease and pathologies.
This includes, but is not limited to anesthesia, obstetrics and gyn-
aecology and surgery including all of its subspecialties. They have
historically been a neglected part of global health with very little
investments made in developing surgical health systems, while an
estimated quarter of the burden of disease worldwide can be at-
tributed to surgical diseases. Moreover, the majority of the world’s
population lacks access to safe, timely and affordable surgical care.
A workforce of 20 surgical, anesthesia and obstetric physician pro-
viders for every 100.000 members of the population is necessary
to provide 80% of the world population essential and emergency
surgical care within 2 hours. This includes emergency surgical and
obstetric care such as caesarian sections and surgical care to prevent
death and disability due to illnesses likely to benefit from surgical
treatment such as injuries,cataracts and cancer.The majority of low-
and middle-income countries (LMICs) fall far below this target,
with the need being especially great in the poorest regions of the
world.
Surgeon shortages may be exacerbated by a lack of gender equity
in the surgical workforce which remains a challenge. Despite the
fact that in a number of countries, there are more female than male
medical students, men still outnumber women by far in the surgical
workforce.
Surgery and anesthesia care have been proven to be cost-effective,
especially in LMICs. Surgical interventions are as cost-effective as
common public health interventions like malaria bed nets, HIV
drugs or childhood vaccinations.
Sixty percent of cancer patients and eighty percent of trauma pa-
tients will need some form of surgical intervention throughout their
treatment. Considering both non-communicable diseases (NCDs)
and injuries are on the rise globally, the demand for surgical care is
expected to continue to increase.
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In 2015 the World Health Assembly recognized surgery and an-
esthesia care as a vital component of Universal Health Coverage
(UHC) through their Resolution 68.15 “Strengthening emergency
and essential surgical care and anesthesia as a component of univer-
sal health coverage”.
Recommendations
WMA recommends that the relevant national authorities:
1. Integrate quality surgical and anesthesia care in all levels of
health care, including comprehensive primary health care in
order to realize UHC and Sustainable Development Goals by
2030.
2. Develop specific surgery and anesthesia guidelines and policies
for their respective countries or jurisdictions adapted to local
needs and capacities.
3. Implement policies regulating the process of task shifting in
surgery and anesthesia care in line with the “WMA Resolution
on Task Shifting from the Medical Profession”.
4. Invest in health system strengthening and advocate for increased
financing and budgetary allocation for surgery and anesthesia
care without depriving other areas of necessary funds.
5. Provide the necessary infrastructure and procurement lines for
hospitals to deliver safe, high-quality surgical care.
6. Ensure policies, including narcotic and regulated drugs policies,
do not hamper access to necessary surgical medications includ-
ing analgesia and anesthetic agents.
7. Create clinical protocols or guidelines at the national or regional
level to assure antibiotics use in the peri-operative period are
prescribed in a sustainable manner and in line with applicable
antimicrobial resistance guidelines.
8. Include surgical care and diseases in relevant courses to fight
the dogma that surgical care is too expensive and complex to
provide in low-resource settings.
9. Offer equitable residency training opportunities to locally
trained medical students of both genders in the field of surgery
and anesthesia based on scientifically projected needs of the
country or region in line with the “WMA Statement on Gender
Equality” and contributing to the Global strategy on human re-
sources for health: Workforce 2030.
10. Allow adaptive training and work schedules to accommodate
the potential need for maternity or paternity leave,and a healthy
work-life balance, in order to make training programs more ac-
cessible irrespective of the trainee’s family responsibilities.
11. Seek regional, national and international collaboration in clini-
cal and academic domains where local capacity and resources
may be lacking and where exposure could be beneficial to those
from areas without high capacity or resources, such as through
bilateral exchange programs.
12. Support national initiatives on surgical data collection, capacity
building, advocacy, policy planning and systems strengthening
through collaboration with NGOs, universities, research initia-
tives, local communities, development banks, governmental or-
ganizations, and other stakeholders;
WMA commits to:
13. Advocate at local, regional and national, and international fora
in favor of person-centered care creating a more holistic health
care system, offering medical, surgical, mental health and pre-
ventive health services in a national UHC approach, support-
ing WHA Resolution 68.15 “Strengthening emergency and es-
sential surgical care and anesthesia as a component of universal
health coverage”.
WMA Statement on Family
Violence
Adopted by the 48th
WMA General Assembly, Somerset West, South Afri-
ca, October 1996, editorially revised by the 174th
WMA Council Session,
Pilanesberg, South Africa, October 2006, amended by the 61st
WMA
General Assembly, Vancouver, Canada, October 2010 and by the 72nd
WMA General Assembly (online), London, United Kingdom, October
2021
Preamble
Family violence is a grave universal public health and human rights
problem that affects individuals, regardless of age, gender, sexual
orientation, racial/ethnic background, culture, religion, socio-eco-
nomic status or any other factor.
Though definitions vary, the term family violence is generally ap-
plied to the physical, sexual, verbal, economic, spiritual, psycho-
logical or emotional abuse, or neglect of a person by someone with
whom the victim is physically, financially, emotionally or socially
related and/or dependent.
Although the causes of family violence are complex, a number of
contributing factors are known, such as lack of basic education, lack
of economic independence/poverty, underlying and/or undiagnosed
mental health issues, substance abuse (particularly alcohol), stress,
rigid gender roles, poor parenting skills, interpersonal conflicts
within the family, the perpetrator’s experience of maltreatment and
family violence as a child, or familial social isolation.
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Family violence has adverse physical, mental, emotional and psy-
cho-social consequences on the individual and negatively impacts
the health and wellbeing of the affected individual. There may also
be socio-economic impacts as well as impacts on a witness of fam-
ily violence, the family and community.These adverse effects could
be short-term/immediate or long-term/chronic. They include
physical harm/injuries, death, impact on reproductive health/mis-
carriage, dysfunctional families, educational disruptions and poor
academic performance, sexually transmitted diseases, juvenile de-
linquency, professional disruptions and loss of employment, social
exclusions and homelessness, insomnia, anxiety, depression, resort
to substance abuse and crime, post-traumatic stress disorder, and
suicide. Victims can become perpetrators of family violence and
violent acts against non-intimates (intergenerational transmission
of violence).
The World Medical Association (WMA) firmly condemns all forms
of violence and reaffirms its policies on Violence against Women
and Girls, Child Abuse and Neglect, the Abuse of the Elderly, and
Violence and Health.
Recommendations
Governments and National Health Authorities
WMA urges governments to:
1. Strengthen the sense of social responsibility,develop and enforce
policies, legal frameworks, and national plans with allocated
budget for the prevention and elimination of family violence, as
well as for protection of victims and witnesses of family violence.
2. Address the root causes of violence in relation to social deter-
minants of health and to promote health equity.This should in-
clude addressing gender inequality and other harmful societal
practices.
3. Recognise that times of intense individual and/or national stress
increase the risk of family violence and ensure that appropriate
resources are publicized and made available during such times.
4. Provide tools to recognize,act upon and if necessary report cases
of family violence.
5. Develop data collection systems on family violence, that holis-
tically include vital aspects of family violence such as mortal-
ity, morbidity, injuries, family or community environment, risk
factors, costs of interventions, loss in productivity, legal costs
among others.
6. Provide secure private reporting mechanisms and safe havens to
protect the individual from feelings of guilt and shame to avoid
stigma and retaliation.
7. Require a guideline that indicates how to act on suspicion of
family violence and what interventions are available. Reporting
should only be done when, in the opinion of the physician, do-
ing so will not endanger the individual experiencing the vio-
lence. If possible, this should be done in consultation with the
individual experiencing the violence.
8. Institute and promote high-quality research programs to pro-
vide a strong evidence base on the multiple facets of family vio-
lence such as the magnitude, risk profiles, underlying factors,
and the complex interplay of factors, as well as cross compari-
sons among settings, countries and regions.
9. Develop and offer family violence services to those experienc-
ing family violence, including policy and legal accompaniments,
case management,advocacy,counselling,safe housing and safety
planning.
10. Encourage multi-stakeholder constructive collaboration be-
tween sectors, disciplines, as well as governmental and nongov-
ernmental bodies, including traditional and religious institu-
tions, to eliminate and prevent family violence.
WMA constituent members and the medical profession
WMA constituent members should:
1. Encourage coordination of action against family violence
between and among components of the health care system,
criminal justice systems and law enforcement authorities, in-
cluding family and juvenile courts, and victims’ services orga-
nizations.
2. Encourage and facilitate research to understand the prevalence,
risk factors,outcomes and optimal care for victims of family vio-
lence.
3. Promote advocacy, public and professional awareness creation,
and community education programs on family violence.
4. Encourage managers of public and private health facilities to
provide educational materials in reception/patient waiting
rooms and emergency departments, to offer patients and clients
general information about family violence, as well as to inform
them about available integrated and professionally good local
services that can be accessed.
5. Advocate for inclusion of courses on violence, including family
violence, in the academic curricula for undergraduate and post-
graduate medical education.
6. Promote capacity building and Continuous Medical Education
programs for physicians, on prevention of family violence.
7. Advocate for rehabilitation, counseling, and therapy to those
who either cause, experience or are exposed to the violent acts,
especially traumatized children.
8. Encourage adequate undergraduate family medicine education
and training in family dynamics, including the medical, socio-
logical, psychological and preventive aspects of all types of fam-
ily violence.
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Physicians
In the light of their obligation to promote the well-being of pa-
tients, physicians have an ethical obligation to take appropriate ac-
tion to recognize and offer assistance to patients harmed by family
violence and abuse.
Physicians should:
1. Routinely consider and be sensitive to signs indicating the need
for further evaluations about current or past abuse as part of
their general health screening or in response to suggestive clini-
cal findings, as physicians are often the first to suspect family
violence.
2. Be acquainted on ways to take an appropriate and culturally
sensitive history of current and past abuse and be acutely aware
of the need to maintain confidentiality and a trusting patient-
physician relationship in cases of family violence.
3. Be aware of social, community and other services useful for vic-
tims,and in some cases,perpetrators of violence and refer to and
use these routinely to support victims, witnesses and/or perpe-
trators of family violence.
4. Report suspected violence against children and other family
members to appropriate protection and security services in keep-
ing with applicable requirements, and take necessary measures
to ensure that victims and witnesses of violence are not at risk.
5. Be encouraged to participate in coordinated community activi-
ties that seek to reduce the burden and impact of family violence.
6. Be encouraged to embrace patient-centred, community specific
care, and to develop impartial attitudes toward those involved in
family violence.
WMA Statement on Medical
Care for Migrants
Adopted by the 50th
World Medical Assembly, Ottawa, Canada, Octo-
ber 1998, reaffirmed by the 59th
WMA General Assembly, Seoul, Korea,
October 2008, amended by the 61st
WMA General Assembly, Vancouver,
Canada, October 2010, and by the 72nd
WMA General Assembly (on-
line), London, United Kingdom, October 2021
Preamble
For the purpose of this Statement, in line with the International
Organisation for Migration index, “migrant” is an umbrella term re-
flecting the common lay understanding of a person who moves away
from his or her place of usual residence,whether within a country or
across an international border, temporarily or permanently, and for
a variety of reasons.
The WMA considers health to be a basic need, a human right, and
one of the essential drivers of economic and social development.
According to the World Health Organisation, universal access to
health implies that all people and communities have access to com-
prehensive health services, without barriers or discrimination, ac-
cording to their needs, within the framework of equitable and sup-
portive health systems.
Recalling the WMA Declaration of Geneva, the WMA underlines
every physician’s duty to not permit considerations of age, disease
or disability, creed, ethnic origin, gender, nationality, political affili-
ation, race, sexual orientation, social standing or any other factor to
interfere with the physician’s duty to his or her patient.
The WMA underlines that physicians should offer help in medical
emergencies in accordance with the WMA International Code of
Medical Ethics.
Taking into account the WMA Declaration of Ottawa on Child Health
and the WMA Statement on Medical Age Assessment of Unaccompanied
Minor Asylum Seekers, the WMA reiterates that children should en-
joy special protection, including the right to adequate health care
without discrimination.
These fundamental WMA principles also echo the principles laid
down in the Universal Declaration of Human Rights, the United Na-
tions Convention on the Rights of the Child and the International Cov-
enant on Economic, Social and Cultural Rights.
The WMA Declaration of Lisbon on the Rights of the Patient declares
that every person is entitled without discrimination to appropriate
medical care. However, national legislation varies and is often not in
accordance with this fundamental principle.
At any time, large numbers of migrants are seeking protection, flee-
ing from natural disasters, desperate poverty, violence and other in-
justices and abuses with potentially very harmful effects to mental
and physical health.
Recalling the WMA statement on Armed Conflicts and the WMA
declaration on Health and Climate Change, the WMA recognizes
that climate change, natural disasters, warfare, armed conflicts and
other emergencies, including continuous civil strife, unrest and vio-
lence, will inevitably lead to the displacement of people from their
homes.
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The WMA is concerned by the precarious situation of certain cat-
egories of migrants, such as refugees, asylum seekers, refused asylum
seekers, undocumented migrants and displaced persons, whose ac-
cess to health care is often undermined, and where physicians are
required in some countries to intervene outside the scope of their
medical duty, in contradiction with medical ethics.
Bearing in mind the above-mentioned principles, international
conventions and WMA policies, the WMA advocates a strong and
continued engagement of physicians in the defence of human rights
and dignity of all people including migrants worldwide, while mak-
ing the following recommendations for its constituent members and
individual physicians:
Recommendations
WMA constituent members should:
• Prioritize the medical care of human beings above any other per-
sonal, material, economic, or political interest.
• Actively support and promote the right of all people to receive
medical care on the basis of clinical need alone and speak out
against legislation and practices that contradict this fundamental
right.
• Call for governments to reach political agreements that facilitate
the availability of sufficient resources for the delivery of adequate
and coordinated health services to migrant populations,including
in refugee camps where the conditions of living make them more
susceptible to the spread of disease and viruses.
• Urge governments to ensure access to safe and adequate living
conditions and essential services to all migrants, even with sup-
port from the donor agencies and/or philanthropists if needed.
• Promote equality, solidarity and social justice, guaranteeing access
of migrants and refugees to health and social services.
• Implement policies, actions and commitments that promote the
health of all, without discrimination, addressing the social deter-
minants of health related to migrants and refugees.
Physicians:
• Have a duty to provide appropriate medical care, based solely on
clinical need, regardless of the civil or political status of the patient.
• Should speak out against legislation and practices that prevent
the fulfilment of this duty.
• Cannot be compelled to participate in any punitive or judicial ac-
tion against migrants, including refugees, asylum seekers, refused
asylum seekers, undocumented migrants and or displaced per-
sons, or to withhold medically necessary treatment, or to admin-
ister any non-medically justified diagnostic measure or treatment,
such as sedatives to facilitate easy deportation from the country
or relocation.
• Must be allowed adequate time and be provided with sufficient
resources, including interpretation services, to assess the physi-
cal and psychological condition of migrants, including refugees,
asylum seekers, refused asylum seekers, undocumented migrants
and displaced persons.
WMA Statement on Medical
Liability
Adopted by the 56th
WMA General Assembly, Santiago, Chile, October
2005, reaffirmed by the 200th
WMA Council Session, Oslo, Norway,
April 2015 and amended by the 72nd
WMA General Assembly (online),
London, United Kingdom, October 2021
Preamble
In this statement the World Medical Association (WMA) address-
es issues related to medical liability claims and the implications of
defensive medicine. The laws and legal systems in each country, as
well as the social traditions, social welfare and economic conditions
of the country, will affect the relevance of some portions of this
statement for some countries, but do not detract from its funda-
mental importance.
A culture of medical liability litigation is growing in some countries,
increasing health care costs, restraining access to health care ser-
vices,and hindering efforts to improve patient safety and health care
quality. In other countries, medical liability claims are less preva-
lent, but National Medical Associations (NMAs) in those countries
should be aware of the issues and circumstances that could result in
an increase in the frequency and severity of medical liability claims
brought against physicians.
Many medical liability systems divert scarce health care resources
away from direct patient care, research, and physician training. The
lawsuit culture has also blurred the distinction between negligence
and unavoidable adverse outcomes. This has led to undue reliance
on litigation and other dispute resolution systems to distinguish be-
tween the two, and a culture that enables the pursuit of cases with-
out genuine merit in the interest of financial gain. Such a culture
breeds cynicism and distrust in both the medical and legal systems
with damaging consequences to the patient-physician relationship.
An increase in the frequency and severity of medical liability claims
may result,in part,from one or more of the following circumstances:
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• Advances in medical knowledge and medical technology that
have enabled physicians to achieve treatment results that were
not possible in the past, but that may involve considerable
risks.
• Pressures on physicians by private managed care, other health-
care organizations or government-managed health care systems
to limit the costs of medical care.
• Confusing the right of access to health care, which is attainable,
with the right to achieve and maintain health, which cannot be
guaranteed.
• The role of the media, advocacy groups and even regulatory bod-
ies in fostering mistrust of physicians by questioning their ability,
knowledge, behaviour, and management of patients, and by en-
couraging patients to submit complaints against physicians.
A growing culture of litigation and an increase in medical liability
claims may result, among other things, in a rise in defensive medi-
cine, defined as “the practice of ordering medical tests, procedures,
or consultations of doubtful clinical value in order to protect the
prescribing physician from malpractice suits.”[1] Depending on the
situation, defensive medicine may entail active behaviour, such as
performing tests and procedures that are not clinically indicated or
prescribing unnecessary hospitalization, or passive behaviour, such
as avoiding high-risk patients or avoiding potentially beneficial but
risky procedures.
A distinction must be made between harm caused by medical negli-
gence, defined as failure to conform to the standard of care in treat-
ing the patient, and harm caused by adverse outcomes occurring in
the course of medical care provided in accordance with appropriate
standards of care.
Compensation for patients suffering a medical injury should be
determined differently for injuries caused by negligence than for
adverse outcomes that may occur during medical care, unless there
is an alternative system in place such as a no-fault system.
The laws of each jurisdiction should provide the procedures for es-
tablishing liability and for determining the amount of compensa-
tion to be awarded to the patient in those cases where negligence
is proven.
Criminalizing medical judgment interferes with appropriate medi-
cal decision making and is a disservice to patients.
The mounting evidence of preventable deaths as a result of medical
error has led for experts to call for improved safety measurements in
hospitals.With this in mind,investigations should take into account
the wider context, identifying systemic failings, with recommenda-
tions for change, in order to improve patient safety.
Recommendations
The WMA:
1. Makes an urgent call to all national governments to ensure the
existence of a reliable system of medical justice in their respec-
tive countries. Legal systems should ensure that patients are
protected against harmful practices, and physicians are protect-
ed against unmeritorious lawsuits.
2. Demands that investigations consider the complete context, in
order to identify systemic failings.
3. Encourages health care providers to develop systems which im-
prove the quality of patient-safety practices.
NMAs should consider the following activities to encourage fair
and equitable treatment for both physicians and patients:
4. Educate and instruct physicians to have clear and detailed docu-
mentation of patient records.
5. Develop appropriate remedial training for physicians found to
be deficient in knowledge or skills.
6. Encourage NMAs and Specialist Interest Groups to produce
updated protocols and guidelines to guide medical professionals
and staff.
7. Inform the public, physicians, and government of the dangers
that various manifestations of defensive medicine may pose.
