WMJ 03 2009 – WMA – The World Medical Association

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No. 3, October 2009
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Editor in Chief
Dr. Pēteris Apinis
Latvian Medical Association
Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@nma.lv
editorin-chief@wma.net
Co-Editor
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suﬀolk IP143QT, UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor Velta Pozņaka
wmj-editor@wma.net
Journal design and
cover design by Jānis Pavlovskis
Layout and Artwork
The Latvian Medical Publisher
“Medicīnas apgāds”, President Dr. Maija Šetlere,
Katrīnas iela 2, Riga, Latvia
Cover painting : Academic painter Juraj
Oravec. Cosmic gravity (combined technique,
a visual metaphor for fertilization of a germ
cell of an ovulum with cosmologic dimension)
Publisher
The World Medical Association, Inc. BP 63
01212 Ferney-Voltaire Cedex, France
Publishing House
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The magazine is published quarterly.
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Subscription fee € 22,80 per annum (inkl. 7%
MwSt.). For members of the World Medical
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Medical Association website www.wma.net
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ISSN: 0049-8122
Dr. Yoram BLACHAR
WMA President
Israel Medical Assn
2 Twin Towers
35 Jabotinsky Street
P.O. Box 3566
Ramat-Gan 52136
Israel
Dr. Kazuo IWASA
WMA Vice-Chairman of Council
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Mukesh HAIKERWAL
WMA Chairperson of the Finance
and Planning Committee
58 Victoria Street
Williamstown, VIC 3016
Australia
Dr. Dana HANSON
WMA President-Elect
Fredericton Medical Clinic
1015 Regent Street Suite # 302,
Fredericton, NB, E3B 6H5
Canada
Dr. Jörg-Dietrich HOPPE
WMA Treasurer
Bundesärztekammer
Herbert-Lewin-Platz 1
10623 Berlin
Germany
Dr. Guy DUMONT
WMA Chairperson of the Associate
Members
14 rue des Tiennes
1380 Lasne
Belgium
Dr. Jón SNÆDAL
WMA Immediate Past-President
Icelandic Medicial Assn
Hlidasmari 8
200 Kopavogur
Iceland
Dr. Eva NILSSON-
BÅGENHOLM
WMA Chairperson of the Medical
Ethics Committee
Swedish Medical Assn
P.O. Box 5610
11486 Stockholm
Sweden
Dr. Karsten VILMAR
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
Germany
Dr. Edward HILL
WMA Chairperson of Council
American Medical Assn
515 North State Street
Chicago, ILL 60610
USA
Dr. José Luiz GOMES DO
AMARAL
WMA Chairperson of the Socio-
Medical-Aﬀairs Committee
Associaçao Médica Brasileira
Rua Sao Carlos do Pinhal 324
Bela Vista, CEP 01333-903
Sao Paulo, SP
Brazil
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
World Medical Association Oﬃcers, Chairpersons and Oﬃcials
Oﬃcial Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reﬂect WMA policy or positions
www.wma.net
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The Israel Medical Association was delighted to host this year’s
Council meeting at the HiltonTel Aviv.The meeting went smoothly.
The discussions were fruitful and agreement was reached on many
of the statements. The scope of topics discussed was broad, includ-
ing child health, medical neutrality, inequalities in health, stem cells
and the use of placebos. However, my greatest delight was being
able to host my long-time friends and colleagues from the WMA
in my home country.
Before beginning the actual Council session, an optional informa-
tive session was oﬀered by the Israel Medical Association. As an Is-
raeli,I am constantly bombarded with questions from my colleagues
abroad that reﬂect the complexity of the region in which I live.The
recent conﬂict in Gaza and continued worry in the Middle East
over the threat of a nuclear Iran have only increased the amount of
inquiries that I receive. This session provided essential background
information on many of the issues frequently covered by foreign
news agencies, to those WMA participants who wished to attend.
Mr.Neil Lazarus is an expert on the Middle East and speaks to over
25 000 people a year through his seminars. Having him speak with
WMA Council visitors was a great opportunity to discuss the real-
ity of the Middle East and I appreciate those who spent their free
time in order to hear him.
Participants arrived in Israel from countries near and far. For many,
this was their ﬁrst trip to the country that is holy to three major
religions. Participants experienced the meaning of that on Thursday,
14 May when we travelled to Jerusalem. In Jerusalem, we saw the
Church of the Holy Sepulchre where Jesus was cruciﬁed and buried.
We saw the Al-Aqsa Mosque which is the second oldest mosque
in Islam and the third in holiness and importance after those in
Mecca. We also had a chance to visit the Western Wall which has
remained intact since the destruction of the Second Jerusalem Tem-
ple. It was my pleasure to participate in this tour and give WMA
guests a taste of Israel. We were led through the Jewish quarter of
the Old City of Jerusalem, the Arab market (or, as we call it, shuk)
and we tasted traditional Middle-Eastern cookies and drank freshly
squeezed lemonade with mint leaves. In the shuk our senses were
overpowered with the strong smells of coﬀee, tobacco and spices,
the vibrant colours of the diﬀerent fabrics and intricate tapestries, as
well as the history of the place.Our tour ended at the historical City
of David where actors and musicians painted us a picture of what it
meant to live in Jerusalem at the time of the Temple.This was a truly
unique experience. We continued at the City of David with dinner
and musical entertainment in the olive garden.
Additional social events included a visit to the Eretz Israel Museum.
There we saw an ancient olive press, ﬂour mill and other working
tools traditionally used in the Middle East in ancient times. We
were lucky to have a cool breeze while we enjoyed dinner on a grassy
lawn at the museum.
Israel, as a melting pot and home to people of all nationalities and
religions was a ﬁtting place to host the WMA, which itself is an
amalgam of people from various countries, languages and cultures.
Our common language, medicine, unites us and allows us to work
together to reach common goals, making the WMA what it is – an
outstanding organization.
WMA meetings in general and this year’s Council Meeting in Tel
Aviv in particular,provided another great opportunity for physicians
from around the globe to become acquainted with one another, so-
cialize and discuss common issues and challenges in an informal
manner. It was my pleasure and my privilege to host this year’s
Council Meeting and I invite all the delegates to return to Israel in
the near future.
Editorial
The 182nd
WMA Council Meeting
Dr. Yoram Blachar, WMA President
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Council was opened by the Secretary Gen-
eral who welcomed the following new mem-
bers, Dr. Ruth Collins Nakai, Dr. Toram
Janbu. Dr. Gebrehiwot, Prof Niewenhui-
jzen Kruseman, Dr. Leonid Mikhaylov,and
Dr. Antonio Tunes.
Following the announcement by the Secre-
tary General of the death of Angel Orozeo,
long-time Executive Director and friend of
the WMA, the Council observed a period
of silent tribute. (a memorial tribute will ap-
pear in the next issue of WMJ )
Dr.Edward Hill was re-elected Chair of
Council,the following oﬃcers were elected,
Vice- chair of Council Dr. Ishii , Treas-
urer Professor Hoppe and members of
Standing Committees and Advisers were
then elected.
Council then received the reports of the
President and Secretary General
Interim Report of the President
“It is my pleasure to host you in Tel Aviv for
this year’s Council. It is an honour to serve
as President of this auspicious organization
that impacts physicians in practically every
country in the world.This organization dic-
tates the standards of ethics and care and
excels in progressing our profession for-
ward. This has been a very busy year for me
as President of the WMA and I am excited
to share with you some of my experiences. I
am pushing many issues and I would like to
now highlight some of them.
Throughout the year I have pushed, and I
continue to push now, the agenda of ﬁght-
ing inequalities in health. On this note I am
happy to report that at this Council session
a draft resolution on Inequalities in Health
will be discussed. I expect this discussion to
lead to the creation of a Work Group on the
topic and I am sure the WMA will reap the
beneﬁts of their work and eﬀorts for many
years to come. The Israel Medical Associa-
tion has also prepared a summary on a sur-
vey regarding inequalities in health that was
distributed to national medical associations
through the WMA. We received responses
from 17 associations and plan to use the re-
sults as a springboard for the work group.
In parallel, I have been working with some
of my contacts around the world to create a
project on inequalities in health.This project
includes a few diﬀerent aspects but revolves
around obesity and diabetes in children. As
a pediatrician I chose to focus on youth and
since low socio-economic status contributes
to obesity and other health complications
such as diabetes, I focused on this as part
of the inequalities in health platform. The
ﬁrst dimension of this project is being de-
veloped with the help of Professor Itamar
Raz. Together we are developing a special
internet course for physicians on the subject
of diabetes.This course will include lectures
by internationally renowned diabetes ex-
perts and allow online participation from
physicians. This course will provide a global
perspective on the issue and will provide
tips for physicians in treating diabetes, es-
pecially to those from low socio-economic
backgrounds. Prof. Raz has been enlisting
his peers in the global medical community
to be involved in building the course and
giving lectures. Prof. Raz has also contacted
Novo about funding and a decision is pend-
ing. I hope that I will be able to be able to
update you on Novo’s positive answer in the
near future.
The second dimension of this project is being
developed in conjunction with the American
Items from the 182nd
WMA Council meeting
in Tel Aviv, May 2009
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College of Endocrinology and American As-
sociation of Clinical Endocrinologists. The
ACE/AACE Power of Prevention program
was initiated by Dr. Don Bergman. Through
introductions provided by Dr. Yank Coble, I
have discussed with members of the AACE
the possibility of expanding Power of Preven-
tion to a global level.With the WMA behind
this initiative, healthy lifestyle habits will be
taught to people all over the world. The ﬁrst
step in this project is translating material that
is already available on the Power of Preven-
tion website and in their magazines. Interna-
tional content will then be added to the web-
site, with some of this content being geared
towards speciﬁc countries and some content
applicable to all countries. The AACE and I
are also discussing the possibility of creating
a partnership through an entirely new project
that will focus solely on obesity and diabetes.
Dr. Yank Coble has been an active player in
this collaboration and is currently investigat-
ing avenues for funding of this project as well.
My agenda as president of the WMA also
includes the encouragement of Arab coun-
tries who are not yet involved, or members,
of the WMA to become involved.In this ca-
pacity, I was privileged to attend the March
Meeting of the International Federation of
Medical Student’s Associations in Tunisia
this year. I was thoroughly impressed by the
young doctors who organized and attended
the conference. At the conference, I had
the honor of presenting the WMA Medi-
cal Ethics Manual to a young and eager
audience. Unfortunately, while I was there
members of the Tunisian Medical Asso-
ciation were unable to meet with me, but I
believe the young generation of leaders that
I met will eventually propel their national
medical associations to greater collabora-
tion. The young generation is interested in
pursuing more global medical collaboration
through organizations such as the WMA.
I look forward to greater cooperation from
these countries in the near future.
More speciﬁcally, through some of my con-
tacts in Israel I have made overtures to con-
tacts in Tunisia and Morocco in attempt to
greater integrate their medical associations
in the WMA. There are many WMA proj-
ects that they could beneﬁt from partici-
pation in and many other WMA projects
that could beneﬁt from their participation.I
hope that in the near future I will receive re-
sponses and meet with representatives from
the medical associations in Tunisia and Mo-
rocco and be able to report positively back
to the Council.
My presidency has also faced many unique
challenges, primarily because of my Israeli
citizenship. Eﬀorts against me have intensi-
ﬁed in light of the conﬂict in Gaza this year.
I must assure you all, as President of the
WMA and as President of the Israel Medical
Association since 1995; I have continuously
worked towards bettering the health of Pal-
estinians with this last conﬂict in Gaza being
no exception. I have continuously and tire-
lessly intervened in cases where a Palestinian
patient was to be evicted from an Israeli hos-
pital due to lack of funds; intervened,includ-
ing by way of petitions to the High Court
of Justice, in situations where Palestinian
patients, physicians or medical students en-
countered diﬃculties at Israeli checkpoints;
and called for funds to be transferred to the
PA in the form of food and medicineso that
help could be given where it is truly needed.
During the recent conﬂict in Gaza I was in
constant contact with various government
oﬃcials in positions to help the Palestinians.
I wrote regarding the restriction of medical
personnel in passing from the West Bank
to their place of work, regarding the hu-
manitarian situation in the Gaza strip and
regarding the safety of medical personnel in
the Gaza strip. I have done my utmost and
I continue to work for the health of the Pal-
estinians. That being said, there is nothing
I can do for combatants who target inno-
cents and use innocents as human shields.
Hamas, a terrorist organization, abhorrently
uses hospitals and schools and even a zoo as
shields. I sincerely hope that all conﬂicts in
this region and around the world will not
turn to violence. When this happens, we
physicians will be allowed to focus on pro-
viding the highest level of care and not have
to spend so much of our eﬀorts on patch-
ing up wounds inﬂicted by other people. As
it says in Isaiah 2:4, “Nation shall not lift
up sword against nation, neither shall they
learn war any more.”
I look forward to a fruitful Council meet-
ing. I am proud of the work that the WMA
does and the many ways it aﬀects the medi-
cal community – both globally and the im-
pact of the WMA on individual physicians
in diﬀerent countries. Throughout my years
being active in the WMA I have been ex-
posed to the great impact the WMA makes
and I am proud to be part of it. It is an hon-
our and a privilege for me to serve as this
year’s President and I hope that my work
will contribute to the WMA”.
From the Secretary General’s Reports
1. Policy
Multi Drug ResistantTuberculosis Project
“The second phase of the Lilly MDR-TB
partnership began in May 2008. The con-
tinuation of this project includes the devel-
opment of a TB refresher course for physi-
cians, which will serve as an introductory
course for the existing MDR-TB course.
The New Jersey Medical School Global
TB Institute has ﬁnalised the draft version
of the word document of the TB refresher
course and has send it out to international
TB experts for review. After the review pro-
cess the MDR-TB and TB refresher course
will be adjusted in their design and will be
made more interactive with case studies,
videos and more.
WHO recently updated their MDR-TB
guidelines and emphasise now more on
infection control and laboratory diagno-
sis. Based on this and on the International
Standards of TB Care we updated our
MDR-TB course as well. The MDR-TB
course has been already translated into
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WMA news
Spanish, Russian, Chinese and Azeri and
French will follow soon. Within the next
few months all courses will be available on
the new server of the Norwegian Medical
Association.