These include:
–
– an increase in health care costs;
–
– an undermining of the doctor-patient relationship;
–
– the commission of unnecessary test or treatments;
–
– the avoidance of high-risk treatments;
–
– the over-prescription of medications;
–
– the disaffection of young physicians for certain higher risk spe-
cialties and
–
– the reluctance by or avoidance of physicians or hospitals to treat
higher-risk patients.
8. Educate the public as to the possible occurrence of adverse med-
ical outcomes, and increased fees, and establish simple proce-
dures to allow patients to receive explanations in such cases and
to be informed of the steps that must be taken to seek resolution,
if appropriate.
9. Encourage medical workplaces to break the culture of blame in
the wake of medical errors or adverse outcomes and advocate for
confidentiality of quality assurance processes in order to enable
physicians to practice medicine to the best of their ability free
from the threat of medical liability litigation and discipline.
10. Advocate for legal protection for physicians when patients are
injured by adverse results not caused by any negligence.
11. Develop emotional and practical support for physicians involved
in adverse events.
12. Participate in the development of the laws and procedures appli-
cable to medical liability claims, with special emphasis on high-
lighting the difference between errors and adverse outcomes.
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13. Actively oppose meritless or frivolous claims.
14. Explore innovative alternative dispute resolution procedures for
efficiently resolving medical liability claims, such as mediation
and arbitration.
15. Require physicians to have adequate medical liability insurance
coverage or other resources against medical liability claims, paid
by the practitioners themselves or by their employer.
16. Encourage the development of voluntary, confidential, and le-
gally protected internal systems for reporting adverse outcomes
or medical errors for the purpose of analysis and for making rec-
ommendations on reducing errors and improving patient safety
and health care quality.
17. Advocate against the increasing criminalization or penal li-
ability of medical judgment in consideration of adverse events.
Aside from truly negligent behaviour or intentional misconduct,
most adverse events are the result of unintentional human error,
system failures, or uncontrollable circumstances and should not
brand the physician with criminal motive or behaviour.
18. Support the principles set forth in the WMA’s Declaration of
Madrid on Professional Autonomy and Self-Regulation.
WMA Statement on Solar
Radiation and Photoprotection
Adopted by the 72nd
WMA General Assembly (online), London, United
Kingdom, October 2021
Preamble
The sun is a great source of health benefits, but it is important to
know its harmful consequences as well.The prevention of the harm-
ful effects of the sun on our skin is advisable at all ages, especially
in children and adolescents. Solar radiation generates a series of
biological and physiological effects in the body that depend on the
proportion and intensity of the radiation and that have beneficial
effects, such as stimulating the synthesis of vitamin D, favoring the
formation of hemoglobin and improving the mood, while other ef-
fects are harmful and aggressive to the skin, such as erythema, pho-
toaging of the skin and precancerous or cancerous lesions. Derma-
toses produced or aggravated by sun exposure are a health problem
that healthcare professionals face most frequently.
Solar light is composed of a continuous spectrum of electromagnetic
radiation divided into three major groups: ultraviolet (UV), visible
and infrared. UV radiation is classified as UV-A, UV-B and UV-C.
The intensity of UV radiation can be measured by international
standardized instruments such as the UV index which measures the
strength of sunburn-producing solar UV radiation at a particular
place and time.
Solar UV radiation, especially through UV-B, is an extremely im-
portant, yet neglected causative factor for skin cancers, both mela-
noma and non-melanoma, for ocular pathologies (e.g., cataracts,
and age-related macular degeneration), and harmful effects on the
immune system [3]. Recurrent and severe sunburns are a risk factor
for non-melanoma skin cancer.
Solar radiation can also induce the onset and exacerbation of chronic
actinic dermatitis (CAD) and melasma. Blue light plays an impor-
tant role as well in the pathogenesis of melasma, therefore broad-
spectrum photoprotection should be advocated and the intake of
photosensitive foods and drugs should be reduced.
Risk of skin cancer differs according to skin type as well as the dura-
tion and intensity of solar light exposure. Chronic, long-term, cumu-
lative UV exposure is associated with actinic keratosis and squamous
cell carcinomas, while high-intensity, intermittent UV exposure, es-
pecially at a young age, is associated with basal cell carcinomas and
melanomas. Therefore, photoprotection is important in young ages.
The World Health Organization (WHO), through the Interna-
tional Agency for Research on Cancer has raised the issue of solar
UV radiation being a carcinogen since 1992 and since 2012 has
classified solar UV radiation as a group 1 carcinogen (carcinogen
to humans). Other well-known group 1 carcinogens are plutonium,
asbestos and ionizing radiation.
Furthermore, current climate changes and the depletion of the
ozone layer by approximately 4% per decade since the 1970s has
led to a diminished filtration of UV-A and UV-B radiation and to
increased UV radiation that reaches sea-level.
As a consequence, the incidence of melanoma and non-melanoma
skin cancer is increasing worldwide.
WHO evidence indicates that four out of five cases of skin cancer
can be prevented and simple preventive measures, such as limiting
UV exposure in the midday sun, wearing UV protective clothing
and hats or using mineral-based sunscreens, are recommended.
Photoprotection also includes make-up products, sunglasses, and
windshields.
The WHO recognizes that while protection against UV exposure
is recommended globally, there is concern that lack of UV exposure
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may reduce beneficial effects of vitamin D, including its potential to
reduce the risk of some types of cancer.
Recommendations
1. Photoprotection is a key preventative health strategy as most
skin cancers are a result of UV solar exposure.
National Governments should:
2. Inform health professionals and the public about the character-
istics that sunscreen should meet (one that provides balanced,
safe and easy-to-use protection) in order to avoid variability be-
tween the products supplied by laboratories, as well as improve
safety and the labelling of the sunscreen.
3. Recognize solar UV exposure as an important risk factor for de-
veloping skin cancer. UV exposure also is a prime cause of some
ocular diseases and immune system dysfunctions.
4. Work together to develop a Global Action Plan for the Preven-
tion of Skin Cancer based on Photoprotective measures. This
should include action against climate change to help reduce
damage from ultra-violet radiation.
5. Support skin cancer screening campaigns.
6. Recognize prevention of skin cancer as a national health priority.
7. Improve skin cancer’s screening, diagnosis and management.
8. Include all forms of skin cancer in all Nationals Cancer Regis-
tries and improve the reporting of UV induced skin cancers and
legislative frameworks to protect outdoor workers (recognition
as occupational disease).
9. Work with relevant stakeholders to liaise, engage and organize
online and offline skin cancer prevention campaigns and educa-
tional programs on sun protection, with a primary focus on ages
0–18,in order to raise awareness of this health hazard and to en-
courage sun safety (use of protective clothing and hats, adequate
sunscreen use, avoidance of excessive exposure) and healthy life-
style choices among the young.
10. Promote policies to fight climate change and air pollution.
11. Consider the environmental impact of sunscreen.
WMA and its members should:
12. Interact with healthcare providers and medical practitioners
who have a significant role in empowering and educating their
patients in the promotion of skin cancer awareness, sun-pro-
tective measures and encouraging patient access to screening,
diagnosis and treatment.
13. Educate primary care physicians and occupational physicians to
recognise and refer patients with suspect lesions to dermatolo-
gists.
14. Support the development of national guidelines on photopro-
tective measures and continued scientific research in this field to
derive the risk-benefit balance of UV exposure.
15. Support continued research and development of adequate pro-
tective clothing.
16. Promote campaigns to encourage the measurement of UV ex-
posure within each nation.
17. Support media campaigns and educational programs that explain
the harmful effects of UV exposure and optimal photoprotec-
tive measures targeting the most vulnerable, such as children and
teenagers, fair skinned people, outdoor workers (e.g. agriculture,
fishery,construction,forestry,athletes,swimming pool attendants).
18. Promote health education and information on sunscreens and
the most recommended and healthy habits for the skin, estab-
lishing correct sun protection habits that make it possible to en-
joy the beneficial effects of the sun and avoid sun damage.
Individual physicians should:
19. Counsel patients about the major health risks associated with
excessive solar UV radiation exposure,inform patients about ap-
propriate sun protective measures (e.g. skin coverage, sunscreen,
and sunglasses) and encourage patients to undergo regular
medical check-ups and to participate in skin cancer screening
campaigns, where available.
20. Counsel patients to self-examine their skin.
21. Counsel those patients at risk (for example, patients on certain
anti-cancer drugs) to understand the extra importance of pro-
tective measures.
22. Counsel employers on UV light as a work-related health risk.
WMA Statement on Trade
Agreements and Public Health
Adopted by the 200th
WMA Council Session, Oslo, April 2015, and ad-
opted, with amendments by the 72nd
WMA General Assembly (online),
London, United Kingdom, October 2021
Preamble
Trade agreements are treaties between two or more countries which
include provisions addressing trade in goods and/or services. Trade
agreements are tools of globalization and typically seek to promote
global wealth through trade liberalization.They can have significant
implications for the social, commercial, political and ecological de-
terminants of health as well as the delivery of health care.
International trade contributes significantly to increases in national
wealth which is a key factor in building strong health care systems.
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While trade agreements are designed to produce economic benefits
and global wealth, it is fundamental to identify public health impli-
cations that may arise from these agreements.
Negotiations should take into account broad impact to ensure that
the right to health and to a healthy natural and social environment
are well-prioritized. Trade agreements should be directed at con-
tributing to global health and equity.
Trade agreements may have the ability to promote the health and
wellbeing of all people when they are well-designed to protect
health and preserve the ability of governments to legislate, regu-
late and plan for health promotion, health care delivery and health
equity.
Recent trade agreement negotiations have sought to establish a new
global governance framework for trade and have been unprecedent-
ed in their size, scope and secrecy. A lack of transparency and the
selective sharing of information with a limited set of stakeholders
are anti-democratic.
There must be recognition of the importance of innovation shar-
ing in public health. This is particularly important during health
emergencies. Access to medicines and medical supplies is essential
to address the major public health problems such as pandemics and
trade agreements must not act as a barrier to that access.
Investor-state dispute settlement (ISDS) provides a mechanism
for investors to bring claims against governments and seek com-
pensation, operating outside existing systems of accountability and
transparency. ISDS in existing trade agreements has been used to
challenge evidence-based public health measures including tobac-
co plain packaging. Inclusion of a broad ISDS mechanism could
threaten public health actions designed to support evidence-based
tobacco control, alcohol control, healthy and safe food consumption
including regulation of obesogenic foods and beverages, access to
medicines, health care services, environmental protection/climate
change and occupational / environmental health protections. Ef-
forts by industry to challenge domestic public health laws and regu-
lation have targeted nations with limited access to legal resources
and some of the world’s most vulnerable populations.
Access to affordable medicines is critical to controlling the global
burdens of communicable and non-communicable diseases. The
World Trade Organization’s Agreement on Trade-Related Aspects
of Intellectual Property Rights (TRIPS) established a set of com-
mon international rules governing the protection of intellectual
property including the patenting of pharmaceuticals. TRIPS safe-
guards and flexibilities including compulsory licensing seek to en-
sure that patent protection does not supersede public health.
The WMA Statement on Patenting Medical Procedures states that
patenting of diagnostic, therapeutic and surgical techniques is un-
ethical and “poses serious risks to the effective practice of medicine
by potentially limiting the availability of new procedures to patients.”
Trade agreements should not pose a new difficulty in accessing
medicines, especially for developing countries and for the most vul-
nerable populations.
There must be a fair balance established between the prices of medi-
cines and the protection of intellectual property through patents.
The WMA considers that patenting on medicines/vaccines must be
regulated in accordance with the ethical principles and values of the
medical profession in order to ensure effective and global action for
public health and therefore recognizes that it may be necessary to tem-
porarily waive patents in times of public health emergencies. More-
over, to produce fast and comprehensive results, sustainable solutions
for patent issues must be supplemented by the transfer of technology,
knowledge, and manufacturing expertise, global investment in manu-
facturing sites, training of personnel, and quality control.
The WMA Resolution on Medical Workforce states that the WMA has
recognized the need for investment in medical education and has
called on governments to “…allocate sufficient financial resources
for the education, training, development, recruitment and retention
of physicians to meet the medical needs of the entire population…”
The WMA Declaration of Delhi on Health and Climate Change states
that global climate change has had and will continue to have serious
consequences for health and demands comprehensive action.
The WMA Declaration on Fair Trade in Medical Products and De-
vices states that purchasing policies for medical goods should be fair
and ethical, working conditions should be safe and modern slav-
ery should be eradicated throughout supply chains. Health prod-
uct manufacturers should establish a plan for continuity of supply
of vital and life-sustaining products to avoid production shortages
whenever possible.This plan should include establishing the neces-
sary resiliency and redundancy in manufacturing capability to mini-
mize disruptions of supplies.
Recommendations
Therefore,the WMA calls on national governments and constituent
member associations to:
1. Call for transparency and openness in all trade agreement nego-
tiations including public access to negotiating texts and mean-
ingful opportunities for stakeholder engagement.
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WMA News
2. Call for a proactive assessment of anticipated effects on health,
human rights, and the environment for all trade agreements.
3. Advocate for trade agreements that protect, promote and pri-
oritize public health over commercial or political interests, and
secure services in the public interest, especially those affecting
individual and public health.This should include new modalities
of health care provision including eHealth.
4. Ensure that trade agreements do not have negative impacts on
health systems, human resources for health and universal health
coverage (UHC).Ensure trade agreements do not interfere with
governments’ ability to protect and regulate health and health
care, or to guarantee a right to health for all. Government action
to protect and promote health should not be subject to challenge
through an investor-state dispute settlement (ISDS) or similar
mechanism.
5. Work to ensure that patents on medicines and vaccines are
regulated in accordance with the principles of medical ethics,
in order to protect public health in global emergency situa-
tions.
6. Therefore, urge NMAs to promote the possibility of temporar-
ily waiving patents on medicines and vaccines to protect public
health in global emergency situations while ensuring fair com-
pensation for the intellectual property of the patent holders,
global investment in manufacturing sites, and knowledge trans-
fer. Promote public health, equity, solidarity and social justice
and protect countries and people who are weaker economically
and health-wise, and therefore most vulnerable.
7. Oppose any trade agreement provisions which would compro-
mise access to health care services or medicines including but
not limited to:
–
– Patenting (or patent enforcement) of diagnostic, therapeutic
and surgical techniques;
–
– “Evergreening”, or patent protection for minor modifications
of existing drugs;
–
– Patent linkage or other patent term adjustments that serve as a
barrier to generic entry into the market;
–
– Data exclusivity for biologics;
–
– Any effort to undermine TRIPS safeguards or restrict TRIPS
flexibilities including compulsory licensing;
–
– Limits on clinical trial data transparency.
8. Oppose any trade agreement provision which would reduce
public support for or facilitate commercialization of medical
education.
9. Oppose any trade agreement which would facilitate the inap-
propriate privatization of public services in areas such as conser-
vation of natural environment, education, healthcare, and daily
necessities such as energy and water.
10. Ensure that trade agreements promote environmental protec-
tion and support efforts to reduce activities that cause climate
change.
11. Ensure that trade agreements promote equity and human rights
and include mechanisms for accountability following imple-
mentation.
WMA Statement on Women’s
Rights to Health Care and How
that Relates to the Prevention of
Mother-to-Child HIV Infection
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA,
October 2002, amended by the 64th
WMA General Assembly, Fortaleza,
Brazil, October 2013 and by the 72nd
WMA General Assembly (online),
London, United Kingdom, October 2021
Preamble
Since the start of the global HIV epidemic, women and girls
in many regions have been disproportionately affected by HIV.
Young women (aged 15–24), and adolescent girls (aged 10–19)
in particular, account for a disproportionate number of new HIV
infections.
Gender inequality contributes to the spread of HIV. It can increase
infection rates and reduce the ability of women and girls to cope
with the illness. Often, they have less information about HIV and
fewer resources to take preventive measures. Sexual violence, a
widespread violation of women’s rights, exacerbates the risk of HIV
transmission.
Many women and girls living with HIV struggle with stigma and
exclusion, aggravated by their lack of rights. Women widowed by
AIDS or living with HIV may face property disputes with in-laws,
complicated by limited access to justice to uphold their rights. Re-
gardless of whether they themselves are living with HIV, women
generally assume a disproportionate burden of care for others who
are sick from or dying of AIDS, along with the orphans left behind.
This, in turn, can reduce prospects for education and employment.
It can also significantly reduce prevention of mother-to-child trans-
mission (PMTCT) efforts and strategies.
Access to healthcare, including both preventative and therapeutic
strategies, is a fundamental human right.This imposes an obligation
on government to ensure that these human rights are fully respected
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35
WMA News
and protected. Gender inequalities must be addressed and eradi-
cated.This should impact every aspect of healthcare.
The promotion and protection of the reproductive rights of women
are critical to the ultimate success of confronting and resolving the
HIV/AIDS pandemic.
Recommendations
The WMA requests all national member associations to encourage
their governments to undertake and promote the following actions:
1. Develop empowerment programs for women of all ages to en-
sure that women are better supported and free from discrimina-
tion. Such programs should include universal and free access to
reproductive health education and life skills training,
2. Develop programme to provide HIV testing and post-exposure
prophylaxis in the form of antiretrovirals to all survivors of as-
sault.
3. Governments must provide universal access to antiviral thera-
py and treatment to all HIV infected women, protecting their
health, and in the case of pregnant women, preventing mother
to child transmission.
4. Provide universal HIV testing of all pregnant women, with pa-
tient notification of the right of refusal, as a routine component
of perinatal care, and such testing should be accompanied by
privacy protection, basic counseling and awareness of appropri-
ate treatment, if necessary.
5. Patient notification should be consistent with the principles
of informed consent. Universal and free access to antiretrovi-
ral therapy must also be provided to all HIV-positive pregnant
women in order to prevent mother to child transmission of HIV.
A Scientific Session on anti-microbial resis-
tance was held as part of the WMA’s annual
General Assembly hosted by the British
Medical Association. The two-day event,
in advance of the Assembly, was organised
online because of the Covid-19 pandemic.
The theme of the event was ‘Global re-
sponse to antimicrobial resistance in the
context of Covid-19’.
7 October 2021 Scientific
Session Day 1
Both days were chaired by Professor Dame
Parveen Kumar, Chairperson of the BMA’s
Board pf Science. Welcoming those who
had logged in online,she said that the threat
of a post-microbial age, where current an-
timicrobials would be rendered ineffectual
due to increasing levels of resistance, was
not limited to a single country. It was an in-
ternational situation. The challenges posed
by AMR had not been resolved. There had
been no dramatic improvements in recent
years and now they were facing a global
pandemic. It was these challenges they
would be discussing over the next two days.
The first session was entitled ‘Harnessing
international cooperation to tackle antimi-
crobial resistance globally’and it began with
two opening speakers. The first was WMA
President Dr. David Barbe, who said that
the WMA first developed a statement on
AMR 25 years ago. The Association de-
scribed it as ‘a growing threat to global pub-
lic health’and as a ‘multi-faceted problem of
crisis proportions with significant econom-
ic, health and human implications’. He said
that AMR was as much a threat now if not
more so than when that statement was first
adopted in 1996.The statement was revised
in 2008 and again in 2019. It had a long list
of recommendations, spanning global and
national and local domains. It encouraged
collaboration among countries. It recog-
nised the importance of surveillance and the
use of new technology, prevention and the
role of vaccination. It emphasised the need
for educating both physicians and their pa-
tients in the more responsible use of antibi-
otics. Hopefully, they had learned from the
current pandemic.They had seen again how
a virus usually responsible for no more than
a common cold could develop a novel form
that was dramatically more virulent and ca-
pable of triggering a global pandemic. The
resources devoted to understanding the be-
haviour of this virus had been unprecedent-
ed. But there was more work to be done. He
concluded by saying that out of challenges
came opportunities and if that was true,
then the Covid-19 pandemic had presented
them with some great opportunities.