A “train-the-trainer course in MDR-TB”
will create champions in the ﬁeld of TB on a
local level. Physicians who are experts in TB
receive training in adult learning and accel-
erated learning principles in order to better
teach their colleagues. The ﬁrst of a series of
workshops took place in Pretoria, South Af-
rica in November 2008 and the next one will
follow in India this year. In cooperation with
the Foundation of Professional Develop-
ment, 15 physicians from South Africa and
ﬁve WHO consultants from Namibia,Leso-
tho,South Africa and Kenya,were trained in
a three-day workshop consisting of interac-
tive facilitation skills, group assessment and
educational strategies. In case studies, role-
plays and interactive methodology they im-
mediately applied the adult learning theory
within their group and received feedback
from the facilitators and the other partici-
pants. The Indian Medical Association is
organising a similar workshop just prior to
the General Assembly. The Chinese Medi-
cal Association announced that it would like
to organise within the MDR-TB project a
train-the-trainer workshop or a GP training
in MDR-TB as well.
The WHO is in the process of developing a
„Policy on ethics in the TB setting“, with a
goal for its adoption at the World Health As-
sembly in 2010.The WMA has been invited
to address the issues related to health profes-
sionals in the policy. Dr. Jeﬀ Blackmer from
the Canadian Medical Association kindly
oﬀered to draft this part of the policy. The
ﬁrst WHO work group meeting to discuss
the policy took place in December 2008 in
Toronto.Over the next few months the draft
policy will be discussed and revised at several
international meetings on Ethics and TB.
Given the already critical shortage of health
providers and generally weak health sys-
tems in the regions most aﬀected by XDR-
TB and MDR-TB, anxiety about safety in
the health care environment runs high and
can dissuade health providers from accept-
ing assignments in these settings. A set of
“Inter-professional workshops on health
care worker safety in the context of drug
resistant TB” in low and middle-income
countries addressed TB infection protec-
tion, with the objective of identifying good
practices, implementing joint recommenda-
tions for facilities and health workers and
establishing a working group with a plan
of action to communicate the identiﬁed
practices and recommendations. WMA, to-
gether with our South African member and
the ICN, IHF and ICRC, organised the
ﬁrst workshop in Cape Town South Africa
in November 2007. a second one took place
together with the Brazilian Medical Asso-
ciation in Rio De Janeiro, Brazil in March
2009 and the next one will be in South Af-
rica again, in Durban in June 2009.
Together with the other NGO partners in-
volved in the ﬁght against MDR-TB, the
WMA participated in a Brieﬁng on the is-
sue for the diplomatic missions in Geneva on
March19th
whichwasWorldTBDay. MDR-
TB still does not receive enough attention and
global advocacy is urgently needed.
On the invitation of the German Asso-
ciation of Research-Based Pharmaceutical
Companies, the Secretary General pre-
sented the work in the ﬁeld of MDR-TB to
German Members of Parliament in Berlin
on March 19th
, 2009. The discussion served
to stimulate interest in the re-occurrence of
tuberculosis and its relevance for countries
that still have decline in TB incidence.
Tobacco project
The WMA joined the implementation pro-
cess of the WHO Framework Conven-
tion on Tobacco Control (FCTC) http://
www.who.int/tobacco/framework/en/. The
FCTC is an international treaty that con-
demns tobacco as an addictive substance, im-
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WMA news
poses bans on advertising and promotion of
tobacco and reaﬃrms the right of all people to
the highest standard of health.The ﬁrst inter-
national treaty negotiated under the auspices
of the WHO,the FCTC entered into force in
2005 and is the most widely embraced treaty
in UN history, with 168 signatories and 154
ratiﬁcations to date.
WHO FCTC held its Third Conference of
the Parties (COP3) in Durban from 17-22.
November 2008 to discuss and amend single
articles of the treaty and receive the report of
the working groups which are implemented
for some of the articles. WMA is a member
of the working groups on article 12 – edu-
cation, communication, training and public
awareness- and article 14 – measures con-
cerning tobacco dependence and cessation.
WMA was represented at the COP3 confer-
ence by Dr.Julia Seyer.WHO recognised the
engagement of WMA in this process and is
eager to increase the cooperation with physi-
cians on the international and especially on
the national level.
Health Workforce
WMA continues its close involvement in the
Positive Practice Environment Campaign
(PPE).This global 5-year campaign – spear-
headed by WHPA members together with
the World Confederation for Physical Ther-
apy and the International Hospital Federa-
tion – aims to ensure high-quality healthcare
workplaces worldwide.During this reporting
period, the PPE partners have been in dis-
cussion with the Global Health Workforce
Alliance (GHWA) about the continuation
of the project and also explored funding op-
portunities. The appointment last March of
a full-time coordinator in charge of running
the campaign on behalf of the organization
members, will allow the PPE to kick oﬀ in
three selected countries: Uganda, Morocco
and Zambia. Taiwan will also be involved in
the PPE as a self-funded country.
At the invitation of the Iceland Medical As-
sociation and WMA past president, Dr. Jon
Snaedal, the World Medical Association
convened a Seminar on Human Resources
for Health and the Future of Health Care
on 8-9 March, 2009. This seminar was an
eﬀort to bring together stakeholders from a
range of health professions to focus on these
issues and help WMA deﬁne some policy
priorities in its approach to the subject. The
ﬁnal report of the event includes ideas to
facilitate WMA policy development in this
area. WMA Advocacy Working Group will
consider these proposals and explore follow-
up opportunities.
In early March, WMA was invited to take
part in the planning process of the next
Conference on Workplace Violence in the
Health Sector, which is scheduled to take
place on 27 – 29 October 2010 in Amster-
dam. The event is supported by the Global
Health Workforce Alliance (GHWA),
WHO, International Labour Organisation
(ILO), the International Council of Nurses
(ICN), Public Services International (PSI)
and other relevant health organizations. We
are still in the very early preparation stage of
this event. The WMA Secretariat intends
to take an active role and to involve con-
stituent members as appropriate.
WHO is developing “Guidelines on reten-
tion strategies for health professionals in
rural areas”, which should be adopted at the
World Health Assembly 2010. The aim is to
ensure access to health care for people living
in rural areas and thus improve the health
outcomes, including the Millennium Devel-
opment Goals (MDGs). The guidelines will
be based on three pillars: educational and
regulatory incentives,monetary incentives and
management,environment and social support.
Decision makers on the national and local lev-
el and health facilities should receive evidence
on the impact and eﬀectiveness of various
retention strategies that have been tried and
tested. WMA, as the secretariat of the World
Health Professions Alliance,is member of the
core expert group developing the guidelines.
Two meetings in Geneva have already taken
place and the next one will be in June 2009.
WMA staﬀ member Dr. Julia Seyer, as
secretariat of the WHPA has been invited
to join an independent merit review panel
organized by the Global Health Research
Initiative. The panel will review research
proposals submitted in response to a com-
petition launch in January 2009 by the
“Africa Health Systems Initiative Sup-
port to African Research Partnerships”
programme (AHSI-RES). AHSI-RES is
a 5-year research programme (2008-2013)
that forms one component of the Africa
Health System Initiative (AHSI) supported
by the Canadian International Development
Agency (CIDA). AHSI is a 10-year initia-
tive focused on strengthening national-level
health strategies and architecture, ensuring
appropriate human resources for health,
strengthening front-line service delivery
and building stronger health information
systems, all with special attention to equity
considerations. The ﬁrst AHSI-RES round
of the review process will be in June 2009.