The second opening speaker was Dr. Chaand
Nagpaul, Chair of the British Medical As-
sociation Council. He said the impact of
AMR would be very far reaching if they did
not act.It knew no borders and impacted ev-
ery single nation. It could not be dealt with
piecemeal, but had to be dealt with globally.
He said they could see a post-antimicrobial
age.That was the threat. It would mean that
patients would not be able to get the treat-
ment to treat them or save their lives. This
was not a small issue. It would impact on
doctors’ abilities to be able to care for their
patients.The United Kingdom Government
had a five-year plan to reduce AMR by 15
per cent by 2024, as well as a longer 20-year
plan.This was an issue that was a problem for
every single nation, but the solution could
London Scientific Session
October 7–8
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WMA News
only occur if all of them pulled together put-
ting pressure on their governments.
The first keynote address was given by
Dr. Kitty van Weezenbeek, Director of the
World Health Organisation AMR Depart-
ment of Surveillance, Prevention and Con-
trol. She talked about the global situation,
the AMR patient pathway and program-
matic AMR response and WHO initiatives.
She said that antimicrobials were crucial for
human and animal health. But they needed
collaboration to address AMR. The threat
was enormous. If nothing was done, there
would be 10 million AMR related deaths
by 2050, nine million of which would be in
low-and middle-income countries. Every
third minute a child died from sepsis due to
antibiotic resistant infections.
She referred to the five objectives approved
in 2015 by member states at the World
Health Assembly – to improve awareness
and understanding of AMR, to strengthen
the knowledge and evidence base, to reduce
the incidence of infection, to optimize the
use of antimicrobial medicines in human
and animal health and to develop the eco-
nomic case for sustainable investment.
Low-and middle-income countries need-
ed urgent support on AMR with further
analysis of underlying causes. Routine diag-
nosis and surveillance required strengthen-
ing. The AMR Patient Pathway was a new
concept and put the patient at the centre of
the AMR response. The six interdependent
building blocks of programmatic AMR re-
sponse required strong national health sys-
tems with political commitment, early di-
agnosis in the laboratory network, access to
appropriate treatment, prevention of infec-
tion, an uninterrupted quality supply chain
and surveillance and evidence generation.
What they now needed was to develop a
second generation of national action plans.
Many countries had plans, but the problem
was that they were not costed. The WHO
had now developed a costing and budgeting
tool for national action plans.
Dr.  van Weezenbeek spoke briefly about
the National AMR Stewardship pro-
gramme and the antimicrobial pipeline.
She said many pharmaceutical companies
were exiting the scene. She spoke about
the WHO’s global activities in AMR re-
search and development. She referred to
SECURE, a new collaboration between
the WHO, Unicef and others to pro-
vide countries with sustainable access to
new antibiotics and existing antibiotics.
­
SECURE would establish a quality as-
sured portfolio driven by public health and
clinical needs
She spoke about infection, prevention and
control and the development of a curricula
for health facility cleaning staff.
Finally, she spoke about AMR and Co-
vid-19, the shared issues and the differ-
ences. Both need strong governance and
leadership co-ordination.The newer lessons
learned from Covid-19 relevant to AMR
included the weak pandemic response ev-
erywhere, societal mistrust, the role of social
media, the potential of digital health and
preaching equity.
The second keynote speaker was Professor
Dame Sally Davies, UK Government Spe-
cial Envoy on Antimicrobial Resistance
and former Chief Medical Officer for
England. She said AMR was costing the
National Health Service at least £90 mil-
lion a year in England. She said she knew
how difficult it was for front line staff to
deal with antimicrobials when they had
patients in front of them. Surveillance un-
derpinned their understanding of an issue
that was a priority. She outlined the vari-
ous activities that were going on around
the world and the global partnerships that
had been formed and she said national ac-
tion plans could drive change. Turning to
advocacy, she said this was very difficult,
but they had to continue spreading the
word. It was vital that AMR was included
in post Covid-19 strategies, as well as in
any new pandemic treaty.
In a question and answer session, Dr. van
Weezenbeek and Dame Sally Davies were
joined by Dr.  Chantal Morel, a health
economist from the University of Geneva,
Dr.  Henry Skinner, CEO of Arm Action
Fund and Dr.  Otmar Kloiber, Secretary
General of the WMA.
Dr. Morel said her work involved looking at
how to incentivise the production of novel
drugs and what drove physicians to wait for
a laboratory result rather than prescribing
too quickly. She also worked on how to en-
courage hospital managers to report cases of
AMR and how to incentivise pharmacists
and veterinarians.
Dr.  Henry Skinner said the Arm Action
Fund came about from a WHO initiative
and was a new fund financing innovation
in new antibiotic drug development. Their
goal was to buy time to look to pay for new
antibiotics.
Dr.  Kloiber said that antimicrobials had
been an extremely important tool for the
past half century,but there were problems in
the quality of prescribing and in the avail-
ability of the drugs. He wanted to broaden
the discussion by saying that it was not
just a clinical problem or a problem of the
supply chain. It was a matter of the social
determinants of health, how they lived and
worked. Hygiene, prevention, availability
of vaccinations were all crucial to reducing
AMR. New drugs were not the sole solu-
tion. He said that when the WMA began
looking at this issue in 1994, they consid-
ered where antimicrobials were being used.
The vast majority were not being used in
health care. They were being used in veteri-
nary health, and they were not tackling this
husbandry.There was some belated EU leg-
islation to reduce antimicrobials as growth
promoters. But a more recent piece of EU
legislation allowed the use of reserve anti-
biotics for mass farming and mass breeding
of animals. He said this was outrageous and
something which should be avoided. These
drugs should be used extremely carefully
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WMA News
and restricted and should not be allowed for
mass breeding of animals, which was ethi-
cally doubtful. He said that economic inter-
ests in the agricultural sector were clearly
weighed much higher by politicians than
public heath, and that was something that
had to be changed.
During the question and answer session,
Professor Davies said that what they had
learnt from Covid-19 was that they could
improve infection prevention and control.
They owed it to the world to deliver sani-
tation, hygiene and clean water across the
world as a basic right. Dr.  Kloiber said
there some countries were doing better than
others. The Scandinavian countries, for in-
stance, had been very successful in drasti-
cally reducing antibiotics in farming. And
their example could be copied elsewhere.
He said the proposed pandemic treaty was
a good place to start with regulation. In
most countries, the use of antibiotics was
not sufficiently regulated.They could still be
bought over the counter and in many coun-
tries there was no control over the quality of
antibiotics. A lot of them were substandard
or even fake. And if there was a sub-stan-
dard drug, there would be resistance.
At the conclusion, each panellist was asked
to choose the most important point from
the day’s discussions. Dr. Kloiber wanted a
broader approach to the debate, as this was
not a single item issue. There were more
ramifications than they had been discuss-
ing and the proposed pandemic treaty was
a good place to start. Dr. van Weezenbeek
wanted a less fragmented, rational, priori-
tised, evidence-based approach at country
level. Dr. Skinner chose global collaborative
solutions as the way forward. Dame Sally
Davies said she wanted everyone to take
personal responsibility to make AMR go
away and Dr. Morel said that they should
not take too many lessons from Covid-19.
They should not assume they could do the
same thing if a multi drug resistant bacterial
infection broke out.
8 October 2021 Scientific
Session Day 2
The second day’s session was entitled ‘Les-
sons learned from Covid-19’, and once
again it was chaired by Professor Dame
Parveen Kumar, Chairperson of the BMA’s
Board of Science.
The first speaker was Prof. John-Arne Røt-
tingen, Ambassador for Global Health at
the Ministry of Foreign Affairs in Norway.
He began by saying that the Covid-19
pandemic had had a devastating impact
on the world with more than 230 million
reported cases, 4.7 million deaths and a
cost of at least nine trillion dollars. They
were now increasing the delivery of vac-
cines worldwide, but a very small number
were being delivered in low income coun-
tries. The inequities in distribution were
particularly evident in Africa and parts of
Asia, where there was very low vaccina-
tion coverage. However, vaccines were now
making Covid less lethal. Antimicrobial
resistance was a global collective problem
and they needed to solve it collectively.The
more antibiotics they used, the faster they
stopped working. However, it was also a
fact that more people were dying because
they were not taking antibiotics.
He then spoke about the functions neces-
sary to deal with the global problem. The
global health system had an overarching
function to provide stewardship and leader-
ship. It had three different functions – the
provision of global public goods, manag-
ing externalities such as cross border health
checks like epidemics and AMR, and it had
to provide solidarity. This should start with
universal access to effective antimicrobials
to prevent infection. Then they needed re-
sponsible use to reduce demand for antimi-
crobials, as well as measures to reduce their
need. And they needed proper surveillance
and monitoring as well as research and de-
velopment and innovation. And he said it
was not only a human health issue, it was
also an animal health issue.
Surveillance policies required stronger in-
ternational collaboration. They needed col-
lective action, collaborative decisions, co-
ordination, communication and common
norms, principles and goals. On innovation
policies,they needed to finance and perform
the necessary research and development.
They now needed to hope that the Cov-
id-19 pandemic would not be forgotten, be-
cause they had seen an increasing frequency
of epidemics caused by zoonosis, as well as
an increase in influenza.
He said that in future there would be an in-
creasing number of epidemics and pandem-
ics, and he asked how they could collabo-
rate better. There were several propositions
on the table. One was to establish a global
health threats board or council. Another
was a global health threats fund proposal.
They had the pandemic preparedness part-
nership proposal. There were also proposals
to strengthen the international health regu-
lations. And finally, there was a proposal
for having a pandemic treaty, or framework
convention. So, many proposals were being
discussed.
He said that global health security was a
global public good. There were five types of
global public goods. These included efforts
to reduce unnecessary use of antimicrobials
in human and animal health sectors,surveil-
lance and alert systems to detect emerging
pathogens.There was the issue of coordina-
tion with common norms and standards,
and joint regulations to prohibit activities
that posed risks.
He talked about the commonalities between
the Pandemic Preparedness Partnership
and AMR. There was the zoonosis aspect
and need for a One Health approach.There
was the need for a health-needs driven re-
search and development model. There was
the need for increasing transparency and
the strengthening of global pharmaceutical
supply chains and finally there was the need
to ensure equitable, affordable and timely
access to health products and prevention
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WMA News
efforts. He concluded by emphasising the
need for an overarching One Heath ap-
proach.
The second keynote speaker was Prof. Ra-
manan Laxminarayan, Director of the
Center for Disease Dynamics, Economics
and Policy, in Washington. He compared
infections in the 1918 influenza outbreak
and in the Covid-19 pandemic. Pneumo-
coccal infections were a major cause of
influenza-associated pneumonia and death
among both military personnel and civilians
in the 1918-19 flu epidemic. They had no
drugs then and now they had no drugs that
worked every single time reliably. So they
had gone through a golden era of antibiot-
ics and landed back closely to where they
started.
There had been a lot of covid co-infections
and superinfections in hospitalized patients.
He also discussed secondary infections in
hospitalised covid-19 patients in India.
He spoke about the challenges where they
had not made progress. Market failure con-
tinued to discourage the development of
new antibiotics and infection control re-
mained weak despite Covid. He said they
now faced climate change, which was both
a challenge to AMR and would also expand
the range of drug-resistant fungal patho-
gens.
He referred to global antibiotic use and re-
sistance by income class and drug resistance
across countries. For most countries there
had been a high level of drug resistance and
there had been an increase in total antibiotic
use between 2000 and 2015. There had also
been an increase in resistance in animals.
The antibiotic development pipeline had
improved, but there were still examples of
companies not making enough money from
innovation to justify continued investment.
Turning to climate change and the risk of
bacterial infections,he said this would make
antimicrobial resistance more common not
less common. Statistics showed an increase
in resistance in low-and middle-income
countries and this was a cause for concern.
The good news was that there were some
opportunities and positive signs coming
out of Covid-19. There was a better under-
standing of zoonoses and one health. There
was also a recognition of the value of science
responding to pandemics, and this recogni-
tion would translate into money for AMR.
There was greater acceptability of adult vac-
cines, which was a key tool against AMR.
They had always wondered what was going
to be the main tool that they used against
AMR. Reducing the need for antibiotics,
particularly by using vaccines, had always
been a significant part of that puzzle, but
had never been really quantified. A number
of papers had been published about the ef-
fectiveness of vaccines on AMR. And the
evidence was very positive. Put simply, vac-
cination led to fewer infections which low-
ered the disease burden with less transmis-
sion, as well as less antibiotic use, with lives
saved. He believed that vaccines were go-
ing to be a major approach to dealing with
AMR.
He finished by saying that although there
was bad news ahead from climate change,
there were also some positives to learn from
Covid-19 and hopefully they could build on
these.
During the question and answer session
that followed, the speakers discussed a
comment that antibiotic prescribing and
infections had fallen during Covid-19. Prof.
Laxminarayan said there had been conflict-
ing evidence. Some parts of the world had
seen more antibiotic prescribing, while in
more developed countries there had been a
drop in infections. He said that at the mo-
ment it was hard to disentangle what had
actually happened.
A question was also asked about national
egoism and vaccine nationalism. Prof. Røt-
tingen said countries’ first responsibilities
were towards vaccinating their own popula-
tion. It was almost impossible to challenge
the fact that governments should look after
their own populations first.
During the final part of the session, the two
keynote speakers were joined by three other
panellists. Prof. Sahiba Essack, Professor at
the University of KwaZulu-Natal, reported
briefly about what was going on with AMR
in South Africa, Dr. Mirfin Mpundu, Di-
rector of ReAct Africa, talked about his
work to support African countries develop
their action plans and raise the voice of the
global south, while Dr. Heidi Stensmyren,
WMA President-Elect, spoke about the
history of WMA policy on AMR since the
early 1990s.
In the question and answer session, Prof.
Laxminarayan spoke about innovations and
said new antibiotics were only one part of
the solution. The big innovations would
come with vaccines, infection control, diag-
nostics and behavioural issues.
Prof. Røttingen said they needed new ways
for treating infections and incentives for
the private sector. Dr.  Mpundu said that
basic things in Africa were not available.
There was no running water in most of the
African health services. It was a chronic
problem. They ended up depending on
whatever was available. There was a supply
chain issue. They also failed to get their po-
litical leaders to buy in to this issue. They
had not effectively communicated what the
consequences of AMR were. The political
will was not really there. They still had a lot
of work to do. They needed to understand
what had not worked. Why had they lost
six pharmaceutical companies in the last
few years? Unless they started raising these
issues, he thought that low- and middle-
income countries would be left behind.
The panellists were asked what they
thought was needed to fully fund national
action plans? Dr.  Mpundu said there had
not been the political will that translated
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39
WMA News
into ­
implementation, especially funding.
Most plans might look good, but in many
countries there was not one full time per-
son dealing with the issue. Dr. Stensmyren
talked about equal access to health care,
strengthening basic health care, developing
more diagnostic tools and the aggregate use
of data to track and target infections.
Dr. Mpundu said that Covid-19 had cre-
ated awareness on infectious diseases. This
had been quite critical. It had shown how
hand washing had paid off and how behav-
iour could be sustained, such as not going
into shops without wearing masks.
Dr. Stensmyren was asked what more the
WMA should do to get its policies imple-
mented. She said that Covid-19 had shown
that they needed to pay more attention to
the health of the population. It had moved
this issue up the agenda. But the window
of opportunity to make changes would only
last a few months. They could not wait to
advocate for the strengthening of global in-
stitutions.They had to start now.Dr. Mpun-
du said that in most countries, professional
leaders did not discuss with politicians.
They did not engage with the public. They
should start having these discussions now.
At the end of the session, all the panellists
were asked to identify one message from
the session. Prof. Laxminarayan said he put
his money on vaccines. This was where they
could make the biggest dent. He hoped that
an AMR set of vaccines would grow out of
the Covid pandemic. Prof. Essack said the
whole world now knew what a pandemic
could do. They should leverage this aware-
ness of the Covid pandemic and mobilize
the whole of society around the silent AMR
pandemic. They should highlight the fact
that the AMR pandemic was going to be far
worse than Covid.It was a One Health issue.
Dr. Mpundu said they had a great opportu-
nity, especially in low-and middle-income
countries, which were not ready for this pan-
demic. They thought that only the west was
going to be affected. They did not prepare
their health systems and they were not ready
to handle anything like Covid-19.They now
needed to do something.They could not keep
silent.AMR was an active volcano.Let them
learn from Covid and strengthen their health
systems. Prof. Røttingen said that physicians
and other professional organisations could
not wait for governments to make the right
decisions. They should liaise with other pro-
fessional organisations to do a one heath
approach on what they could do and chal-
lenge their governments. And Dr.  Stens-
myren said her priority was vaccines globally,
and to work for universal health coverage to
improve access to health care for the whole
population globally.
Thursday 1 July 2021
More than two years ago, before the out-
break of the Covid-19 pandemic, the
World Medical Association, the German
Medical Association and the Pontifical
Academy for Life began discussing the
idea of a joint seminar on vaccination to
be held in the Vatican.This was to be a fol-
low up to the successful European Region
Meeting on End-of-Life Questions in
November 2017 in the Vatican. However,
following the Covid-19 pandemic in 2020,
the in-person seminar had to be postponed
twice. On July 1 this year, the event finally
took place in the form of a one-day round-
table webinar.
The event was opened by Dr. Ramin Parsa-
Parsi, Head of the International Depart-
ment at the German Medical Association.
He introduced the speakers and spoke
about the importance of the three organiza-
tions – the World Medical Association, the
German Medical Association and the Pon-
tifical Academy for Life – coming together.
He said that what physicians had in com-
mon all around the world was the duty to
promote the health and wellbeing of their
patients, and to fight for the equitable pro-
vision of care and promote strong and resil-
ient heath care systems. In this spirit, it was
only natural that physicians collaborated in-
ternationally. The WMA had always been a
cornerstone of these efforts. Another highly
rewarding approach was cross sectoral ac-
tivities. With partners from other sectors
and different areas of expertise they could
complement their knowledge and resources
and expand their networks to contribute to
the health and wellbeing of the people they
served. During the pandemic, the need for
such collaboration had become even more
evident.
He said the seeds for their meeting today
were planted more than two years ago,when
the three organisations agreed to join forces
to address the challenges of global vaccine
equity and vaccination hesitancy. They saw
the vast opportunities that extraordinary
collaboration could provide in their efforts
to build trust,to raise awareness and achieve
a broader dissemination of accurate and un-
derstandable information on vaccines.
The Presidents of the three organisations
then addressed the webinar.
Dr.  David Barbe, President of the World
Medical Association, said the WMA had
had strong policy on vaccines for a long
time. As they all knew, vaccine hesitancy
was not new. They had seen it evolving and
becoming a louder voice around the world.
One of the critical reasons that this needed
to be emphasized was that for many of the
International Roundtable Webinar on Vaccination
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40
WMA News
diseases for which they had vaccines there
was no direct treatment. So when there
was no direct treatment, it was especially
important and critical that they promoted
the vaccinations to prevent the disease or
reduce its severity.
This pandemic, although the worst in their
lifetime, was not the first pandemic there
had been and it would not be the last. But
they had learned much from this pandemic.
And he hoped they would be able to put
into practice some of the things they had
learned so that they would do a better job
for public health preparedness, and be able
to lay the groundwork for even greater col-
laboration between countries and govern-
ments.
Very early in the pandemic, questions arose
about how long it would take to develop a
vaccine and how it would be distributed.
They had also seen a very natural human
response, when those more affluent coun-
tries put in advance orders for vaccines.
There was also the question about whether
third world countries with fewer economic
resources would have access to the vaccine.
As they had seen,these fears had played out.
There were many countries that for a vari-
ety of reasons had not yet had access to the
vaccine and were facing vaccination rates
that were in some cases negligible. He said
the response to this could not be parochial
or focused on just one country’s ability to
obtain the vaccine. So they must work to-
gether and collaborate to ensure equitable
distribution.
During the roundtable discussion they
would be focusing on the individual re-
sponse to vaccination. That was critically
important. They could have all the infra-
structure and the supply, but if the indi-
vidual was not prepared to take that step
and be vaccinated, the rest was for naught.
But all the other steps were still very impor-
tant. One step was access to supply. There
were countries that simply did not have ac-
cess to that supply.They needed to continue
to work diligently to make sure distribu-
tion was available. Secondly, once the vac-
cine was available, the distribution within
a country was critical. Many countries did
not yet have the infrastructure in place for
efficient and effective distribution.
There was also the question of prioritisation.
Who should get the vaccine first and how
should it be allocated and distributed?
A third factor was affordability and access.
Many countries had very remote and ru-
ral populations. Lastly, they would spend
time today talking about what was called
vaccine hesitancy. The concept of vaccine
confidence needed to be emphasized. They
had seen, unfortunately, a lack of persuasion
in attempts to debunk misinformation and
disinformation. While this was a very im-
portant part of their approach, it would not
necessarily win the day. They had to help
people see the benefit of these vaccines and
help them to make an intelligent risk ben-
efit decision for themselves.
Dr. Klaus Reinhardt, President of the Ger-
man Medical Association, said that at this
year’s German Medical Assembly, the Ger-
man medical profession passed a resolution
in support of global vaccine equity. Dele-
gates called on the German Bundestag and
the European Parliament to wave Covid
vaccines patent temporarily, while ensuring
fair compensation for the intellectual prop-
erty of the patent holders. A proposal to lift
patents was first introduced last year to the
World Trade Organisation by South Africa
and India. Although the German Govern-
ment and the European Commission cur-
rently supported alternative approaches,
including limiting export restrictions, they
hoped that with increasing pressure, they
would become more engaged and do justice
to Europe’s global responsibilities.
The need to take immediate action on
speeding up the global production of vac-
cines was clear.They must achieve the high-
est possible vaccination rate around the
world as quicky as possible. But this should
not be dependent on a country’s economic
influence. The response from wealthier
countries must also include greater support
for the COVAX initiative.
He said that a threat to progress was vac-
cine hesitancy. This was a very complex is-
sue and was influenced by many factors.
But one thing was certain  – the medical
profession had a tremendous responsibility
to counter disinformation and build public
trust in vaccines. One way they could meet
this responsibility was by working across
the disciplines and cultures to amplify their
message about the safety and importance of
vaccines. This was one of the reasons why
the German Medical Association decided
to join forces with the WMA and the PLA.
Through this unique collaboration, they
hoped that their message would resonate
with a broader audience from medical pro-
fessionals, to religious communities, vaccine
producers, governments and other stake-
holders worldwide.
Archbishop Msgr Vincenzo Paglia, Presi-
dent of the Pontifical Academy for Life,
said that although plans for this confer-
ence were made before the pandemic, it
now presented them with the possibility of
co-operating with all parties in pursuit of
common goals. This did not mean ignoring
differences. But neither did they want dif-
ferences to block initiatives that protected
health and life, especially for those who
were made weaker and more vulnerable by
reason of social, national and international
injustices. It was important to unite their
voices and their strengths so that vaccines
could be made available to all those who
needed them. This was a commitment that
would ensure their declarations about want-
ing to overcome inequalities and injustice
did not remain a dead letter.
He spoke about the scientific and ethical
doubts being expressed on vaccines. The ef-
fects produced by such doubts were danger-
ous and negative for everyone, not just for
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41
WMA News
those who declined to be vaccinated. Even
Pope Francis had spoken to this point on a
number of occasions, reminding them that
vaccination was about not only one’s own
health and that of others, but also about the
common good and justice.
The Pope had said: ‘If there is a possibility
of curing a disease with a drug, it should
be available to everyone. Doing otherwise
gives rise to injustice. There is no place for
medical marginalisation’.
The first key speaker was Dr. Andrea Am-
mon, Director of the European Centre for
Disease Prevention Control. She said the
pandemic had taken an unbelievable toll in
human life and had forced countries to take
unprecedented measures to protect and save
people’s lives.Now,vaccines had given them
hope, but they were still struggling, partly
because of the availability and uptake.
She said there was quite a favourable epi-
demiological situation in the European
Union. Only in five countries could they see
a reason for concern. The variant of most
concern was the Delta variant, which was
increasing in the EU. They estimated that
by August about 90 per cent of the new in-
fections would be due to this variant. The
question was whether the vaccines worked
against these variants, and the evidence
so far said yes. However, it required a full
course, meaning a double vaccine dose.
Dr. Ammon said vaccine hesitancy was an
important problem, although it was not
new. It started with Edward Jenner and his
smallpox vaccine. Healthcare workers had
a key role in working towards the goal of
improved vaccine coverage and confidence.
Vaccine hesitancy had many aspects. Not
everybody who was not vaccinated rejected
vaccination. There was the issue of confi-
dence and trust in vaccines. Did they work?
Were they safe?This was particularly the case
with new vaccines. Then there was the issue
of complacency. People thought they had no
risk from the disease. They thought it was
just like flu. This was really a lack of knowl-
edge. The last aspect was convenience and
this ranged from people who thought they
could not go to the doctor because it was too
far away, to some populations that were hard
to reach. Now they were seeing that some
continents did not even get the vaccine.
Then there was the small group, possibly
five per cent of hard core people who were
rejecting the vaccine. The first three groups
could be addressed, but the hard core rejec-
tions were very unpromising to address. So
the effort had to go into the three previous
areas.
There were a lot of questions being asked
about product specific issues. How long
would the protection last? Were the vaccines
safe? Did people really need two doses?
In 12 countries, almost half of the EU, there
was specific hesitancy about the Astra Ze-
neca vaccine. Here there were information
activities going on to support the increase in
vaccination and to address these concerns.
The second dose was also an issue of general
concern and this was being addressed.
Turning to the issue of misinformation,
Dr. Ammon said that migrant communities
were more susceptible to misinformation,
partly because of language difficulties and
social exclusion. There were also other so-
cially vulnerable populations that needed to
be addressed. Misinformation and disinfor-
mation were being spread online, and a sur-
vey conducted in the EU showed that there
was a vast difference between countries.
The survey examined why people were get-
ting vaccinated and why they were refusing.
It was important to understand what was
driving vaccine hesitancy so that they could
tailor interventions to specific populations,
involve the addressed populations and sup-
port healthcare providers in their commu-
nication with patients. This communication
should include the importance of vaccina-
tion, support for family and friends, mak-
ing it clear that a full vaccination course was
needed, and addressing misinformation.
Dr. Ammon spoke about some of the re-
sources being produced for public health
authorities in the EU. A project had been
launched last month countering online
misinformation. It was important to moni-
tor misinformation, then correct it. Trends
should be monitored and all these measures
had to be evaluated.
She concluded by emphasizing that the pan-
demic was not over yet.The summer season
was on them.The emergence of variants was
of concern. Relaxation of non-pharmaceu-
tical interventions could be instrumental,
but should be done with extreme caution.
There were challenges in vaccine access and
uptake and that meant addressing misinfor-
mation and disinformation.
The next keynote speaker was Dr. Soumya
Swaminathan, Chief Scientist at the World
Health Organisation, who spoke about
global vaccine equity. She said that only five
countries had not not started a vaccination
campaign, while ten countries had domi-
nated doses, administering almost 80 per
cent of all three billion doses. The list was
headed by China. Rollout had started in
215 countries, but in countries on the lower
economic scale there had been less cover-
age. The AstraZeneca vaccine was the most
widely used, followed by the Pfizer vaccine.
She said the gap in vaccine coverage was
widening. The gap between the United
States at one end and Nigeria at the oth-
er was huge, and this was something that
the WHO was trying to address. But most
countries had started vaccinating.
The WHO was leading several initiatives to
tackle the issue of sustainable manufactur-
ing capacity, by monitoring, strengthening
local capabilities, and enhancing clinical
research. It was releasing frequent ethical
guidance updates for research,development,
trials and vaccination.The WHO, as part of
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WMA News
the COVAX initiative, was aiming to estab-
lish new and expanded sustainable capacity
in low and middle income countries. But
she said that all this would take time.
The next speaker was Prof. Stefano Sem-
plici, Professor of social ethics at the Tor
Vergata University of Rome. He addressed
the issues of individual freedom of choice
and the common good in minimising the
number of deaths and suffering.
His first observation was to say that ‘my
choice has a relevant impact not only on
myself’, in the same way as the choice made
at community level had an impact not only
on that community.
They were confronted between the duty to
respect individual freedom and the duty to
protect the common good. Early on in the
pandemic there was a big debate about tri-
age and the necessity to vaccinate as many
people as possible. He said the issue was
never just about science, but always about
ethics and therefore about politics.
On the issue of individual freedom, he said
it was about trust and public confidence, as
well as solidarity. He referred to the view
that individuals should welcome the vaccine
not only for the sake of their own health,
but also out of solidarity with others, espe-
cially the most vulnerable.
He asked what should happen if this did not
succeed, and turned to the issue of manda-
tory vaccination.He quoted the Italian con-
stitution that no-one should be forcefully
submitted to medical treatment unless pro-
vided for by law. This meant that it was not
absolutely impossible. The Italian Commit-
tee for Bioethics had said that the possibil-
ity of making vaccination mandatory should
not be excluded, especially for professional
groups that were at risk of infection and
transmission of viruses. He said this issue of
mandatory vaccination was a matter to be
discussed, maybe not for this pandemic, but
for preparedness in the future.
Prof. Semplici concluded that it was always
a bad thing when individual freedom and
the common good could not be brought
together. A pandemic was a moment when
they should be brought together more than
ever. Solidarity should not be looked at as
just a matter of top down beneficence. Mass
vaccination was not always a scientific issue.
It was a matter of ethics and anthropology.
Solidarity required a sense of belonging, of
integration of each individual within the
group – their group first, then their country
and then humankind as a whole.
Dr.  Frank Ulrich Montgomery, Chair of
the WMA Council, opening up the discus-
sion with the panel, said he was interested
to hear from Dr. Ammon about having to
fight the issue of confidence, complacency
and convenience. There was an obligation
on the medical profession to talk to their
communities to get acceptance of the vacci-
nations. He said they should not forget the
prevention paradox, that the better people
were, the more they were complacent and
thought it was just flu and a small infection.
He was also interested to hear that three
billion doses had been administered world-
wide, but eighty per cent of them had been
administered in ten countries, and the rate
of vaccination in low income countries
was 62 times less than that in high income
countries.
Dr.  Montgomery then introduced
Dr.  Demetre Daskalakis, Deputy Inci-
dent Manager and Senior Leader in CO-
VID Data and Engagement, at the United
States Centers for Disease and Prevention.
Dr. Daskalakis emphasized again that this
was a global pandemic that required a global
view and a global response. He spoke about
the pandemic in the US, where 180 million
people had received at least one dose of the
three available vaccines. Vaccine rollout had
been a fascinating experience. Nothing on
this scale had been done before. It was not
just about public health. There had been
considerable interaction with all stakehold-
ers, government departments, as well as as
hospitals, pharmacists, and distributors.
To begin with they had prioritised vacci-
nations because there was a limited supply.
Then this gave way to generating demand,
particularly among those who were vulner-
able.
Turning to the problem of vaccine hesi-
tancy, he said the way to deal with this
was to build confidence and trust based on
clear and honest information. Trust relied
on monitoring safety and providing safety
data. They were constantly learning about
how effective the vaccines were against the
variants of the virus.
Looking ahead, Dr. Daskalakis said it was
the people who were not interested in vac-
cines who were the challenge.
Continuing to focus on equity was also vital.
Confidence in vaccination was key. People
had to trust the vaccine, the vaccinator
and the system that produced the vaccine.
Engaging with stakeholders was critical.
Community level engagement, not just na-
tional but local, was also critical in moving
forward. And finally, communication and
education, really sharing transparently good
information and truth about vaccines were
the cornerstone of successful vaccination
and were necessary to boost confidence and
address vaccine hesitancy.
During the panel discussion, Dr.  Mont-
gomery referred to the role of large reli-
gious communities, Catholic institutions
and institutions of all other religions. How
could they become involved as stake-
holders in information communication?
Dr.  Daskalakis agreed and said it was
critical to go to trusted messengers and to
educate them. They had to get deep into
the community.
Dr.  Montgomery, referring to common
good, said that physicians considered the
common good to be the best of health. But
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43
WMA News
politicians lived in a rectangle. They had to
consider the economy and social questions,
such as closing schools and depriving chil-
dren of education.
Dr.  Ammon spoke about engaging com-
munities. They had seen a development
where at the beginning of the pandemic the
overwhelming proportion of the population
was very willing to go along with restrictive
measures. But this broke down because the
communication did not emphasise enough
how important the contribution of the pop-
ulation as a whole was to the control effort,
communicating the importance of knowl-
edge and the necessity for restricting their
rights. That was something they missed.
They needed to mobilise anthropologists,
sociologists and psychologists. Dr.  Mont-
gomery agreed that they had failed to bring
the public along with them.
A question was raised about the amount
of misinformation on social media. Should
social media be used to respond to this mis-
information? Dr. Ammon replied that this
was exactly what needed to be done. The
channels people were using for their infor-
mation were the channels that should used
for responding to misinformation.
Dr. Montgomery concluded the day’s pro-
ceedings with a brief summary. They had to
reach out to communities in a combined ef-
fort of science and medicine, and multipli-
ers, such as religious communities.They had
to fight misinformation and fake news.They
had to ensure solidarity. And they had to
ensure , because in the long run they would
have to make sure equity was guaranteed.
He thanked all the speakers and brought
the proceedings of the day to an end.
The following day, a joint communique (see
box on p. 45) was issued by the World Medi-
cal Association, the German Medical As-
sociation and the Pontifical Academy for
Life, and a press conference was held at the
Vatican about the outcome of the seminar.
The three panellists, Dr.  Parsa-Parsi,
Dr.  Montgomery and Archbishop Paglia
made opening speeches.
Archbishop Paglia said it had now become
a kind of mantra that vaccines belonged to
everyone. But vaccinations also affected the
common good and justice. There should be
no restrictions made based on low-income
countries’ limited capacity to buy vaccina-
tions. He said it was important that the ini-
tiatives now undertaken in response to the
Covid-19 emergency took future needs and
structural concerns into account.
Dr. Parsa-Parsi said two key messages were
highlighted in the statement. It called on all
relevant stakeholders to exhaust all efforts
to ensure equitable global access to vaccines,
which was a key prerequisite for a success-
ful global vaccination campaign. And it
confronted vaccine hesitancy by sending a
clear message about the safety and necessity
of vaccines and counteracting vaccine myths
and disinformation.
He went on: ‘The current pandemic has il-
lustrated the importance of vaccination,
but it has also laid bare the great inequity
of access to vaccines and the dangers posed
by vaccine nationalism. Many develop-
ing countries are at a disadvantage due to
financial restrictions and limitations on
production capacity, while higher-income
countries have the resources to access highly
effective vaccines.
‘Unfortunately, there is not yet an adequate
supply of vaccines available and, even if vac-
cine production was increased, it wouldn’t
be enough to meet the demands of all re-
gions of the world in a reasonable and
timely manner. Ultimately, vaccines need
to be produced locally, but for this to occur
several barriers need to be overcome. Solv-
ing patent issues is certainly one important
element needed to support a self-sustaining
system of vaccine production But this must
be bolstered by the transfer of knowledge
and expertise and the training of staff,
international investment in vaccine produc-
tion sites in resource poor settings and the
guarantee of adequate quality control.
‘Sadly, there are also countries where vac-
cines are readily available but subject to
scepticism and mistrust. Vaccine hesi-
tancy is a complex issue. Some reluctance
in disadvantaged communities is rooted in
historical inequities, breaches of trust in
medical research, negative experiences with
health care and suspicion about pharmaceu-
tical companies.But a more malignant form
of vaccine hesitancy is driven by unfounded
and misleading claims and myths, including
disinformation about side effects.
‘The best antidote for vaccine hesitancy
is building trust, increasing transparency,
and addressing communication failures.
As trusted voices in the community, medi-
cal professionals play a crucial role in this
scenario. By working together with the
Pontifical Academy for Life, we hope to
complement our efforts to generate vac-
cine confidence by fostering awareness and
fighting the spread of myths and disinfor-
mation. Furthermore, economically or po-
litically motivated active dissemination of
false information regarding the safety and
effectiveness of approved vaccines needs to
be counteracted. Improving vaccine confi-
dence is indeed an international challenge
which requires international engagement,
including interdisciplinary collaboration of
the kind we are engaging in today.
‘We are very much aware that it is not vac-
cines that save lives, but rather vaccination.
Our collaboration will hopefully help to
boost vaccine confidence and to encourage
solutions to the hurdles faced by parts of the
world where vaccines are still scarce’.
Dr. Montgomery, Chair of Council of the
World Medical Association, said: ‘Vaccina-
tion is life! Since Edward Jenner introduced
vaccination to Europe in 1796 – exactly 225
years ago – billions of lives have been saved
worldwide through vaccinations. There is
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44
WMA News
probably no other intervention in medicine
that has saved more lives and prevented
more suffering than vaccination. We have
eradicated smallpox, we are close to wip-
ing polio off the surface of the earth and
deadly diseases like measles have lost their
frightening appearance. And science moves
on – fast. New biological agents, viruses and
bacteria are emerging, and new bacteria are
spread out over the globe in a world of high
mobility and increasing populations. Virus
and bacteria strike back. They develop vari-
ants,mutations or simply develop resistance.
‘This is a challenge for medicine. We have
just proven that we are willing and able to
take up this fight. Vaccines against Corona
have been developed in record time.Billions
of people have already been vaccinated –
less than 18 months since we learned about
the existence of Sars-Cov2.
‘We have also learned about gross inequi-
ties. Whilst rich, affluent countries urgently
started vaccination campaigns, the majority
of the world’s population was left behind.
Developing nations do not have the tech-
nology to develop vaccine production and
they don’t have the resources to buy vaccines
from the rich producing countries. It is our
moral obligation to overcome this outcrying
inequity as fast as possible.
‘And whilst children and their parents, el-
derly people and chronically ill in develop-
ing countries cry out for help and ask for
vaccines, we see reluctance to get vaccinated
and opposition to vaccination in general –
without any scientific evidence.The preven-
tion paradox hits us with its full impact.
Because we are so successful in preventing
disease, people forget the terrorizing sights
of large numbers of people dying in endem-
ic or pandemic situations.