WMA participates as a member of the steer-
ing group in the Mobility of Health Profes-
sionalsresearchproject.Thegeneralobjective
of the research project is to assess the current
trends of mobility of health professionals to,
from and within the European Union and
their reasons for moving.Research will also be
conducted in non- European sending and re-
ceiving countries,but the focus lies on the EU.
This research project is a medium-scale col-
laborative project, with the goal of facilitating
informed policy decisions on health systems
by developing a scientiﬁc evidence base relat-
ed to the impact of mobility of health profes-
sionals. The ﬁrst meeting with all partners was
held in November 2008 in Brussels.
Counterfeit Medical Products
Counterfeit medicines are drugs manufac-
tured below established standards of safety,
quality and eﬃcacy and therefore risk caus-
ing ill health and killing thousands of people
every year. Experts estimate that 10 per cent
of medicines around the world could be
counterfeit. The phenomenon has grown in
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recent years due to increasing sophistication
of counterfeiting methods and the increasing
amount of merchandise crossing borders.
At the last Executive Board Meeting of the
WHO in January 2009,a report and draft
resolution on counterfeit medical products
were discussed and all member states stressed
the importance of protecting public health
against risks caused by counterfeit medica-
tions. However an intense debate began on
the deﬁnition of counterfeits versus sub-
standard medicines. So far WHO has fo-
cused on counterfeits while largely ignoring
the broader ( and more politically sensitive)
category of substandard drugs. WHO’s rec-
ommendations are subject to the whims of
member states. They ﬁnd it easier to tackle
counterfeits rather than substandard drugs
because the latter are often manufactured by
taxpaying ﬁrms within their borders.
WMA, together with the members of the
WHPA, organised a very well attended
Mission and NGO brieﬁng on this im-
portant topic in April 2009 just prior to the
WHA.The objective was to raise awareness
of this public health threat and communi-
cate the opinion of the health professions.
Primary health Care
The World Health Report of 2008, ‘Pri-
mary Health Care – Now More Than
Ever’, critically assesses the way that health
care is organized, ﬁnanced, and delivered in
rich and poor countries around the world.
The WHO report documents the failures
and shortcomings over the last decades that
have left the health status of diﬀerent popu-
lations, both within and amongst countries,
dangerously out of balance.The report urges
the importance of a holistic health care ap-
proach where primary health care plays an
important role as a facilitator between pre-
vention, secondary and tertiary care.The re-
port focuses health care systems on 4 pillars:
universal coverage, people-centred health
care, leadership reform to make health au-
thorities more accountable and to promote
and protect public health in general. With
the World Health Report 2008, and the
report on Social Determinants of Health,
WHO placed inequity in health care and
social disparities at their centre of activities.
The Executive Board of the WHO in Janu-
ary 2009 discussed a draft resolution on pri-
mary health care, including health care sys-
tem strengthening. On behalf of the World
Health Professions Alliance,the WMA made
a public statement during the Executive Board
session. Further debate will take place during
the World Health Assembly in May 2009.
WHO invited WMA to take part in a global
consultation on the contribution of health
professions to primary health care and the
global health agenda in June 2009.
Alcohol
In May 2008, the World Health Assembly
adopted a resolution requiring WHO to
intensify its work to curb harmful use of al-
cohol. Members States call upon WHO to
develop a global strategy for this purpose.
The resolution also requests the WHO Di-
rector- General to consult with intergovern-
mental organizations, health professionals,
nongovernmental organizations and eco-
nomic operators regarding ways in which
they can contribute to reducing the harmful
use of alcohol.In line with the WMA State-
ment on Reducing the impact of alcohol on
health and society (WMA General Assem-
bly, Santiago 2005), the WMA secretariat
monitors the drafting process of the WHO
strategy and has developed contacts with
relevant WHO oﬃcials and civil society or-
ganisations to collaborate in the process.
On the 23 October 2008, the WMA Advo-
cacy Advisor, Ms. Clarisse Delorme, mod-
erated an NGO brieﬁng on reducing the
global alcohol harm, organised by GAPA
(Global Alcohol Policy Alliance). The ob-
jectives of the brieﬁng were to understand
the WHO process related to the strategy,
to begin discussions on substantive and po-
litical proposals to promote an eﬀective, ev-
idence-based global strategy, and, ﬁnally, to
develop further working relations between
civil society actors involved in this area.
On the 24 November 2008, Dr. Otmar
Kloiber, and Ms. Clarisse Delorme, par-
ticipated in the WHO roundtable meeting
with representatives of NGOs and health
professionals on ways they could contrib-
ute to reducing harmful use of alcohol.
This was an opportunity to raise, amongst
others issues, WMA’s concerns that medi-
cal associations and individual physicians be
fully involved in WHO strategy on alcohol.
As a follow-up to this, Ms. Clarisse De-
lorme, together with George Hacker from
GAPA, met with several Permanent Rep-
resentatives (Denmark, Sweden, Norway,
Chile, South Africa, US, New Zealand) in
Geneva to discuss countries’ positions and
involvement within the WHO regional
consultative process on the draft strategy.
Obesity and Diabetes
The World Medical Association has devel-
oped, together with the Geneva Social Ob-
servatory, a Workplace Strategy on Diabe-
tes and Wellness. The Workplace Strategy
on Diabetes and Wellbeing is a guideline
for employers and employees to educate and
raise awareness about diabetes, and provide
examples of healthier lifestyles during work.
The aim is to mitigate the ill eﬀects of diabe-
tes on personal health, workplace productive
and health care costs. In a research study,ex-
amples of activities to improve the well-be-
ing of employees are collected and oﬀered as
a menu of choices for companies.Depending
on their capacity and needs, companies can
implement all or only individual parts of the
menu. The guideline are now ﬁnalised and
the implementation phase will begin soon.
Health and the environment
WMA Workgroup on Health and the
Environment, chaired by the Canadian
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Medical Association, was established in the
summer of 2008. For 2009, the workgroup
agreed to focus its attention on health and
climate change,in view of the global United
Nations conference on this topic in Co-
penhagen in December 2009. In 2010, the
workgroup will focus on environmental
degradation and the built environment.
In January 2009, the workgroup produced
a set of recommendations, which it circu-
lated to WMA constituent members for
input prior to presentation of a resolution at
the 182nd
Council Session in May 2009. A
WMA conference on health and climate
change will take place on 1 September,
2009 in Copenhagen, with a view to “test-
ing” and developing further WMA recom-
mendations. Following further revision
after this conference, the WMA resolution
will be considered again by the Council at
its pre-Assembly meeting. If approved, it
will be submitted to the 2009 General As-
sembly for adoption. If adopted, the WMA
will be in a position to advocate strongly for
input and changes at the UN Conference in
Copenhagen in December 2009.