‘This bring us into a most cynical position:
whereas a child in a developing country is
denied a safer life or even survival because
its nation or its family cannot afford vac-
cinations, there is also a child in an affluent
country that is denied the life-saving pre-
vention because of the ignorance or reluc-
tance of their parents.
‘There is one more important point about
vaccination. It is not only a prevention for
the vaccinated person self – it also serves the
population around that individual. People
that cannot be vaccinated or that are not re-
sponsive to vaccines are preserved through
the simple act of vaccinating others.
‘As physicians, as leaders in this world, we
have an obligation to protect our people. We
therefore have to offer as much prevention
through vaccination as possible in an equi-
table way and we must undertake all possible
attempts to convince “anti-vaxxers”of the ad-
vantages and the chances of vaccination.
Our speakers highlighted these issues from
different angles. The necessity of vaccina-
tion was not challenged, but speakers and
audience discussed ways to communicate
and fight “fake-news”. Misinformation is
one of the core reasons to vaccine-hesitancy.
But we also see three vital factors for im-
proving vaccinations: we have to improve
confidence, fight complacency and deliver
convenience.
‘Equity is a core issue for international co-
operation. Ten countries in the world have
delivered 80 per cent of the three billion
given doses up to now. And finally, the
philosophical aspects of individual freedom
versus common good were highlighted and
led to an interesting discussion on the issue
of mandatory vaccination’.
The panellists then faced several questions
from the media, about why vaccine sceptics
were not included among the speakers in
the roundtable discussion.Why were experts
representing all sides not included, including
experts against the vaccine, they asked.
Archbishop Paglia replied that the Pontifi-
cal Academy for Life, which has decided
some time ago to discuss the issue of the
vaccines, wanted to treat it in a comprehen-
sive way, bringing together all sides dealing
with the issue. He said this was not only a
technical, scientific issue, but also an ethi-
cal and social issue, which required a new
anthropological perspective. So they would
continue to debate the issue of vaccines.
Dr. Montgomery said the question showed
a misconception about the webinar. They
had heard from independent individuals
from European Centre for Disease Preven-
tion Control, the United States Centers
for Disease and Prevention and the World
Health Organisation. He refused to accept
the undertone of the question that the other
‘experts’ were recognised scientists.
Dr.  Parsa-Parsi said it had originally been
planned to have a two-day conference with a
lot of speakers.They hoped in future to have
another seminar to cover a broader range of
all aspects. But he added: ‘We are physicians.
We represent physicians. And we are bound
to science and to evidence-based medicine’.
Another journalist questioned the use of
the term ‘anti vaxxers’, saying that the use of
such derogatory name calling came across
as very one sided. Were the doctors willing
to accept that the whole debate over the
MRNA vaccines was contested and that
there was a high level of doubt about safety.
Dr.  Parsa-Parsi said there was no reason
why they should not be confident about
these vaccines, while Dr. Montgomery
said he had looked at one peer-reviewed pa-
per that had been sent to him and said he
was appalled by the gross misconceptions
and statistics. He said that for ideological
reasons there were some people who would
be against the science.These people differed
from those who were vaccine hesitant.
In the days that followed the press confer-
ence, extensive worldwide media coverage
was given to the roundtable webinar and to
the joint press communique.
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45
WMA News
Press statement
World Medical Association, German Medical Association and
Pontifical Academy for Life collaborate to promote vaccine eq-
uity and confront vaccine hesitancy
Millions around the world are still suffering the effects of the
­
COVID-19 pandemic and vaccination is widely seen as a fast
and effective way to control the spread of the virus and save hu-
man lives. Much as the current pandemic has brought home the
importance of vaccination, it has also laid bare the great inequity
of access to vaccines and the dangers posed by vaccine national-
ism. While many higher-income countries had the resources to
quickly sign bilateral agreements with pharmaceutical companies
for promising COVID-19 vaccine candidates, this left many de-
veloping countries at a disadvantage due to financial restrictions
and limitations on production capacity.
Vaccine accessibility still poses great challenges in many parts of
the world, but there are also countries where vaccines are readily
available but subject to skepticism and mistrust. Vaccine hesitancy
is a complex issue. Some reluctance in disadvantaged communities
is rooted in historical inequities, breaches of trust in medical re-
search, negative experiences with health care and suspicion about
pharmaceutical companies’behavior focused on profit. But a more
pernicious form of vaccine hesitancy is driven by unfounded and
misleading claims and myths, including disinformation about side
effects, which are amplified by social media and other means of
enhanced communication. Adding to this complexity is the fact
that vaccine hesitancy even exists in the medical community and
some religious groups. Vaccine hesitancy and refusal can ultimate-
ly give rise to difficult ethical questions about the tension between
individual freedom of choice and the common good.
Considered one of the greatest achievements of modern medicine,
vaccines play a vital role in the prevention of infectious diseases.They
have been proven to avoid millions of deaths and protect millions
more from getting sick each year. But to unlock the full innovative
potential of vaccines, action must be taken to overcome barriers to
vaccine equity and to address the root causes of vaccine hesitancy.
Recognizing the urgency of these issues and the essential role in-
ternational and cross-sectoral collaborations can play in advancing
these causes, the World Medical Association (WMA), the Pon-
tifical Academy for Life (PAL), and the German Medical As-
sociation (GMA) have joined forces to demand that all relevant
stakeholders exhaust all efforts to:
• ensure equitable global access to vaccines, which is a key prereq-
uisite for a successful global vaccination campaign, and
• confront vaccine hesitancy by sending a clear message about the
safety and necessity of vaccines and counteracting vaccine myths
and disinformation.
A year after the Córdoba General As-
sembly had to be held virtually because of
­
Covid-19, the postponed scientific session
was finally held online, on September 17
this year. Entitled ‘Physicians in the Or-
gan Donation and Transplantation Process:
Ethical Challenges’, the event was organ-
ised by the WMA, the Spanish Medical
Council and the National Transplantation
Organisation of Spain (ONT).
Dr.  Heidi Stensmyren, President Elect
of the WMA, took the chair for the first
part of the session, which was divided in
two. The first theme looked at the ethics of
transplantation and the second focused on
illegal trafficking.The day’s proceedings be-
gan with two opening speeches.
The first was from Dr. David Barbe, Presi-
dent of the WMA, who welcomed del-
egates. He said the challenges in organ
donation and transplantation seemed to get
more complex and difficult despite much
work that had been done by many organisa-
tions. He said the first WMA Statement on
Human Organ Donation and Transplanta-
tion was adopted just over 20 years ago and
had been superseded by the WMA State-
ment on Organ and Tissue Donation in
2012.This was revised in 2017.The 40 prin-
ciples in that document continued to form
the basis for the global ethical practices on
these issues.He asked why the development
and promotion of medical ethics was so
important. Couldn’t they just rely on what
their governments declared permissible? To
answer this, he referred to the 1930s and
1940s when there were horrific abuses of
medicine in concentration camps and even
in hospitals. When the doctors were held
responsible, they claimed in the Nuremberg
Trials to have acted on government orders.
Partly because of this, it was now accepted
that just because something was ordered
by government or was even allowed by law,
did not mean it was necessarily ethical or
permissible for physicians.This should have
been self-evident after the Nuremberg Tri-
als. However, they continued to observe the
participation of physicians in torture and
this led to the WMA Declaration of Tokyo
on torture.
Dr. Barbe said the profession had to take
responsibility for the enforcement of medi-
cal ethics. This was not an option, but a ne-
cessity. It could not be replaced by govern-
Cordoba Scientific Session
BACK TO CONTENTS
46
WMA News
ment decision or laws. It was a professional
duty that went with professional autonomy.
The second opening speaker was Ms. Caro-
lina Darias, from the Spanish Ministry of
Health, Consumer Affairs and Social Wel-
fare. She said that for more than 30 years
Spain had been advocating for donation
and transplantation to be an essential ser-
vice in any health system. She spoke about
the benefits of transplantation, improv-
ing the lives of those who received organs.
But she said there were people who were
profiting at the expense of the health and
lives of others, through the practice of or-
gan trafficking that was both reprehensible
and dangerous. She said they had to make
a common front against this scourge of or-
gan trafficking, and Spain was leading that
fight. In its latest campaign it was inviting
Spanish citizens to leave their mark through
their donations. Every donor left an invalu-
able mark on a recipient.
Dr.  Stensmyren then moved the session
on to the first round table discussion with
its theme of ‘Donations as Part of End of
Life Care’.The first speaker was Dr. Beatriz
Domínguez-Gil, Director General of ONT,
the National Transplantation Organisation
of Spain responsible for the oversight, co-
ordination and organization of the dona-
tion and clinical use of organs, tissues and
cells in Spain. She said that in 2019 there
were nearly 154,000 transplants worldwide,
but these covered only 10 per cent of needs.
Covid-19 had had an impact on transplan-
tation programmes which had diminished
by 20 per cent last year. She asked why de-
ceased donation rates varied so much be-
tween countries. One study carried out on
end-of-life care and decision-making in the
EU showed there was considerable variation
in the type of care given to patients dying as
a result of a devastating brain injury. Some
professional providing end-of-life care to
patients might not consider the possibility
of organ donation or might not facilitate it
for reasons that might include legal bound-
aries, lack of institutional support, workload
or lack of knowledge. In her view, organ
transplants saved lives, improved quality of
life, prevented organ trafficking and trans-
plant tourism and promoted moral values in
society. But the primary motivation of the
professional should be the care of the pa-
tient or donor and their family.
Prof. Francis L. Delmonico, Chair of the
World Health Organisation Task Force on
Donation and Transplantation of Organs
andTissues,said that a decision to withdraw
life-sustaining treatment was derived by a
conclusion that further treatment would
not enable a patient to survive or would not
produce a functional outcome with accept-
able quality of life that the patient and the
treating team regarded as beneficial. But al-
though many hospitalised patients died un-
der such circumstances, controlled donation
after the circularity determination of death
programmes had been developed only in a
few countries. He went on to outline the
International Collaborative Statement pub-
lished last year, which aimed at expanding
the circulatory determination of death in
the world. This addressed three fundamen-
tal elements of the pathway: i) the process
of determining a prognosis that justifies the
withdrawal of life-sustaining therapies, a
decision that should be prior and indepen-
dent of any consideration of organ dona-
tion and in which transplant professional
must not participate; ii) the determination
of death should be based on the permanent
cessation of circulation to the brain; iii) the
acceptability of ex situ and in situ preserva-
tion measures as long as restoration of brain
perfusion is precluded to not invalidate the
determination of death.
Dr. Dale Gardiner, Associate Medical Di-
rector of Deceased Organ Donation at the
United Kingdom NHS Blood and Trans-
plant, spoke about the ethical conflicts for
healthcare professionals in offering dona-
tion as part of the end of-life-care plan. He
asked whether donation should be offered
as part of routine end-of-life care on ICU
and said that all the facts had to be outlined,
as well as the outcomes of relevance to the
various agents involved,such as the patients,
their family, ICU doctors and nurses, and
society. There were many questions, such as
whether donation provided a good death,
and the ethical and legal challenges. They
all needed answers. From the perspective
of the principles of autonomy, beneficence,
nonmaleficence (burden) and justice, organ
donation should be offered as part of end-
of-life care by health professionals, as long
as the burden can be properly addressed by:
i) ensuring that donation does not risk a
good death (avoiding suffering and respect-
ing the wishes of the dying patient); ii) un-
derstanding organ donation always as Kan-
tian, not utilitarian, where patients (donors)
are ends in themselves; iii) making evident
the delayed benefits of organ donation; iv)
learning to understand the needs of patients
outside of our hospital or unit.
Prof. Milka Bengochea, Director at the Na-
tional Institute of Donation and Transplan-
tation in Uruguay, discussed the challenges
of incorporating organ donation in end-of-
life care in Latin America. She referred to
the need to promote a new paradigm that
included organ donation as a patient’s right
and the critical pathways for organ dona-
tion. And she talked about the situation in
Argentina, Brazil and Uruguay, where many
characteristics of their regulatory donation
systems were shared.
The second part of the scientific session
looked specifically at organ trafficking. The
first speaker was Dr.  Ravindra Sitaram
Wankhedkar, Past President of the Indian
Medical Association, and current treasurer
of the WMA. He talked about the current
realities and said that organ trafficking and
human trafficking for illegal organ trans-
plantation was one of the biggest crimes
on humanity, having international implica-
tions. It was rising due to high demand and
low supply, economic inequalities, progress
in transplantation techniques and increas-
ing migration. Most vulnerable were wom-
en, children and migrants. He said govern-
BACK TO CONTENTS
47
WMA News
ments, international organisations, NGOs
and medical associations must join hands to
fight this menace.No country was left unaf-
fected by this black market organ trade. But
some countries were known more for hav-
ing doctors who would illegally transplant,
while others were more known for citizens
seeking out illegal transplants. He referred
to those countries where people sought or-
gan transplantation and said that the preva-
lence of black market organ trades in these
countries stemmed from having doctors
willing to perform the transplants, brokers
willing to set up deals and citizens willing to
sell their organ illegally. On a conservative
estimate, 10 per cent of all registered trans-
plants were illegal, approximately 14,000.
But in reality,the figure was much more.He
said that transplant tourism undermined
waiting lists and safety regulations and
often abused marginalised and oppressed
people in order to gain the necessary organs.
A lack of access to transplants and a lack of
availability of organs were the driving forces
behind this trade. He said the average age
of a seller was 33.6 years, and their average
income was $15.4 US dollars. Many were
migrants. Joint projects had been conducted
to combat this trade, but often there was no
power to back this up.
Dr. Wankhedkar concluded by saying that
the solutions included developing better
systems of deceased organ donations, en-
couraging altruistic living conditions, pre-
venting needs for transplantation by treat-
ing diseases that led to organ failure and
implementing laws that prohibited organ
trading and trafficking.
The next speaker was Dr.  Marta López-
Fraga, the Scientific Officer in charge of the
donation and transplantation activities at
the European Directorate for the Quality of
Medicines & Healthcare at the Council of
Europe. Since 2011, she has been in charge
of the European Committee on Organ
Transplantation, the Steering Committee
in charge of the donation and transplanta-
tion activities at the Council of Europe.The
committee actively promotes the non-com-
mercialisation of organ donation, the fight
against organ trafficking and the develop-
ment of quality and safety standards in the
field of organs, tissues and cells.
Dr. López-Fraga said that organ trafficking
was a global phenomenon. It was estimated
that up to 10 per cent of kidney transplants
performed annually were the result of traf-
ficking, a total of up to 6,800 kidneys per
year. It was a highly lucrative business, with
recipients usually paying between $70,000
and $160,000 for an organ. Healthcare
professionals had opportunities to prevent
these crimes through detection, reporting
and then combating them. She said there
were critical points at which healthcare
professionals had a decisive role. These in-
cluded the evaluation of prospective donors
and recipients, the management of patients
who were considering travelling abroad for
transplants and managing patients who had
received a transplant abroad and returned
home for follow up care. At each stage,
healthcare professionals had specific actions
they could take. She said that health profes-
sionals and authorities could no longer turn
a blind eye to these illicit practices. These
activities needed to be regulated and health
care professionals had an important role in
preventing and combating these practices.
Dr. Dominique Martin,Associate Professor
in Bioethics and Professionalism at Deakin
University, Australia, spoke about the ethi-
cal duties that might influence professional
participation in collecting and reporting
data. Routine collection and reporting of
data were a key issue, because there might
be data indicating potential crimes. Profes-
sional duties towards individual patients
included privacy and confidentiality, a per-
son’s right to autonomy in decision making
and the prevention of harm. Professionals
might face ethical uncertainty regarding
their reporting obligations. Would report-
ing be legal? What data should be report-
ed? Would reporting cause other harms?
Dr.  Martin said health professionals were
at the heart of transplant donation and
the issue of trafficking. There was a clear
necessity for them to be involved in collec-
tion and reporting. They were at the heart
of patient care and were ideally placed to
collect this information. They had ethical
and professional duties to collect and report
information about suspected transplant re-
lated crimes, especially where reporting was
expected to reduce the risk of future harm
to others. Tensions might arise between
reporting duties and obligations to respect
patient privacy and confidentiality. And the
extent of reporting duties and their ethical
weight would be dependent on the context
in which reporting occurred and on the sys-
tems that were in place to ensure that infor-
mation would be used effectively and that
vulnerable individuals would be protected
from harm.
Prof. José Antonio Lorente, Professor of Le-
gal Medicine at the University of Granada,
talked about a programme called DNA-
PRO-ORGAN that was launched in
Granada in 2016 focusing on kidney trans-
plantation.This promoted the creation of da-
tabases of biological samples helping trace-
ability from donor to recipient and vice versa.
It was expected to become a useful tool to
investigate suspected cases of organs traffick-
ing, a type of crime where the lack of docu-
mentation or the use of forged documents
make investigation highly challenging.
In the closing session,two speakers summed
up the day. Dr. Frank Ulrich Montgomery,
Chair of the WMA Council, thanked the
speakers. He said that combining ethics
and organ trafficking in one session had
been very fruitful. He was impressed by the
phrase that if physicians did things badly
their patients and their families would nev-
er forgive them, but if they did things well,
they would never forget them. Dr. Tomás
Cobo, President of the Spanish General
Medical Council also thanked the speakers.
He said the session had emphasised the fact
that physicians were involved in the fight
against this scourge of trafficking.
BACK TO CONTENTS
48
Covid-19
The pandemic of COVID-19 caused by
SARS-CoV-2 since December 2019 is
still very serious and affects human life
and health globally, and conventional
pharmaceutical interventions are ineffec-
tive in controlling the disease progression
and epidemic spread. Based on previous
experience in combating the epidemic,
the development of a safe and effective
vaccine as soon as possible is a powerful
measure to mitigate the epidemic shortly.
Thanks to the active research and valida-
tion of ­
COVID-19 Vaccines by several
vaccine research and development in-
stitutions around the world, several vac-
cines have been administered worldwide
currently. This article reviews the vaccines
that have been put into use worldwide
in terms of their development process,
mechanism of action and safety, hoping
to help people understand the produc-
tion process and clinical effects of the
COVID-19 Vaccine, and encourage more
people to receive the COVID-19 vaccine
in time to reduce the impact of the epi-
demic on global public health, economy
and society.
1. Vaccination is a
matter of urgency
According to a study from the University
of Maryland School of Public Health, the
global epidemic of COVID-19 is growing
due to the emergence of highly infectious
mutant strains such as the Delta strains,
which are evolving in their ability to spread,
with mutant viruses becoming increasingly
airborne and increasing infections even in
countries with vaccination rates of over 40%.
As of October 17, 2021, the total number
of ­
COVID-19 infections worldwide is ap-
proaching 250 million, and the number of
deaths is about to cross 5 million. In terms
of the regional distribution of ­
COVID-19
infections worldwide, the United States
remains the country with the most severe
epidemic,with more than 44.64 million con-
firmed infections, while the top four coun-
tries are India, Brazil and the United King-
dom, with 34.06 million, 21.63 million and
8.4 million confirmed infections,respectively.
Studies have shown that patients who recov-
ered from COVID-19 infection after active
treatment produce antibodies to varying
degrees, which neutralize the COVID-19
in vitro, creating a longer period of immu-
nity so that the virus can no longer infect
and spread [1]. The COVID-19 vaccine is
a biological agent developed and authorized
to combat the COVID-19. When a healthy
population is fully vaccinated, their body’s
immune system produces a large number of
neutralizing antibodies and thus gains the
ability to fight the COVID-19 infection. In
the absence of an effective tool to control
the epidemic and in the absence of specific
treatment for patients infected, widespread
vaccination is currently an effective way of
controlling the deterioration of the epidem-
ic situation.
Herd immunity, which refers to the pro-
tective barrier of a larger population when
a certain percentage of the population has
acquired immunity through vaccination
or previous virus infection, can reduce the
spread of the virus [2]. For the proportion
of the population needed to reach herd im-
munity,WHO gave a number of 60–70% in
November 2020. As of 15 September 2021,
vaccination rates have reached 70% in Chi-
na, about 60% in European countries rep-
resented by the UK and Germany, slightly
more than 50% in the US and Japan, and
only 15% in India. However, the global epi-
demic is on the rebound as the delta variant
emerges, and the delta variant could spread
among those who have been vaccinated,
causing “breakthrough infections,”in which
vaccinated individuals test positive for
­
COVID-19 more than 14 days after com-
pleting two doses vaccination. Studies have
shown that vaccines are still effective against
delta strains and disease progression, but
that herd immunity can only be achieved
with greater rates of vaccination. No vac-
cine provides 100% protection, and herd
immunization does not provide protection
for those with contraindications to vaccina-
tion. But through herd immunization, these
people can be indirectly protected by the
immunization from those around them, so
vaccination can protect not only themselves
Focus on COVID-19 Vaccine
Jinjian Yao Shuang-qin Xu
BACK TO CONTENTS
49
Covid-19
but also those in the community who are
not eligible to be vaccinated. In addition,
WHO Europe Director Kruger said that
the ­
COVID-19 could be around for years
and that health officials must now “antici-
pate how to gradually adjust our vaccination
strategy”, especially with regard to the need
for additional booster shots to maintain im-
mune protection against COVID-19.
2. Development of
COVID-19 vaccines
Vaccines are designed to assist the body’s
immune system in safely recognizing and
blocking COVID-19 viruses that en-
ter the body, with antigens derived from
the disease-causing components of the
­
COVID-19, such as proteins or glucose, or
possibly the entire virus after inactivation.
In addition, the vaccines sometimes contain
other ingredients to maintain the safety and
efficacy of the vaccine, such as preservatives
(to prevent contamination of the vaccine
after opening the glass vial), stabilizers (to
prevent chemical reactions within the vac-
cine and to prevent the vaccine components
from adhering to the vial), surfactants (to
keep miscible all the components of the
vaccine), diluents (to dilute the vaccine to
the correct concentration of liquid before
use ), adjuvants (to retain the vaccine at the
injection site for longer or to stimulate lo-
cal immune cells), residues, all of those have
chance to contribute to the allergic response.
The types of COVID-19 vaccines currently
under development are: (i) whole inacti-
vated or attenuated vaccines by inactivated
or weakened viruses in the lab, which do
not cause clinical signs and symptoms of
COVID-19 pneumonia, could stimulate
the body’s immune response, with the ad-
vantages of mature technology, high safety,
and easy storage and transport, and the dis-
advantages of a potentially short duration
of immune protection and a single route of
immunity (slightly less effective in the face
of delta variants). (ii) Recombinant pro-
tein vaccines, which use harmless protein
fragments or protein shells that mimic the
­
COVID-19 virus to safely trigger an im-
mune response. (iii) Viral vector vaccines,
which use safe viruses that do not cause
disease and use them as a platform for pro-
ducing coronavirus proteins to trigger an
immune response, with the advantages of
being safe and efficient, easy to store and
transport, and less adverse effects, and the
disadvantage is that the immune effect of a
single dose is generally weaker than 2 doses,
and the effect on mutated variants is di-
minished. (iv) RNA and DNA vaccines, a
cutting-edge approach using genetically
engineered RNA or DNA to generate pro-
teins that can safely elicit an immune re-
sponse by generating antigen proteins, with
the advantages of rapid development and
production, strong immunity and higher
safety, and the disadvantages of immature
technology, poor stability and high storage
and transport requirements [3].
WHO and its partners are committed
to accelerating the development of the
­
COVID-19 vaccine while following the
highest safety standards. The vaccine is
subject to different stages of development
and testing clinical trials typically consist
of three phases, Phase I: vaccination of a
small number of young and healthy adult
volunteers to assess its safety, confirm that
it produces an immune response, and deter-
mine the correct dose. Phase II: Vaccination
of hundreds of volunteers to further assess
its safety and efficacy in producing immune
antibodies. This phase usually also includes
a group of unvaccinated individuals as a
control group to determine whether the
changes in the vaccinated group are caused
by the vaccine or occur by chance. Phase 3:
Vaccination of thousands of volunteers and
comparison with a similar group of people
who were not vaccinated but received a
control product to determine the effective-
ness of the vaccine in the disease prevented
and its safety in the broader population.The
final phase is to evaluate the ability of the
vaccine to prevent disease, known as vaccine
efficacy. After all, stages have been evalu-
ated for safety, the vaccine is then reviewed
by national regulatory agencies and policy
committees, which determine whether the
vaccine is safe and effective enough to be
marketed and how it should be used.
In the past, the series of steps to develop
a vaccine could take many years to com-
plete. Now, however, the urgent need for
a ­
COVID-19 vaccine has led to a restruc-
tured approach for vaccine development
with unprecedented financial investment
and scientific collaboration. The develop-
ment process is proceeding with a number
of steps in parallel while maintaining strict
clinical and safety standards. For example, a
number of clinical trial programs are evalu-
ating multiple vaccines simultaneously;
strong financial and political support for
vaccine development, etc., but this does not
compromise the rigour standards of the re-
search program.
At least 13 different vaccines (across four
platforms) and more than 6.5 billion doses
are currently in use. Of these, Pfizer/Bio-
tech’s Fupirtide vaccine (a nucleic acid vac-
cine with 2 doses administered at 3-week
intervals apart) was added to the WHO
emergency use list on 31 December 2020.
On 16 February 2021, the Serum Institute
of India/Covishield vaccine and AstraZen-
eca/AZD1222 vaccine (developed by As-
traZeneca/Oxford and produced by Serum
Institute of India and SK Biologics, an ad-
enovirus vector vaccine, 2 doses total with
an interval of 4-12 weeks apart) was added
to the emergency use list. At March 12,
2021, Janssen/Ad26.COV 2.S vaccine (ad-
enovirus vector vaccine, 1 dose total) devel-
oped by Johnson & Johnson was added to
the emergency use list. On April 30, 2021,
Modena mRNA 1273 (nucleic acid vaccine,
2 doses total with an interval of 3 weeks)
was added to the emergency use list. 2 doses
with an interval of 3-4 weeks apart) was
added to the emergency use list. On May 7,
2021, the COVID-19 vaccine (inactivated
BACK TO CONTENTS
50
Covid-19
vaccine, 2 doses in total with an interval of
3 weeks) was manufactured by the Beijing
Institute of Biological Products Limited
Liability Company, a subsidiary of China
Biotechnology Corporation, was added to
the emergency use list. On June 1, 2021, the
Coxing-Kerrif vaccine (inactivated vaccine,
2 doses in total with an interval of 3 weeks)
was added to the emergency use list. 2 doses
in total, separated by 2-4 weeks) is added to
the emergency use list [4].
3. Safety of the COVID-19
Vaccine
China completed the COVID-19 vaccine
research, development and approval process
in record time with unprecedented scientific
collaboration, thereby meeting the urgent
need for a COVID-19 vaccine while main-
taining high safety standards. As with all
vaccines, COVID-19 vaccines have under-
gone rigorous clinical trials to demonstrate
that they meet international requirements
for safety and efficacy.The COVID-19 vac-
cine is safe for most people 5 years of age
and older, including those who already have
a variety of diseases, including autoimmune
diseases, that include hypertension, diabe-
tes, asthma, lung disease, liver disease [5],
kidney disease and chronic infections that
are in a stable and well-controlled [6]. For
people with compromised immune systems,
who are pregnant or breastfeeding, who
have a history of severe allergies, especially
to vaccines (or any component of vaccines),
and who are very weak, the decision to vac-
cinate should be made in consultation with
a health care provider.
Like other vaccines, different kinds of
COVID-19 vaccines may cause different
side effects. Most of the reported side ef-
fects of the COVID-19 vaccine are mild to
moderate and short-lived, including fever,
fatigue, headache, muscle pain, chills, diar-
rhoea, and injection site pain, and will go
away on their own within a few days [7].
In very rare cases, the vaccine can produce
more serious or longer-lasting side effects.
The rare cases of myocarditis (inflammation
of the heart muscle) and pericarditis (in-
flammation of the outer membrane of the
heart) have been reported after the second
dose of COVID-19 mRNA vaccine, mainly
in young men aged 12-29 years (40.6 cases
of myocarditis per million-second doses),
compared with 4.2 cases per million-second
doses in women in the same age group,
usually with milder symptoms, with rapid
medication and rest can help avoid causing
long-term damage or death to the heart, so
the WHO believes the benefits of vaccines
far outweigh the risks of myocarditis and
pericarditis because they prevent hospital-
ization and death from COVID-19 [8, 9].
What we need to know is that no vaccine
has 100% protection[10]. There may even
be a small percentage of people who do not
receive the expected protection after the
­COVID-19 vaccination.In addition,we still
do not know well about how long the im-
munizing effects of the various ­
COVID-19
vaccines last, and are subject to several fac-
tors, such as age, underlying medical condi-
tions, or prior exposure to COVID-19, in
addition to the specific characteristics of
the vaccine, which may have an impact on
the effectiveness of the vaccine itself [11].
Therefore, even with COVID-19 vaccina-
tion, we must continue to use all effective
public health measures, such as maintaining
physical distance, wearing masks and hand
washing regularly [12].
4. Challenges
To sum up, the following are the main
challenges to promotevaccination globally:
Global NCC vaccination is unbalanced: dif-
ferent countries or regions are affected by
various factors such as local economy and so-
ciety, and currently the global vaccination is
unbalanced[13], China has already achieved
a 70% vaccination rate, although variant
strains are emerging, but Zhong Nanshan,
an academician of the Chinese Academy of
Engineering, said that China reached 83.3%
vaccination rate is expected to establish herd
immunity, however, the population in un-
derdevelopment countries COVID-19 vac-
cination rate is far from the WHO proposed
60%-70% vaccination rate[14], as the time
pass by, may be in the less vaccinated coun-
tries to appear more contagious the mu-
tant strains, that is, the global need to face
the challenge of the outbreak waves; mu-
tated strains emergence: as it spread widely
around the world, new variants continue
to emerge, including B.1.1.7 (now named
Alpha), first identified in the UK, B.1.351
(now named Beta) in South Africa,P.1 (now
named Gamma) in Brazil,and B.1.617 (now
named Delta), these variants tend to have
multiple mutations and exhibit increased
infectivity and immune escape [15-16],
posing great challenges for future outbreak
control; SARS-CoV-2-specific antibody of
levels s continued to decline in serum of in-
fection or vaccinated people [17] who need
to a booster vaccination.Distribution imbal-
ances limit the speed of herd immunization:
in order for everyone around the world to
benefit from a safe and effective COVID-19
vaccine, WHO has led the development of
an equitable distribution framework that
aims to ensure that successful COVID-19
vaccines and therapeutic drugs are shared
equitably among all countries. The goal is
to deliver at least 2 billion doses of vaccine
by the end of 2021 and 1.8 billion doses to
92 low-income economies by early 2022 to
protect those at the highest risk of infection
and severe disease. And in some countries
facing greater threats and vulnerabilities.
The achievement of these goals will require
technical assistance from more developed
countries as well as economic assistance, and
it is believed that with the unity of purpose
of the global population, the epidemic will
eventually crab.
5. Vaccination is imperative
Since December of 2019, people around the
world have been tenaciously battling the
BACK TO CONTENTS
51
Covid-19
COVID-19 virus and have some progress
in epidemic control. There is now a global
consensus that vaccination against CO-
VID-19 may be the most effective measure
to address the epidemic in the future, and
vaccination against COVID-19 has been
actively promoted worldwide. However, the
virus is still changing, and the phenomenon
of immune escape has emerged from the
mutated strains that keep evolving, which
has brought new uncertainties to the pre-
vention and control of the epidemic in fu-
ture among countries, so the vaccine devel-
opment and vaccination strategy should be
more up-to-date and constantly improve
the speed of research and development and
vaccine types,faster than COVID-19 muta-
tion, there is a long way to go in the preven-
tion and control of the epidemic around the
world, and the people of the world need to
work together, we should be confident that
with the jointed efforts around the world,
the COVID-19 will eventually be defeated
by humans, and the people of the world will
usher in the final victory in this battle.
References
1. Radbruch A, Chang HD. A long-term perspec-
tive on immunity to COVID. Nature. 2021.
2. Paim A, Lopes-Ribeiro Á, Daian E Silva D, et
al. Will a little change do you good? A putative
role of polymorphisms in COVID-19. Immunol
Lett. 2021. 235: 9-14.
3. Shin MD, Shukla S, Chung YH, et al.
­
COVID-19 vaccine development and a poten-
tial nanomaterial path forward. Nat Nanotech-
nol. 2020. 15(8): 646-655.
4. https://www.who.int/zh/emergencies/diseases/
novel-coronavirus-2019/covid-19-vaccines.
5. Markus Cornberg, Maria Buti, Paolo Antonio
Grossi, Daniel Shouval EASL position paper
on the use of COVID-19 vaccines in patients
with chronic liver diseases, hepatobiliary cancer
and liver transplant recipients. 2021 Feb 6. pii:
S0168-8278(21)00081-7.
6. Won Suk Choi, Hee Jin Cheong COVID-19
Vaccination for People with ComorbiditiesIn-
fect Chemother. 2021; 53(1): 155–158
7. Farhang Babamahmoodi, Majid Saeedi, Reza
Alizadeh-Navaei, etal Side effects and Im-
munogenicity following administration of the
Sputnik  V COVID-19 vaccine in health care
workers in Iran.
8. Julie Helms, Alain Combes, corresponding
author, and Nadia Aissaoui Cardiac injury in
COVID-19. Intensive Care Med. 2021, 2 : 1-3
9. Se Yong Jung, Min Seo Kim, Han Li, etal
Cardiovascular events and safety outcomes as-
sociated with remdesivir using a World Health
Organization international pharmacovigilance
database. 31 October 2021.
10. Stephanie L.S. Penetra, Michele F.B. da Silva,
Paola Resende, etal Post-acute ­
COVID-19
syndrome after reinfection and vaccine break-
through by the SARS-CoV-2 Gamma variant
in Brazil. Int J Infect Dis. 2021 Oct 29
11. Noam Barda, MD, Noa Dagan, Cyrille Co-
hen, etal Effectiveness of a third dose of the
BNT162b2 mRNA COVID-19 vaccine for
preventing severe outcomes in Israel: an obser-
vational study. Lancet. 2021 Oct 29
12. Yihang Pan, Yuan Fang, Meiqi Xin etal. Self-
Reported Compliance With Personal Preven-
tive Measures Among Chinese Factory Workers
at the Beginning of Work Resumption Follow-
ing the COVID-19 Outbreak: Cross-Sectional
Survey Study. J Med Internet Res. 2020 22 (9),
e22457.
13. Bawa Singh, Vijay Kumar Chattu. Prioritiz-
ing ‘equity’ in COVID-19 vaccine distribution
through Global Health Diplomacy. Health Pro-
mot Perspect. 2021; 11 (3), 281-287
14. Julio S Solís Arce, Shana S Warren, Niccolò F
Meriggi, etal. COVID-19 vaccine acceptance
and hesitancy in low- and middle-income coun-
tries. Nat Med. 2021.16
15. Al Kaabi N, Zhang Y, Xia S, et al. Effect of 2
Inactivated SARS-CoV-2 Vaccines on Sympto-
matic COVID-19 Infection in Adults: A Ran-
domized Clinical Trial. JAMA. 2021. 326(1):
35-45.
16. https://www.biorxiv.org/content/10.1101/2020.
08.14.250258v1.
17. JinJian Yao, Hangfei Wang, Weiling Yu, Yimin
Li, Zhiqian Luo, Biao Wu, Wei Zhang, Xiaoran
Liu, Chuanzhu Lv. Dynamic Changes of An-
tibodies to SARS-CoV-2 in Close Contacts.
Journal of Inflammation Research 2021:14
4233–4243.
Acknowledgements
Shuang-qin Xu and Jinjian Yao are co-first
authors in this manuscript. This study was
supported by the
Disclosure
The authors state that they have no conflicts
of interest to disclose
Shuang-qin Xu1,3
*, Jin-jian Yao2
*,
Jin Qian1,3
, Qi Li1,3
,Tang Deng1
,
QiFeng Huang1
, HangFei Wang1,3
,
XinXin Wu4
, Nan Li1,3
, Ji-chao
Peng1
,Yang Yi1,3
,Yue Huang1,3
XiaoRan Liu1,3
*
1. The First Affiliated Hospital of Hainan
Medical University, Hainan Medical
University, Haikou 571199, China.
2. Emergency Department, Hainan General
Hospital Affiliated to Hainan Medical
University, Haikou, 570311, Hainan, China
3. Emergency and Trauma College, Hainan
Medical University, Haikou,571199, China.
4. Hainan Medical University,
Haikou, 571199, China.
Chinese Society of Emergency Medicine,
Chinese Medical Association
E-mail liuxiaoran3192@163.com
*These authors contributed equally
BACK TO CONTENTS
52
Medical Ethics
The past few decades have seen the increas-
ing speed of technological evolution. What
seemed impossible a few years ago is now
getting closer to becoming a reality. How-
ever, should we not consider if every tech-
nical possibility is ethically good, that it is
something truly good for humanity?
In the book The Art of Being Fragile by Ales-
sandro D’Avenia,we find an idea which aids
reflection on this matter: “There is no time
left: the chrysalids, the embryo, the seed are
realities, all of them, which take too much
time and too much effort to become fruit.
We want everything now forever. We cover
our fragility with a technological armor that
allows us not to notice it” [1]. The world is
full of fragility, but maybe instead of pro-
tecting that fragility, we are making it more
vulnerable,disguising it with a layer of tech-
nology. As Alessandro D’Avenia mentions,
one of the fragile realities is the human em-
bryo,a fundamental reality that is in conflict
with the evolution of technology.
Since the birth of the first test tube baby in
1978, the situation of the embryo in medi-
cal fertilization and research has changed
progressively, increasing the vulnerability of
the embryo because further applications of
the technique have developed.
This article briefly reviews the historical
outcomes of using embryos in medicine
and research to show that a slippery slope
is forming for the permissible uses of hu-
man embryos. The recent publication of
the guidelines for Stem Cell Research and
Regenerative Medicine of the International
Society for Stem Cell Research (ISSCR)
could be a good example of that [2].
Historical Issues
In 1978 Louise Brown was born, becoming
the first baby born by in vitro fertilization
(IVF). Since then, according to data from
the European Society of Human Reproduc-
tion and Embryology, more than 8 million
children have been born by IVF through
2018 [3]. Nevertheless, the production of
embryos is much bigger than the number of
children born through IVF.The 2020 report
of the ISSCR on the clinical use of human
germline genome editing, states that only
20% of the IVF procedures end in actual
birth [4].
Following the birth of the first test tube
baby, different countries developed legisla-
tion to determine how these embryos were
being used, indicating rules that limit and
regulate these techniques.