Following the adoption by the 2008 Gen-
eral Assembly of the WMA Statement on
Reducing the Global Burden of Mercury,
WMA joined the UNEP Global Mercury
Partnership in December 2008 in order to
contribute to the partnership goal to pro-
tect human health and the global environ-
ment from the release of mercury and its
compounds (http://www.chem.unep.ch/
MERCURY/Sector-Speciﬁc-Information/
Mercury-in-products.htm)
Human Rights
During the reporting period, the WMA
secretariat launched several lobbying ac-
tions, based on information from Amnesty
international, to support physicians in dis-
tress worldwide:
2 Egyptian doctors Raouf Amin al-Arabi
and Shawqi Abd Rabbuh sentenced to 15
and 20 years of prison and 1500 and 1700
lashes respectively in Saudi Arabia for hav-
ing facilitated the addiction of a patient to
morphine after prescribing the medicine for
her pain relief following an accident – De-
cember 2008
Dr. Arash Alaei and Kamiar Alaei (Republic
of Iran) sentenced to 6 and 3 years of impris-
onment respectively for ‘cooperating with
an enemy government’, speciﬁcally with US
institutions in the ﬁeld of HIV & AIDS pre-
vention and treatment – January 2009;
The WMA also intervened on behalf of
Majid Movahedi who was sentenced last
March in Iran to be blinded in both eyes
with acid – a process that would involve
medical professionals. Recalling its ﬁrm
opposition to punishments that constitute
cruel, inhuman and degrading treatment
amounting to torture,WMA emphasizes in
the letters to Iran authorities that, accord-
ing to international medical standards, it is
unacceptable to involve physicians in this
inhuman and degrading treatment
WMA is actively involved in developing the
“Right to Health as a Bridge to Peace in
the Middle East” joint seminar, which will
to take place 27-30 October 2009 in Tur-
key. The seminar is being organised by the
International Federation of Health and Hu-
man Rights Organisations (IFHHRO), the
Norwegian Medical Association (NMA),
the Human Rights Foundation of Turkey
(HRFT), the Turkish Medical Association
(TMA) and the WMA. The objectives of the
meeting are to discuss what role the medical
profession can play in securing equal access
to health care for the population and to fa-
cilitate the communication among health
professionals in the participating nations.
WMA maintained regular contact with
Anand Grover, the UN Special Rappor-
teur on Health in order to increase the role
of health professionals in the promotion of
the human right to the highest attainable
standard of health.
Social determinants of health
In August 2008, the Commission on Social
Determinants of Health published its ﬁnal
report “Closing the Gap in a Generation –
Health Equity through Action on the
Social Determinants of Health”. In this
200-page report, the Commission addresses
global health through social determinants,
i.e., the structural determinants and condi-
tions of daily life responsible for a major
part of health inequities among and within
countries,and proposes a new global agenda
for health equity.
WMA – on behalf of the World Health
Professions Alliance (WHPA) – presented
a statement on this report, with a focus on
the health workforce. In this statement, the
WHPA welcomed the recommendation
directed at national governments and do-
nors to “increase investment in medical and
health personnel”, but regretted that the
report in general does not give more atten-
tion to health professionals as key players in
addressing the social determinants of health
and the inequalities health professionals
face in their daily work.
Ethics
Clinical research involving human subjects
has proliferated in developing countries in
the recent past, increasing concerns about
ethical and legal implications of miscon-
duct and violations of subjects’ human
rights and welfare because scientiﬁc and
ethical review of protocols are inadequate
or as a result of poor or absent drug regu-
latory systems. WMA was invited to the
international Round Table – Biomedical
Research in Developing Countries: the
Promotion of Ethics, Human Rights and
Justice – to compare and exchange exper-
tise and experiences between national and
international institutions, on the issue of
protection of human participants in bio-
medical research. Participants stressed the
importance of building capacity in bio-
medical ethics review in developing coun-
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tries by supporting education and training
curricula of health professionals and com-
munity health workers, in order to facili-
tate the creation of institutional Research
Ethics Committees.
Speaking book
WMA launched the Speaking book on
Clinical Trials on the occasion of its Gen-
eral Assembly in Seoul 2008. This project
was done together with the South African
Medical Association, the SADAG (South
African Depression & Anxiety Group) and
the Steve Biko Centre for Bioethics in Jo-
hannesburg. The purpose of the project is to
provide proper information on clinical re-
search to illiterate populations so that they
can make informed decisions about partici-
pation. The project was made possible by
an unrestricted educational grant provided
by Pﬁzer, Inc.
Caring Physicians of the World (CPW)
Initiative “Leadership Course”
The CPW Project began with the Caring
Physicians of the World book, published
in October 2005 in English and then pub-
lished in Spanish in March 2007. Regional
conferences were held in Latin America,
Asia-Paciﬁc and Africa regions. The CPW
Project was extended to include a leadership
course organized by the INSEAD Business
School in Fontainebleau, France, in De-
cember 2007, in which thirty-two medical
leaders from a wide range of countries par-
ticipated and the second Leadership Course
was held at the same place in December
2008 for one-week with thirty participants
and it turned out with successful results
and feedbacks. Planning has begun for the
third Leadership Course at the INSEAD
Business School in Singapore in February
2010. The curriculum includes training in
decision-making, policy work, negotiating
and coalition building, intercultural rela-
tions and media relations. The courses were
made possible by an unrestricted education-
al grant provided by Pﬁzer, Inc.
2. External Relations
World Health Professions Alliance
The WPHA is now a decade old.The context
within which it is working has changed, and
so have the organisations which make up the
alliance.Three of the four organisations have
taken on new leadership since the alliance
was created. As a result, the CEO’s feel that
it is time to refresh its strategy, and identify
how it can best use the resources available to
achieve its objectives. This will be done in a
two-day strategy seminar in June 2009.
World Federation for Medical Education
The WFME brings together medical facul-
ties and the profession. During recent years
it has focused on describing global standards
for basic and post-graduate education of
physicians as well as for the Continuing Pro-
fessional Development. The WMA General
Assembly endorsed these standards.
Currently, the WFME works on encourag-
ing and supporting countries and medical
schools to engage in, or to improve, their ac-
creditation. Although not itself an accredit-
ing body,the WFME – together with WHO
– strongly support the use of accreditation as
a method of documenting and improving the
quality of education and achieving compara-
bility in the international arena.
Based on a mutual agreement with the
WHO, the WFME together with the Uni-
versity of Copenhagen (which hosts the
WFME oﬃce) has taken over from WHO
Headquarter the register of institutions
for higher education in health care. The
WFME now develops this register in an
online database called Avicenna Directo-
ries, which will not only list the institutions
as named by their governments, but also
provide information about their accredita-
tion status and the accrediting body.
Administration
After renegotiating the contract with the
company DGN-Service, the WMA has
ﬁnally signed a contract with DGN to de-
velop and install a new web portal for the
WMA.The new web portal will provide the
platform for cooperation with the members
of WMA, allow online payments for meet-
ings, books and associate membership dues,
and, most of all, it will facilitate more timely
presentation of content on the public web-
site. Work on the new design and infor-
mation structure, as well as for the payment
system, is underway.
The Secretariat wishes to record its appre-
ciation to member associations and interna-
tional organizations for their interest in, and
cooperation with, the World Medical Asso-
ciation and its Council during the past year.
It thanks all those who have represented the
WMA at various meetings and gratefully ac-
knowledges the collaboration and guidance
received from the oﬃcers, as well as the As-
sociation’s editors, its legal, public relations
and ﬁnancial advisors, and its oﬃcials.”
Council then received the Reports of
Standing Committees, noting the appoint-
ment of Dr. Jen Winther Jensen as Chair
of Ethics Committee, of Dr. Haikerwal as
Chair of Finance and Planning and of Dr.
J.C.Gomez Amiral as Chair of Medical
Social Aﬀairs Committee.
Ethics Committee Report
In the course of consideration of the re-
port of the Ethics Committee, Council ap-
proved the following new or revised state-
ments for referral to the General Assembly
and recommended their adoption:
Declaration of Madrid on Professionally•
led Regulation ( revised May 2009);
Statement on Conﬂict of Interest•
Revision of WMA Declaration of Ot-•
tawa on Child Health (Section 1)
Revision of Statement of Medical Pro-•
cess Patents
WMA (revised) Statement on Genetics•
and Medicine.
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The Global Health Workforce Alliance
(GHWA) is organising regularly online
discussions on topics dealing with health
workforce issues.The ﬁrst one was on Task-
Shifting in May 2009. Over a duration of
nine days round about 250 experts, health
professionals and politicians from 56 coun-
tries highlighted diﬀerent important themes
of Task Shifting.
The discussion started with an acknowl-
edgement of a global shortage of health
workforce, which results in unmet health
care needs in many areas of the world.
However the problem lies not only in the
quantity of delivered health care, it’s also
very important to deliver high quality of
care worldwide, even in areas with a high
burden of health care workers shortage.One
way to achieve the high quality of care is to
shift from an public health care approach
only toward a patient focussed care within a
Council also approved section 2 of this revi-
sion to be used as a guideline for Advocacy..
Council also approved the Third section of
the revision of the Declaration of Ottawa
(revised) for publication on the WMA web-
site, on the understanding that it was not
WMA policy. Council approved the ap-
pointment of Ms Delorme as the WMA’s
nominated representative to the Interna-
tional Rehabilitation Council on Torture
Victims, replacing Professor Nathansen
whose six year term had expired.
Medico-Social Aﬀairs Committee.
Council approved the following new or
revised Statements and Resolutions to be
forwarded with a Recommendation for ap-
proval by the General Assembly:
Declaration with Guidelines for Con-•
tinuous Quality Improvement in Health
Care
Revised WMA Resolution on the Medi-•
cal Workforce ( as amended)
Revised Resolution on Improved Invest-•
ment in Health now entitled
“Improved Investing in Public Health”•
Proposed Statement on Health and Cli-•
mate Change”
Finance and Planning Committee
Council noted that the Committee had re-
ceived reports on Dues, the Interim unau-
dited Financial Statement,and an oral report
on the Strategic Plan. It was also informed
that the arrangements for the General As-
sembly in New Delhi in October 2009 and
in Vancouver 2010 had been approved and
that in connection with Future Meeting
Planning, invitations for the 188th
General
Assembly had been received from the Czech
and Australian Medical Associations. It was
also reported that the WMA website was
being redeveloped and it was hoped that
this would be launched at the meeting in
New Delhi later this year..
Council also approved a proposal “Coop-
erative Relations with Academic Centres
and Institutes”.
World Health Assembly(WHA)
Council received a report on the agenda for
the World Health Assembly of WHO and
the Advocacy Advisor spoke on the logistics
and the WMA activities during the WHA.
the following week,
Other business
CouncilResolutiononMedicalNeutrality
The Israel Medical Association introduced
a new proposed resolution (Council 182/
Resolution Medical Neutrality/May2009)
reaﬃrming existing WMA policy. The
Council made one amendment to the docu-
ment and approved the revised resolution.
(Council 182/Resolution Medical Neutral-
ity/May2009)..
Nuclear Weapons
A report that the Japanese Medical Asso-
ciation (JMA) had adopted a Resolution
on the Abolition of Nuclear Weapons was
supported by Council reaﬃrming WMA
existing policy on Nuclear Weapons (.) The
JMA also reported that it was trying to in-
volve physicians in environmental issues
Prohibition of Physician
Participation in Torture
Council also amended and adopted a
Resolution from the Norwegian Medical
Association(NMA) revising the WMA reso-
lution on Prohibition of Physician Partici-
pation in Torture. (Council 182?Resolution
Non-participation on Torture/May2009/
Rev) )
The American Medical Association( AMA)
requested that copies of a letter to President
Obama from the AMA be circulated to
Council. This expressed its grave concern
about the allegations of involvement of
health personnel in torture of detainees and
oﬀered the President its assistance in ensur-
ing that all physicians were aware of their
ethical obligations and that such actions
never occur under US jurisdiction.
Violence against Physicians
The Spanish Medical Association (EsMA)
reported that violence against health profes-
sionals was now a major problem in Spain.
Dr. Alan J. Rowe, Co–Editor of
the World Medical Journal
Task Shifting On-Line Moderated Discussion
Summary of the discussion, held in May 2009
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Quality Control – standards of profes-6.
sionalism must be created, monitored
and maintained.
Systems Development – task shifting7.
should take place within a proper func-
tioning system to ensure smooth func-
tionality.
Regulations – to ensure that equity, re-8.
spect, and uniformity of personhood
is brought to the persons who are part
of the new cadres of workers. Legal
frameworks that would support task
shifting must be put into place. Task
shifting should not be considered cheap
labour.
Retention – solutions must be found9.
that will ensure that individuals remain
i) not only within the health care sys-
tem, but ii) within their own countries’
health care system and in iii) the areas
(regional and district) where demand
for services is greatest.Thus career paths
must be set, incentives created and ac-
knowledgements introduced.
More information about this topic and the
report of the discussions can be found under
the link http://www.who.int/workforcealli-
ance/en/
Each WMA member is welcomed to partic-
ipate in future GHWA online discussions.
In order to get registered at the GHWA
online platform please contact either Julia
Seyer Julia.seyer@wma.net or directly to
Yann Siegenthaler at GHWA siegenthale-
ry@who.int .
Julia Seyer, WMA Medical Advisor
Shaping the Future of Health Professionals’ Regulation
2nd
World Health Professions Conference on Regulation
The regulation of health professionals is
emerging as one of the most topical issues
among health care disciplines in the 21st
century. Next February 18th
,19th
2010, the
2nd
World Health Professions Conference
on Regulation WHPCR 2010 will be held
in Geneva, hosted by the World Health
Professions Alliance and World Council of
Physio Therapy.
Professions,governments and policy makers
alike are devoting time, money and energy
into investigating how regulation can im-
prove comprehensive patient care and out-
comes, and decrease the costs of healthcare.
That is why the World Health Professions
Alliance, with World Council of Physio
Therapy, has taken up the task of bringing
together experts in all ﬁelds of healthcare
and regulatory policy at the World Health
Professions Conference on Regulation
WHPCR 2010.