In 1979, the Ethics Advisory Board of the
United States Department of Health, Edu-
cation and Welfare proposed the 14-day
limit, which was endorsed in the United
Kingdom (UK) in 1984 by the Warnock
Committee. In the UK, one year later it le-
galized human embryos for research use [4].
The statements,defined in these documents,
covered various aspects such as: 1) no hu-
man embryo would be created by cloning;
2) no human embryo would be genetically
modified; 3) no part of the human embryo
could be created; 4) the use of human em-
bryos in assisted reproduction and research
would be regulated with the utmost care,
and 5) no experimentation on human em-
bryos would be permitted after 14 days [5].
In 1987, the World Medical Association
(WMA) adopted certain statements re-
garding the field of IVF and embryo trans-
plantation, mentioning that IVF was to be
utilized for alleviation of infertility and to
avoid genetic disorders [6]. In 1990, the UK
Human Fertilisation and Embryology Au-
thority (HFEA) established regulations for
the creation and use of embryos in research
and treatment [7].
We can observe that within the first de-
cades, there were restrictive regulations for
the use of the human embryo. But, since
1998, extensions of the limits were pro-
duced, as embryonic stem cells were used in
research, resulting in the Donaldson Report
in 2000.
The British Donaldson Report was drafted
to assess the new area of research using hu-
Paula Díaz-Herráez Pablo Requena
Embryo: Are Researchers Working to
Protect It?
BACK TO CONTENTS
53
Medical Ethics
man embryos. The report maintained the
14-day rule and indicated the “restricted”
conditions for using human embryos in
research. Nevertheless, 48,000 embryos
no longer needed for IVF treatment were
used in research between August 1991 and
March 1998 and, in the same period, 118
embryos were created for direct research
use [7], a number that is hardly limited.
Moreover, the report indicates that the re-
strictions formulated were due to respect
for the human embryo, stating that respect
increases as it develops as a “potential” hu-
man being and not because of having “full”
human status from the time of its fertiliza-
tion. Another aspect reflected in the docu-
ment was that the only ethical concern in
embryo research was to create them by cell
nuclear replacement.
One year later, in 2001, the US government
placed a ban on the production of any hu-
man embryonic stem cell (hESC) line that
requires the destruction of an embryo, lim-
iting the research using hESCs lines that
were already available at this time [8].
A further step was taken in 2008, as the
WMA reviewed the statements of IVF and
embryo transplantation. The Association
became more permissive, as they considered
the following: 1) the possible selective ter-
mination of multiple pregnancies to increase
the chances of the pregnancy proceeding to
term; 2) preimplantation genetic diagnosis
(PGD) may be performed on early embry-
os to search for the presence of genetic or
chromosomal abnormalities, discarding the
embryos carrying the abnormalities and im-
planting those which appear normal; 3) not
allowing PGD use for trivial reasons, since
sex selection is only allowed where it is used
to avoid a serious sex chromosome related
condition or to select embryos to treat a se-
riously ill sibling; 4) the research using hu-
man embryos should be carefully controlled
and should be limited to areas in which the
use of alternative materials will not provide
an adequate alternative, but never creating
the embryos for research; 5) opposition to
the use of cell nuclear replacement with the
aim of cloning human beings [9].
In 2009, the WMA adopted a statement
for stem cell research. Its revision in 2020
indicates that the fields of stem cell research
and therapy are among the fastest growing
areas of biotechnology, allowing the use for
the aim of “spare” or “excess” embryos from
IVF but not producing them directly for re-
search purposes [10].
In 2015, the US National Institute of
Health (NIH) announced the suspension of
further research funding for studies involv-
ing human pluripotent cells introduced into
vertebrate embryos [11]. That same year,
the use of mitochondrial replacement ther-
apy (MRT) was approved in the UK [12].
Nevertheless, in 2016, a further step was
taken when the UK Home Office issued a
new guideline for scientific research involv-
ing using human material in animals. The
guideline divided human-animal chimera
and hybrid research into three categories
and specified how to regulate each of them
accordingly [11].
A crucial moment in the use of embryos for
reproduction and research arose with pro-
fessor He Jiankui’s experiment, which led to
the first gene-edited babies in 2018.He used
the CRISPR-Cas9 technique to modify the
baby’s germline, arguing that it is faster, less
expensive, and more precise than zinc-fin-
ger nucleases (ZFNs) or transcription ac-
tivator-like effectors nucleases (TALENs).
But this does not keep in mind that the
targeting efficiency of CRISPR-Cas9 is
still inadequate [13]. This experiment went
against many well-established Chinese and
international ethical norms relating to hu-
man germline editing and clinical research
[13].The international response was directly
against conducting experiments in this field,
arguing that this technology is still under
development. The experiment highlighted
the robust oversight in the developing glob-
al standards for governance and oversight
of human genome editing by the World
Health Organization (WHO), who started
working on it in March 2019 [14].
After years of work and debates, the 71st
WMA General Assembly, held in 2020, ap-
proved a statement on human genome edit-
ing.The document reflects on the ethical is-
sues regarding genome editing, identifying
various concerns, such as: 1) using editing
not for therapeutics but for enhancement
purposes; 2) creating classes of individuals
defined by the quality of their engineered
genome; 3) eugenics; 4) leading to unpre-
dictable epigenomic changes that may affect
future generations, since once introduced
into the human population, genetic altera-
tions would be difficult to remove [15].
The same year, the ISSCR published the
guidelines of the International Commission
on the clinical use of human germline ge-
nome editing. The guidelines indicate that
genomically edited human embryos should
not be used to produce a pregnancy until
genomic changes can be precisely made
and without introducing undesired changes.
It also emphasized the prohibition, for the
time being, of modifying the nuclear ge-
nome of human embryos for human repro-
duction purposes [4].
Finally, in May of 2021, the ISSCR pub-
lished its updated guidelines for stem cell
research. The guidelines increased the per-
missible clinical use of embryos, arguing for
“promoting an ethical, practical, appropri-
ate, and sustainable enterprise for stem cell
research and the development of cell thera-
pies that will improve human health and
should be available for patients in need”[2].
They include a division into three catego-
ries of different experiments that use hu-
man embryos, indicating what can be done
in each situation and the reasons for this
classification. The document also mentions
that the research should use the minimum
number of embryos necessary to achieve
the scientific objective. But the 14-day rule
has been expanded when research objectives
make it necessary due to the development
BACK TO CONTENTS
54
of culture systems and based on the argu-
ment that it allows a better understanding
of infertility, pregnancy loss, developmental
disorders that occur after implantation, and
for the sake of improving IVF pregnancies
[2]. It also increases the possibilities in re-
search of chimeric embryos, even reaching
full gestation if it is among the well-justified
goals of the research, and facilitates further
research of MRT.
Additionally, these guidelines note that cer-
tain research activities are currently not per-
mitted, adducing that these approaches are
“currently unsafe”or raise unresolved ethical
issues, but that “may be valid in the future”.
Under future perspectives, they include the
genome-modified human embryos and em-
bryos generated from human gametes that
have had their nuclear DNA modified.
Reflections
Bearing in mind all the documents devel-
oped since the use of human embryos start-
ed more than 40 years ago, we can observe
that the advance of technology is opening
new possibilities. The “restrictions” on us-
ing human embryos have diminished, with
allowance for aspects that initially were
completely banned but now seem reason-
able because of the possible benefit of un-
derstanding the causes of infertility, why
many pregnancies do not reach their end,
improving IVF or contraceptive therapies,
and more.
If we consider closely the evolution of the
aforementioned documents, we see that
technological possibilities seem to be con-
sidered more of value than the relevant ethi-
cal issues. Guidelines for reproduction and
research using human embryos were de-
veloped because human embryos were not
seen as “a simple group of cells”, even if they
were not considered the first stages of a new
human being. Consequently, all these docu-
ments mention some “kind of respect” the
human embryos deserve. But this respect is
not the respect a human life deserves. Over
time, we have seen that the myth of Pan-
dora’s box has played out. Once the box is
opened it is very difficult to choose a stop-
ping point, as the research discovers new
and further possibilities.
We live in a utilitarian society, seeing util-
ity as the unique reasonable aspect to have
in mind. But often utility is not a good pa-
rameter to think of what is really important.
Making decisions within a utilitarian ethic
could be useful in some contexts in which
the value of the human being is not at stake.
But utilitarianism is not able to reach an-
swers that show the deep dignity of each
human being.It is clear here how the choice
of an ethical theory to decide what is ap-
propriate or inappropriate is decisive for the
practical ethical answers,and not all theories
are able to avoid unjust discrimination. In
this case, utilitarianism is not able to over-
come age or developmental discrimination.
It does so by hiding behind the concept of
“potential human.” But it is enough to look
at a current book on embryology to realize
that what is in potential is not the human
being but his or her anatomical structures
and functions.
Technological possibilities cannot be the
parameter to indicate what should or
should not be done, because it gives techni-
cal and evasive answers to ethical questions.
These two fields, technical and ethical, are
at two different levels of reflection, even if
they are connected. The ocean tides change
depending on the phase of the moon, but
the dignity of human embryos should not
be mutable depending on the results of an
experiment.
One of the limits in human embryo re-
search that have remained most constant is
the 14-day rule. But in the last few years,
it has been questioned in various articles
[16] and the ISSCR guidelines of 2021
have made it flexible [2]. The 14th
day was
selected because it is the moment when the
embryo finishes implantation and begins
gastrulation, meaning that the embryo is
individuated, making twinning impossible.
Most importantly, it is prior to the forma-
tion of the primitive streak at which time
the embryo can experience pain and suffer-
ing [16].
The argument to extend the limit up to
28 days indicates to the fact that up to that
point no functional neural connections or
sensory systems exist in the embryo [16].
Consider this extension as useful for learn-
ing more about the developing nervous
system without any risk, for gaining a bet-
ter understanding of the early development
of cells into organs during early embryonic
development, and for improving the safety
and success rate of current IVF procedures
[17; 18]. After the 2021 ISSCR guidelines
were published, some articles commented
on the rule flexibilization, like the one of
Robin Lovell-Badge, who was the chair
of the task force to elaborate the guide-
lines. In his article, Lovell-Badge says that
“fourteen days is shortly before the stage at
which the first signs of the central nervous
system (CNS) appear, as the first neurons
appear at day 42” [19]. Nevertheless, no
limit date is indicated in the ISSCR guide-
lines, as they only mention that “currently
it is not technically feasible to culture hu-
man embryos beyond the formation of a
primitive streak or 14 days post-fertiliza-
tion, but as culture systems are evolving it
could be possible in the near future” [2].
This raises the question: what would be the
limiting day of human embryo develop-
ment for employing it in research? Say, 14,
28, or 42 days? Can we move on without
any limit until the requirements of the ex-
periment are met, or will the socio-cultural
context not allow it?
The remarkable question is not which day
could be the limit, nor to think that the 14
days was an arbitrary date selected.We think
that the questions have to be focused on a
different aspect such as what value we grant
the human embryo. How can we define the
human embryo? Are we relaxing not only
Medical Ethics
BACK TO CONTENTS
55
the limits but also failing to ­
recognize the
dignity of the human embryo? These are all
aspects that some researchers have reflected
on [5].
When the limits of ethics are not given
more value than considerations of tech-
nological possibilities, we face a very weak
ethic that can be changed at every moment.
Everything would be open to discussion,
and truth would be constructed by what
technical knowledge shows to be the ulti-
mate demand in that particular moment.
Curiously, the 2021 ISSCR guidelines are
proposed as an international standard for
scientific and ethical rigor as well as trans-
parency in stem cell research.They establish
the basis for the implementation of new
regulatory frameworks in nation states and
assure that research is conducted with in-
tegrity [20]. But what all these years have
demonstrated is that the research limit is
constantly reached.
It is frequently questioned if it is ethically
allowed what seems to be the most perti-
nent aspect of doing research, making it
necessary to elaborate new guidelines that
will allow the previous limit to be crossed.
If we had solid ethical principles, supported
by an adequate anthropology, we would not
need to ask ourselves so often about the
limits, because they would be obvious.
Although it has been more than two de-
cades since the first hESCs were derived,
the controversy over their use in research
and translational medicine has not dimin-
ished over time [21]. If for so long the
ethical dilemma has come out in each small
change that has been produced, maybe it is
because we are not answering properly, or
simply trying to justify ourselves for what
we see as more beneficial to us, rather than
thinking where we are going.
For some researchers, the ethical dilem-
ma involving the destruction of a human
embryo was and remains a major factor
that has slowed down the development of
hESC-based clinical therapies [8].The cen-
tral moral question is whether the destruc-
tion of many early human lives is justified
by the development of a therapy that may
save many others. In other areas of moral
reflection, it is clear that the answer would
be negative. There is no justification for
sacrificing one human life to save another,
even to save many. The difference here
is that the life sacrificed is a life that is in
the early stages of its development, that we
do not even know if it would be able to be
born or not. But despite these differences, it
seems to us that a society such as ours, with
its particular sensitivity to the rights of the
most fragile and vulnerable, should be more
attentive when it comes to assessing how
prenatal life is protected.
Since fertilization has taken place, there is
a new biological entity with a unique ge-
nome and with the biological information
and autonomous mechanism for the devel-
opment into an adult human being. Each
embryo is a unique individual of the hu-
man species that is starting its first steps of
life; the embryo is also a he or a she, as this
new entity has a determinate sex. Given all
this, how could a human individual not be
a human person? By explaining and show-
ing how the human embryos from their
beginning have a substantive continuity in
human development, we provide a valuable
reason to say that, since fertilization, we
have a new human being [22]. “The reality
of the human being for the entire span of
life, both before and after birth, does not
allow us to posit either a change in nature
or a gradation in moral value since it pos-
sesses full anthropological and ethical sta-
tus. The human embryo has therefore from
the very beginning, the dignity proper to
a person. In this way, the embryo deserves
the protection that is due to a human per-
son” [22].
Another problematic aspect is considering
many embryos created through in vitro fer-
tilization techniques to be “spare embryos.”
No one would use such nomenclature to
speak about human beings, as there is no
human being that can be considered as a
“spare.” Basically, these techniques of ma-
nipulation and of the destruction of human
embryos are based on a theoretical con-
ception in which the embryo has no value
whatsoever, even if one does not want to
recognize it. Perhaps it is claimed that the
value is greater than animal embryos value,
but the actions show that this is not the case.
Sometimes, there is mentioned a gradual
value and dignity for the human embryo.
But as soon as an embryo is allowed to be
destroyed, it means it does not possess value
and dignity at all.
Conclusion
Without having a robust and consolidated
ethic, it is impossible to establish guidelines
that can truly protect the human embryo.
The ongoing research that uses human em-
bryos constantly shows that we face a vul-
nerable reality that demands protection and
recognition of its true nature. To perform
research employing utilitarian ethics does
not reach the proper question, let alone its
answer. Instead, this ethic moves us much
further from reaching them, opening new
and more complex questions.
That is why it is important to define solid
ethical criteria that do not always change
with technological development. These are
criteria to guarantee the protection and
dignity of all human beings – including the
most vulnerable – both at the initial phases
of life and as its end approaches.
Although the documents that have been
written since human embryos started to
be used either for reproduction or research
were seeking to answer how and in which
way these embryos can or cannot be “used,”
none of them have arrived at an answer that
concerns the fundamental aspect which is
the great value and dignity each human
embryo possesses. Instead they have only
Medical Ethics
BACK TO CONTENTS
56
Environment and Healthcare
Do the environmental improvements we
make in our clinics and offices really im-
pact the big picture? This month, the World
Medical Association’s My Green Doctor
answers this question and shares ideas for
your practice (Reading time: 5 minutes):
https://mygreendoctor.org/the-environment-
healthcare-do-our-choices-matter-2/
Register at My Green Doctor and save $60
(U.S.) by using discount code,MGDWMA,
making My Green Doctor a free member-
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meeting. Everything you need is in the
“Meeting-by-Meeting Guide” so there’s
nothing for the
clinic manager or
you to study. You
will also be helping
to prepare your pa-
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threats of climate change.Please register to-
day and ask your manager to register as well:
https://www.MyGreenDoctor.org/ or https://
www.MyGreenDoctor.es (en espanol). That
discount code is MGDWMA; please share
this with members of your nation’s medical
organizations.
contributed to increasing the vulnerability
of these embryos. That is why we appeal
to researchers for a deeper understanding
of the ethical aspects of their work so that
they can do research that respects each hu-
man being.
References
1. D’Avenia A.The Art of Being Fragile. 2019
2. Guidelines for Stem Cell Research and Clini-
cal Translation of the International Society for
Stem Cell Research (ISSCR). 2021
3. https://www.sciencedaily.com/releases/2018/
07/180703084127.htm
4. International Commission on Clinical Use of
Human Germline Genome Editing. ISSCR.
2020
5. Jones D.A and Wee M.Tinkering with embryos
up to a limit of 14 days is wrong: What happens
when the limit vanishes. 2021. Available from:
https://mercatornet.com/tinkering-with-
embryos-up-to-a-limit-of-14-days-is-wrong-
what-happens-when-the-limit-vanish-
es/72532/
6. WMA Statement in Vitro Fertilization and
Embryo Transplantation, adopted in 1987 and
rescinded in 2006. Available from: https://
www.wma.net/policies-post/wma-statement-
on-in-vitro-fertilization-and-embryo-trans-
plantation/
7. Donaldson L. Stem cell research: progress with
responsibility. Report at the UK parliament.
2000
8. Volarevic V. et al. Ethical and Safety Issues of
Stem Cell-based Therapy. 2018. In: J Med Sci,
15(1):36-45
9. WMA Statement on Assisted Reproductive
Technology, adopted in 2006. Available from:
https://www.wma.net/policies-post/wma-state-
ment-on-assisted-reproductive-technologies/
10. WMA Statement on Stem Cell Research,
adopted in 2009, revised in 2020. Available
from:https://www.wma.net/policies-post/wma-
statement-on-embryonic-stem-cell-research/
11. Sawai T. et al. Japan significantly relaxes its hu-
man-animal embryo research regulations. 2019.
In: Cell Stem Cell, 24(4):513-514
12. Sharma H. et al. Development of mitochondrial
replacement therapy: A review. 2020. In: Heli-
yon, 6(9):e04643
13. Jing-ru L. et al. Experiments that led to the first
gene-edited babies: the ethical failings and the
urgent need for better governance. 2019. J Zhe-
jiang Univ Sci B, 20(1):32-38
14. Expert Advisory Committee on Developing
Global Standards for Governance and Over-
sight of Human Genome Editing. Report of
the third meeting of the WHO. 2019. Available
from: https://www.who.int/docs/default-source/
ethics/genomeediting3rdreport-forrelease-con-
verti.pdf?sfvrsn=e084c909_8
15. WMA Statement on Human Genome Editing.
Adopted by the 71st
WMA General Assembly.
2020. Available from: https://www.wma.net/
policies-post/wma-statement-on-human-ge-
nome-editing/
16. Appleby J.B. and Bredenoord A.L. Should
the 14-day rule for embryo research become
the 28-day rule? 2018. In: EMBO Mol Med,
10(9):e9437
17. Shahbazi M.N. et al. Self-organisation of the
human embryo in the absence of maternal tis-
sues. 2016. In: Nat Cell Biol, 18:700-708
18. Bredenoord A.L. et al. Human tissues in a dish:
the research and ethical implications of organoid
technology. 2017. Science, 355:eaaf94142017
19. Lovell-Badge R. Stem-cell guidelines: why it
was time for an update. 2021. In: Nature. Avail-
able from: https://www.nature.com/articles/
d41586-021-01387-z
20. https://www.isscr.org/news-publicationsss/
isscr-news-articles/article-listing/2021/05/26/
the-isscr-releases-updated-guidelines-for-stem-
cell-research-and-clinical-translation
21. Ilic D. and Ogilvie C. Concise Review: Hu-
man embryonic stem cells – what have we done?