This will be the second such conference –
the ﬁrst was held in May 2008 and was met
with an overwhelmingly positive attend-
ance and response. Over 500 participants,
representing a diverse selection of health
practitioners and policy makers, were en-
gaged in the theme “The role and future of
health professions regulation”.
This time the theme will be “Shaping the
future of health professionals’regulation”. It
will be an opportunity for learning, knowl-
edge exchange and multidisciplinary profes-
sional growth on an international platform,
and is aimed at professional organisations,
representatives of regulatory bodies, gov-
ernments, along with leaders in healthcare,
academia and patient groups. All confer-
ence delegates will be invited to participate
in the ﬁrst ever global survey designed to
capture information about the regulation of
health professionals. Data obtained from
this survey will be presented early in the
conference and be available for discussion
during the professional group sessions.
Regulation is a consequence of the social
contract established between professions
and society representatives (i.e. govern-
public health care system approach as well.
Emphasis lies also on preventive care,health
promotion and “health literacy”(which is to
teaching individuals how to better take care
of themselves).
Furthermore it is important to focus on ca-
pacity building and training to attract,retain
and educate health professionals. The re-
gional imbalance of capacity building leads
to migration of health professionals and a
lack of health professionals and specialists
for certain diseases.
While implementing task shifting in the
healthcaresystemmuchresistanceisencoun-
tered.The fear in general is that task shifting
leads to a downgrading of quality care and
ends in two class health care. Therefore it’s
important to understand which type of care
could be shifted?, are the health workers or
new cadres qualiﬁed for this?, who is taking
the responsibility and is there supervision?.
Sometimes governments use task shifting
and the implementation of these new cadres
as short-term solutions to address the human
resources in health crises in countries.
Key Summary Recommendations
Given the fact that task shifting could1.
be considered when looking at solutions
to human resources in health shortages,
broad recommendations ﬂowed from
the discussion:
Planning – task shifting must be consid-2.
ered as only one aspect of the national
health workforce and health care plan.
Involvement of the local level – a bot-3.
tom-up approach in local level planning
to ensure what is demanded is necessary
and will be supported by the community.
Adaptability – there is no one size ﬁts all4.
for task shifting thus the implementa-
tion of task shifting must be determined
in context – situation, resources and
types of tasks to be shifted.
Education & Training – a minimum5.
level of education and well-structured
training programmes are necessary for a
successful implementation of tasks.
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An integrated and eﬃcient health system
that provides primary, secondary and tertia-
ry care is an essential element of a healthy
and equitable society. In many parts of the
world, where access to health care is limited
to certain groups of the population, there
is a persistence of profound inequalities in
health status.
Undocumented migrants are among the
most vulnerable groups in society and they
occupy a position from which accessing
health care is very diﬃcult. While health
care provisions are often in place for refu-
gees and asylum seekers, undocumented
migrants are repeatedly excluded from so-
cial protection plans.
Deﬁnition
Undocumented migrants are people with-
out any residence permit authorising them
to stay in their desired country of residence.
They may have been unsuccessful in the
asylum procedure, entered irregularly by
evading boarder control, entered using false
documentation, or overstayed their visa. In
referring to this group we do not include
those who have been granted refugee sta-
tus nor asylum seekers who have applied for
refugee status and whose requests are being
processed. Asylum seekers whose applica-
tion for refugee status has been denied and
whose residency is not oﬃcially tolerated
are considered undocumented migrants. Ir-
regular residency status,ineligibility to work
legally, insuﬃcient and ambiguous health
care entitlements, all in combination with
the constant fear of being denounced, pre-
vent undocumented migrants from seeking
health care along normal paths.
In referring to this group, the term “un-
documented migrant” as opposed to “ille-
gal migrant” or “illegal alien” is preferred.
In employing this alternative terminology
we avoid the negative and discriminatory
stigma of ‘criminal” that is implied by ‘ille-
gal migrant”.
Pregnant women, child birth and children
are particularly sensitive areas within the
larger discussion of health care for undocu-
mented migrants. While this article does
not provide speciﬁc details of these issues,
it recognizes that they may deserve the par-
ticular attention of the WMA and national
medical associations.
Lack of Data
There is little quantitative data about this
population’s general health status and access
to health care.There is a need for publication
of data where it exists and further research
where it does not. Even the number of un-
documented migrants in Europe remains at
best a rough estimate. Increased publication
of data,and research would prevent instanc-
es in which legislation is developed based
on qualitative or anecdotal evidence.
The 2007 the Hamburg Institute of Eco-
nomics was involved in a study funded by
the European Commission, DG Research,
under the Sixth Framework Programme,
called “Clandestino: Counting the Un-
countable”. This project estimates that in
2005, 2.8 – 6 million undocumented im-
migrants resided in Europe. This number
includes foreign nationals without any valid
residence permit and working tourists, but
excludes asylum seekers and oﬃcially toler-
ated persons [1].
A report by Médecins du Monde in 2007
published the ﬁndings of a survey given to
835 undocumented migrants from seven
countries within Europe (Belgium, Spain,
France,Greece,Italy,Portugal,and the Unit-
ed Kingdom). Among other ﬁndings, the
most common reported health concerns were
digestive, musculoskeletal, physiological and,
for women, gynaecological [2]. This survey,
similar to others like it, is not representative
of the health status of the entire population
of undocumented migrants, as participants
had already made contact with a treatment
center when they completed the survey.
Barriers to accessing health care for undoc-
umented migrants vary signiﬁcantly among
migrant-receiving countries, as national
legislation varies. Though not providing
Accessing Health Care for Undocumented
Migrants – European observations
ment). While the scope and practice of
many healthcare professions change and
will change throughout the world, so is and
will be the regulation model. Regulation
encompasses many aspects of the health-
care professionals’ life, from their educa-
tion to their activities and their entry in the
profession. Each of the chosen themes will
explore these aspects of regulation and how
each profession may best contribute to the
constructive evolution of health professions
regulation worldwide.
The objectives for the themes of WHPCR
2010 are to:
Debate the future control and direction of•
health professional regulation within the
context of changing scopes of practice;
Examine the regulatory and professional•
issues related to the international migra-
tion of health professionals;
Critically evaluate the relationship be-•
tween health professional education, reg-
ulation and standards of practice.
The 2nd
World Health Professions Confer-
ence on Regulation (WHPCR 2010) 18-19
February, 2010 Geneva. For more informa-
tion on the programme and how to register,
please visit www.whpa.org/whpcr2010
Julia Seyer, WMA Medical Advisor
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WMA news
speciﬁc details into each of these situations,
this article should serve as a general intro-
duction to the issue.
There are a number of factors that prevent
undocumented migrants from seeking
health care along normal paths.
Insuﬃcient Entitlement
In the majority of migrant-receiving coun-
ties, health care entitlements for undocu-
mented migrants are insuﬃcient; entitle-
ments are limited to “emergency”, “urgent”,
or “immediately necessary” care [3, 4].These
concepts are poorly deﬁned and, as a result,
the provision or withholding of health care is
often at the discretion of health care staﬀ. In
some instances these deﬁnitions are largely
meaningless. In the case of chronically ill
patients, long-term regular treatment, which
might not be considered emergency care, is
nonetheless vital to the patient’s health. In
many instances, national law does not reﬂect
international obligations to recognize access
to health care as a basic human right.