What are we doing? Where are we going? 2017.
In: Stem Cells, 35(1):17-25
22. Requena P. On the Status of Human Embryos
and Cellular Entities Produced Through ANT:
Are They Persons? 2011. In: Suarez A., Huarte
J. (eds.) Is this Cell a Human Being? (pp.97-
115) Springer, Berlin, Heidelberg. https://doi.
org/10.1007/978-3-642-20772-3_7
23. Pennings G. et al. Human embryo research in
Belgium: an overview. 2017. In: Fertil Steril,
108(1):96-107
Paula Díaz-Herráez, PhD (1)
Humanities and Medical Ethics Unit,
School of Medicine, University of Navarra
E-mail: pdherraez@gmail.com
Pablo Requena Meana, MD STD (2)
Professor of Moral Theology and Bioethics
Pontifical University of the Holy Cross
Vatican Medical Association
Delegate to the WMA
Pontifical Academy for Life, Rome (Italy)
Clinical Ethics Commission, Bambin
Gesù Pediatric Hospital, Rome (Italy)
E-mail: requena@pusc.it
The Environment & Healthcare:
Do Our Choices Matter?
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57
Environment and Healthcare
The perspective on health as a creative adap-
tive process proposed in this paper [1] is
largely psycho anthropological overarching
the discussion of etiological influences be-
hind various diseases, with inhomogeneous
boundaries and insufficiently explained by
ostensible clinical differences between them.
The psycho anthropological background al-
lows summarizing the complex influences
of the demographic characteristics of peo-
ple, their behavioural lifestyles and socio-
cultural living conditions on health, in gen-
eral,of evolutionary interaction between the
person and its environment. In this sense,
modern evidence-based medical models of
categorical disease entities are rather nomo-
thetic, when person-centred medicine is the
predominantly idiographic paradigm.
We would like to compliment the ingenious
approach of Cloninger and co-authors [1]
with another, analytic perspective. New sci-
entific discoveries eliminate the dichotomy
between nature and society, health and dis-
ease (situated in diagnosis, or not). For ex-
ample, there is clear evidence that bacteria,
viruses and fungi in the human body “turn
into, or transform into the human body” –
43% of the body consists of human cells,
the other 57% are bacteria, fungi, viruses or
non-human organisms, and they are pres-
ent in human corporeality and subjectivity.
Recent research provides insights that cer-
tain dysfunctions of microorganisms in the
human body are related to gastrointestinal
disorders, allergies, autoimmune diseases,
obesity. Furthermore, there is data on the
relationship between various microorgan-
isms and mental health in terms of anxiety,
depression, obsessive-compulsive disorder,
autism. Processes of transformation and
adaptation are especially significant in the
plan of evolution. The innate resilience of
human beings is the focus of Cloninger’s
main claim ( leading to and strongly asso-
ciated with, health, longevity, well-being,
good life, and happiness) is interpreted as
a form of creative solidarity – again through
the example of coexistence and symbiosis
between the microbiome and human body,
lasting thousands of years. Why creative
solidarity? Because solidarity (unanimity) is
expressed in the ability of human beings to
create supportive living conditions, to share
work, food, space, home, emotional and ra-
tional support [2]. Health and well-being
are embodied in biopsychosocial learning
abilities that allow the individual to share
and adapt to ever-changing internal and ex-
ternal conditions [3].
Our research in the field of psychology dur-
ing and before the pandemic,reports a trend
of inter-correlative links between constructs
such as emotional intelligence, sense of co-
herence and burnout among health profes-
sionals, physicians and teachers in Bulgaria.
Emotional intelligence and a sense of coher-
ence are defined as constructs of salutogenic
functioning. This means that they constitute
mental health independently from disease and
its pathogenic focus (diagnosis, symptoms).
They are negative predictors of proneness
to burnout [4, 5, 6, 7]. Burnout is predicted
by personality structure and influences of a
specific professional context. For instance,
the harm-avoidant person in conditions
of pressure is more vulnerable to burnout,
while the more persistent person is likely to
be prone to burnout measured in terms of
decreased personal accomplishment when
exposed to an environment characterized by
low levels of autonomy and innovation [4].
In other words, cognitive, instrumental and
motivational components of the psyche
moderate resilience and vulnerability – per-
sonality traits or abilities.This again returns
us to the idea of innate resilience.
Emotional intelligence, for example, is an-
other facet of human intelligence. Epige-
netically, it is considered as a common vari-
able – a mechanism of emotional regulation.
Only 10% of a person’s ability to show em-
pathy is due to genetic characteristics. The
remaining 90% are not encoded by genes
but depend on early developmental factors,
the environment and lifestyle [8].Therefore,
in the empirical field of evidence-based sci-
ence, we can examine dependent variables,
but it is difficult to measure specific causal
factors. In our research, there have not been
identified any particular factors explain-
A commentary on “Health is a Creative
Adaptive Process”, C.R. Cloninger et Al
Kristina Stoyanova Drozdstoy Stoyanov
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58
Climate Change
ing resilience/vulnerability and behaviour
of coherence, except personality traits. We
have identified attitudes and personal-
ity structures that explain trends in human
behaviour. The diversity of specific causal
factors regulated by personality traits and
intelligence resources in terms of health and
diseases may be quantified and measured.
However conventional scientific inquiry
and practice in medicine are currently in-
sensitive,or unprepared,to a philosophy and
humanities driven approach and research
outside their established instrumental and
experimental framework. They tradition-
ally belong to paradigms of treatment and
health care, focused and hence restrained
to intervention and study of pathological
symptoms as representations of discrete
disease entities.
C. Robert Cloninger notes that inclusion
and exclusion criteria in clinical trials such
as age and comorbid conditions aiming to
avoid research confound actually extrapolate
results to the general populations that they
are not genuinely supposed to represent.
Rethinking, redefining modern approaches
to treatment and health care, then integrat-
ing them into broader cultural, ideographic
background has the potential to generate
science-grounded cultural, epigenetic and
personal variables, and can deliver and cul-
tivate significantly more comprehensive sci-
entific results for a better informed medical
practice.
In conclusion,it is no exaggeration to define
human creativity as a fact and an artefact of
epigenetics. This also applies to health and
attitude towards health and illness.
References
1. Cloninger, C. R., Appleyard, J., Mezzich, J. E.,
Salloum, I., & Snaedal, J. (2021). Health is a
Creative Adaptive Process: Implications for
Improving Health Care and Reducing Burn-
out Around the World.  World Medical Jour-
nal, 2021, 67(3).
2. Kignel, R. Time for Transformation and Crea-
tivity.International Body Psychotherapy Journal,
2021, 20 (1): 119-123
3. Cloninger, C.R., Svrakic, D.M., Przybeck, T.R.
A psychobiological model of temperament and
character. Archives of General Psychiatry, 1993,
50 (12): 975-990
4. Stoyanov, D. S. Ed. New Model of Burn Out
Syndrome: Towards Early Diagnosis and Pre-
vention, Aalborg, Denmark, River Publishers,
2014
5. Stoyanova, K. Burn Out, Emotional Intelligence
and Coping Strategies in Teachers (PhD Dis-
sertation), 2020, Blagoevgrad, Bulgaria, South
West University
6. Stoyanova, K., Stoyanov, D. Burn out across
persons and systems: comparative studies on
vulnerability and resilience. European Journal
for Person Centered Healthcare, 2019, 7(2):
410-411
7. Stoyanova, K., Stoyanov, D. S. Sense of Coher-
ence and Burnout in Healthcare Professionals
in the COVID-19 Era.  Frontiers in psychia-
try, 2021, 12, 709587. https://doi.org/10.3389/
fpsyt.2021.709587
8. Georgieva, M., Miloshev, G. The Epigenetic
Roots of Emotional Intelligence. International
Body Psychotherapy Journal, 2021, 19 (2): 123-
129
Kristina Stoyanova,
Drozdstoy Stoyanov
Medical University-Plovdiv,
Research Institute, Bulgaria
E-mail: stojanovpisevski@gmail.com
The climate crisis is a health crisis. For the
first time, this was one of the themes and
often-repeated points made by participants
in the health sector as well as some gov-
ernment officials at the Conference of the
Parties (COP 26) in Glasgow, Scotland
on 01-13 November 2021. Five members
of the World Medical Association joined
other health-related delegations to promul-
gate this message to participants and insert
language in discussions/negotiations. There
were numerous educational sessions and
panel discussions in the World Health Or-
ganization pavilion, the first time ever that
health had an ongoing voice and physical
presence at the conference. In addition, on
06 November,our partner at the conference,
the Global Climate & Health Association
(GCHA) held an off-site live in Glasgow
that was also live streamed specifically on
the science of climate and health as well as
advocacy and commitments from some na-
tions.
The week began with Michelle Glekin,
members of the International Federation
of Medical Student Associations (IFM-
SA), and I  meeting with several country
delegations to 1) discuss the relation-
ship between climate change and health,
2) why this relationship is negatively af-
fecting citizens in that nation today and
how that will likely worsen in the years to
come, 3) review of their National Deter-
mined Contribution (NDC) for mention
Report from COP 26, Glasgow, Scotland,
UK
Ankush Kumar Bansal
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59
Climate Change
of health, 4) discussion of the Healthy
Climate Prescription (see below), and 5)
including mention and/or proposed lan-
guage of health in high-level negotiations.
Most countries were highly receptive to
these points, and some offered to present
language or advocate for including such
language in the documents coming out of
negotiations. We had strong support from
countries such as Bolivia, Iraq, and Paki-
stan in the first week. Collaborators re-
ported strong interest from Côte d’Ivoire,
Rwanda, and the European Union (in-
cluding several member-states). The Unit-
ed States Government was also highly
supportive. Dr.  John Balbus, a physician
and Director of the Office of Climate
Change and Health Equity was supportive
of including health concerns and equity in
the discussions and to increase efforts to
address these concerns in the U.S. Addi-
tionally, Dr.  Rachel Levine, a physician
and the Assistant Secretary of Health &
Human Services, made a major announce-
ment at the 06 November satellite confer-
ence in which she pledged that the United
States would work to reduce carbon emis-
sions at all federal healthcare facilities in
the next 10-15 years. This is significant
because, while the federal healthcare sec-
tor is just one part of the entire healthcare
sector, the entire U.S. healthcare sector
accounts for 8.5% of all carbon emissions
from the United States. This commitment
follows the previous commitment by the
National Health Service (NHS) of the
United Kingdom. In the second week,
Dr. Haim, Dr. Ekpe Philips Uche, Dr. In-
nocent Achanya Otobo Ujah , Maira Su-
dabra, and I met with additional delega-
tions. All in all, the WMA delegation met
with around 15 nations. With our collabo-
rators, the healthcare sector met with al-
most 50 nations. Attempts were also made
to meet with Alok Sharma, the President
of COP 26 to formally include language
on health in the proceedings and commit-
ments.Though this ultimately failed, there
was strong interest from many countries
and the COP 27 organizers in Egypt.
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60
Climate Change
One of the key written messages of the
WMA delegation and the health sec-
tor representation at the Conference was
the Healthy Climate Prescription, https://
healthyclimateletter.net.This document asks
the government delegations to take action
to meet the Paris Agreement commit-
ments of stopping warming to the 1.5 C
target by further reducing greenhouse
gas emissions (GGE) particularly from
high-income countries; include health in
those plans; transition from fossil fuels to
clean energy, transfer of funds from high-
income to low-income countries towards
mitigation and adaptation;, build climate
resilient, low-carbon, sustainable health
systems; and ensure that pandemic recov-
ery investments support climate action
and reduce social and health inequities.
While many countries, particularly middle
and low-income countries supported this
and some are working towards these goals,
unfortunately there was pushback from a
few high-income countries, particularly in
North America and Europe, on the trans-
fer of funds. This was evident in the nego-
tiations in the final days of COP as well.
Regardless, by the end of COP, approxi-
mately 600 organizations representing
50  million healthcare workers signed on
to this letter. This included World Medi-
cal Association and a few national medical
associations.
Several Ministers of Environment, Climate
Change, and/or Health from around the
world are physicians. This was important
in our meetings with these government
delegations because they understood the
importance of addressing health in climate
change mitigation, adaptation, and political
negotiations. Furthermore, there was al-
most unanimous support of the efforts of
WMA and GCHA to bring health to the
main discussions at COP 26. For example,
the Deputy Minister of Environment &
Health for Iraq, the Secretary to the Min-
istry of Environment for Sri Lanka, and
the Director of National Climate Change
for Colombia, as well as Drs. Balbus and
Levine of the United States are physicians
who understood and supported our position
from clinical and public health perspectives.
This highlights the importance of physi-
cians in advocacy of our patients and public
health in government and as citizens in our
countries.
From an educational perspective,the WHO
held approximately 65 sessions for partici-
pants including panel discussions, presenta-
tions, reports, and classrooms that were all
live streamed during the two weeks. One
of the important points made during the
sessions and in the discussions with del-
egates was climate change response and
health equity. These are in line with current
WMA policies such as universal health care
access and resolutions such as Protecting
the Future Generation’s Right to Live in a
Healthy Environment, Climate Emergency,
and Divestment from Fossil Fuels. In one
of the sessions, the relationship between
five of the COP aims and health aims was
discussed; namely,adaptation and resilience,
energy transition, clean transport, nature,
and finance. This was also paraphrased in
10 recommendations to make the health
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III
Obituary
In 1976 Dr.Albert Gyang Boohene became
Chair of the World Medical Association
Council. A paediatrician from Ghana, he
was uniquely suited to lead this interna-
tional body through a professional career
that started with a medical education in
London. After working in his home coun-
try and teaching physiology at the Ghana
Medical School, he returned to London for
post graduate education.
In 1969 he returned to Ghana as a paedia-
trician and academic teacher. During his
first and second periods of work in his home
country he served in various functions in the
Ghana Medical Association – as National
Assistant Secretary from 1963 to 1966 and
as Honorary Secretary from 1970 to 1973.
This engagement led him to the WMA as a
delegate of the Ghana Medical Association.
With the exit of most African medical asso-
ciations from the WMA because of WMA’s
reluctance to join the international boycott
of South Africa in the 1970s his participa-
tion in the WMA ended as well.
Despite this exit, Dr. Boohene achieved
ground-breaking influence for sub-Saharan
Africa at the WMA. In a letter to the fam-
ily of Dr. Boohene, the WMA Secretary
General wrote: “The World Medical Asso-
ciation will keep him, his achievements and
leadership in our institutional memory. We
remain grateful for the engagement he de-
voted to the global medical family.”
Dr. Albert Gyang Boohen died on 29 No-
vember 2021 at the age of 88.
Obituary
Dr. Albert Gyang Boohene (1933–2021), Past Chair of the WMA Council
argument for climate change. There were
several scientific summary presentations on
specific harms to health by climate change
such as energy and air pollution, food sys-
tems, and mobility. The importance of di-
etary modification/change and food system
sustainability/resilience was mentioned in
several sessions which again is line with
WMA policy. Currently, health is not re-
quired in the NDC framework. However,
some countries do include health in their
NDC reports. The importance of formally
including health in the NDCs that are pub-
lished every 5 years was also presented and
was one of our points in our meetings with
delegations.
Ultimately, health was not made part of
the formal COP reports despite multiple
attempts by different sectors of the health
community, including the WMA delega-
tion. One of the biggest hurdles, primar-
ily from the Global North was transfer of
funds to lower income countries, primarily
in the Global South, for climate mitiga-
tion and adaption, including health. This
involved other areas of discussion besides
health resulting in impassioned speeches
from leaders or representatives of small,
lower-income nations. Despite this, both
higher and lower income nations showed
support for including health and address-
ing health inequity in their own countries
now with hopes of international agree-
ment at the next COP in November
2022 in Sharm el Sheikh, Egypt. Of note,
42  countries pledged during COP 26 to
lower carbon emissions from their health-
care systems with twelve pledging to go
net-zero by 2050. These nations included
high-income countries such as the United
States, United Kingdom, and Germany.
While the major part of the U.S. health-
care system is privately-owned, the pledge
by the Department of Health & Human
Services and The White House to become
net-zero in the federal system (Depart-
ments of Veterans Affairs and Defense,
Bureau of Prisons, Indian Health Service,
etc.) is significant because the entire U.S.
healthcare sector accounts for over 25% of
global healthcare carbon emissions.
The WMA delegation also made numer-
ous contacts with other non-governmental
organizations, universities, and climate
change and health educational programs/
courses for medical students, junior doc-
tors, and practicing physicians to groom the
next generation of physician researchers,
policy makers, and advocates on the climate
change and health intersection.
While all of the aims were not achieved,
there was significant progress. The health/
medical community is continuing these ef-
forts in preparation for COP 27. There is
excitement and hope for the future by many
advocating for climate action and the in-
volvement of physicians was welcomed by
many during the meeting.
Ankush Kumar Bansal,
MD, FACP, FACPM, SFHM, United
States of America, Associate Member
E-mail: dr.akb1@gmail.com
Michelle Glekin, MD
Israel Medical Association
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IV
WMA News
220th
WMA Council Session,
Paris 2022
Start Date: April 7, 2022
End Date: April 9, 2022
Location: Hôtel du Collectionneur, Paris, France
The WMA Council Session is open to all Constituent Members
of the World Medical Association, to Associate Members, to ob-
servers and to other individuals by special invitation.
Although there are continued uncertainties and restrictions in
place in response to the Covid-19 pandemic and its variants,
the Council decided to hold the meeting as scheduled from 7 to
9 April 2022 but in hybrid format.
JUST IN CASE…
The Secretariat will be closely monitoring the situation and in case
that the situation becomes impossible to hold even a hybrid in-
person meeting, the ExCo might decide to convert into virtual.
In that case, the meeting dates will be from Tuesday 5 April to
Friday 8 April and the time will be 11:00 to 14:00 UTC. Please
note this alternative schedule in your calendar!
Registration and more details are available through the members’
area.
14th
World Conference on
Bioethics, Medical Ethics and
Health Law
Dear Colleagues,
We would like to inform you of the postponement of the 14th
World Conference on Bioethics, Medical Ethics and Health Law
to a new date: 7–10 March, 2022 in Porto, Portugal.
The International Chair has decided on this postponement after
lengthy discussions.
The decision to postpone from 2021 to 2022 stems from the need
to preserve the participants’ lives and health during this difficult
period of the corona plague. We are pleased to inform you that
the conference will take place under the same conditions and at
the same venue. We are confident that you will remain loyal to the
International Chair and the World Conference.
The Conference will undertake to retain the full rights you have
acquired in the registration fee you have paid. This commitment
applies both to your participation in the conference and to your
accommodation at the hotel you booked (if at all).
Bonus for participants: The International Chair will hold a num-
ber of additional international projects virtually in 2021, which
will be offered to all participants. This coming March and No-
vember, the Chair will host a virtual international conference ded-
icated to discussing ethical dilemmas which has arisen during the
COVID-19 pandemic.
REGISTER
CALL FOR ABSTRACTS
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