Article 25 of the 1947 United Nations Uni-
versal Declaration of Human Rights states
“Everyone has the right to a standard of liv-
ing adequate for the health and well-being
of himself and of his family, including food,
clothing,housing and medical care and neces-
sary social services,and the right to security in
the event of unemployment, sickness, disabil-
ity,widowhood,old age or other lack of liveli-
hood in circumstances beyond his control.”
Similarly, article 12 of the International
Covenant on Economic, Social and Cul-
tural Rights, which entered into force 1976
and which 160 parties have ratiﬁed to date,
states that member states are obligated to
recognize the “right of everyone to the en-
joyment of the highest attainable standard
of physical and mental health.”
According to the WHO fact sheet No.31 ti-
tled The Right to Health,“the right to health
is a fundamental part of our human rights and
of our understanding of a life in dignity.”
The WHO understands the Right to Health
to include the following entitlements: The
right to a system of health protection pro-
viding equality of opportunity for every-
one to enjoy the highest attainable level
of health, the right to prevention, treat-
ment and control of diseases, access to
essential medicines, maternal, child and
reproductive health, equal and timely ac-
cess to basic health services, the provision
of health-related education and informa-
tion, participation of the population in
health-related decision making at the na-
tional and community levels.
Furthermore, the WHO maintains that
“Non-discrimination is a key principle in
human rights and is crucial to the enjoy-
ment of the right to the highest attainable
standard of health” [5].
The International Convention on the Pro-
tection of the Rights of all Migrant Work-
ers and Members of Their Families, which
entered into force in 2003, seeks to outline
the rights of migrant workers, including
those residing irregularly whose irregular
status renders them natural targets of ex-
ploitation. Articles 25 and 28 speak directly
to the right of health care of migrants resid-
ing irregularly. Unfortunately, while several
countries of origin of migrants have ratiﬁed
the convention, critical western migrant-re-
ceiving states have not. (neither the United
States, Canada nor any nation of the Euro-
pean Union has ratiﬁed the Convention).
Sweden has been long hailed as a leader in
human rights and social welfare programs.
Health care access of vulnerable groups in
Sweden was examined by Paul Hunt, former
UN Special Rapporteur on Health, in his
2007 report “Mission to Sweden”.This report
reveals some signiﬁcant gaps in the Swedish
health care system. In it he communicates
clearly the right to health as a fundamental
human right. He makes an interesting point
by distinguishing human rights from citizen
rights. In section 72 of his report he writes
“The Special Rapporteur notes that under
international human rights law, some rights,
notably the right to participate in elections,
to vote and to stand for election,may be con-
ﬁned to citizens. However, human rights are,
in principle, to be enjoyed by all persons”[6].
Health care, as it follows, is not a citizen’s
right but a human right. In many countries
the right to health is not enjoyed universally
as it is linked to citizenship.
Often national law does not fully integrate
the right to health into domestic policy. Ex-
clusionary legislation and in other cases lack
of legal entitlements limit access to second-
ary care for undocumented migrants.
In the UK, subsidized care to undocu-
mented migrants is limited to emergency
care. Here, when undocumented migrants
are unsuccessful in registering with a GP to
acquire coverage under the National Health
System, they are liable for all charges for
care beyond that deemed “urgent” and “im-
mediately necessary”. In the UK a pregnant
undocumented woman with HIV is not
entitled to subsidized medication to reduce
the risks of HIV transmission to her baby
[3]. In the UK all undocumented migrants
are liable for the full charge of ARV treat-
ment. Undocumented migrants, as a popu-
lation, when left unable to access subsidized
health care, pose a risk to public health.
Lack of Health Literacy
There is signiﬁcant lack of awareness and
understanding of health care entitlements
of undocumented migrants on the part of
both health care professionals and undocu-
mented migrants themselves. This concept
can be referred to as Health Literacy. Even
in situations where legal entitlements to
subsidized care do exits, a lack of aware-
ness and understanding of entitlements and
other administrative barriers inhibit the re-
alization of those entitlements.
In France undocumented migrants are
theoretically entitled to State Medical As-
sistance (Aide Médicale de l’Etat – AME)
which entitles them to all kinds of free
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WMA news
health care. However, according to a report
released by Médecins du Monde in 2005,
this right is rarely realized [7]. Undocu-
mented migrants often do not know they
have the right to health care and when they
do, sometimes have diﬃculty meeting ad-
ministrative requirements. Among other
documents, applicants for AME coverage
are required to provide a valid identity card
(passport,birth certiﬁcate,national ID card)
and proof of residency in France (even if ir-
regular) for more than three months. Both
requirements can prevent undocumented
migrants from accessing healthcare.
In Germany providing assistance to un-
documented migrants for ﬁnancial gain can
be criminalised under the “penalization of
assistance” regulation and some public in-
stitutions have the “duty to denounce”when
they interact with undocumented migrants.
While medical professionals are exempt
from both these regulations, a report by
NGO PICUM suggests that the mere ex-
istence of these laws creates an atmosphere
of distrust that further discourages undoc-
umented migrants from seeking out the
healthcare they may be entitled to [3].
Ethical perspective versus
political perspective?
The WMA Declaration of Geneva – In-
ternational Code of Medical Ethics,adopted
in 1949 by the World Medical Association
during its 3rd
General Assembly, outlines a
physician’s ethical obligation to the patient.
The Lisbon Declaration, adopted by the 34th
World Medical Assembly in 1981, outlines
the rights of the patient. Within the Lisbon
Declaration, Principle 1 – Right to Medical
Care of Good Quality speciﬁes that “every
person is entitled without discrimination
to appropriate medical care.” The Lisbon
Declaration further speciﬁes that “whenever
legislation, government action or any other
administration or institution denies patients
these rights,physicians should pursue appro-
priate means to assure or to restore them.”
From some perspectives this clause could be
applied to the professional ethical dilemma
physicians face as they treat undocumented
migrants. National regulations may indicate
that as a result of his or her status a patient
is not entitled to a particular form of care.
Physicians, however, have the responsibility
to provide unbiased evaluation of patient
health and treatment. Once a patient’s sta-
tus becomes known, physicians may have to
interpret ambiguous health policy to deter-
mine whether care will be covered. In cases
where patients are liable for all charges,
physicians may need to decide whether he
or she will give care to someone who may be
not legally entitled to it. In situations where
undocumented migrants have no entitle-
ments to healthcare beyond that which is
“emergency”in nature,physicians who agree
to give care to undocumented migrants may
receive no remuneration. Such regulations
attempt to force physicians to compromise
their ethical obligation to give treatment on
a non discriminatory basis.
The protection of the physician, therefore,
deserves the particular attention of the
WMA. Individual physicians and hospitals
who treat undocumented migrants should
not be perceived as taking a political stance,
nor seen as acting in discordance with na-
tional regulations as they carry out their
ethical obligations to provide care.
In many countries access to state subsidized
health care is linked to legal residency status.
In some nations there is a trend to strength-
en this link as a method of immigration
control. Denying undocumented migrants
access to health care becomes a punitive
measure; a method of deterring future ir-
regular immigration and encouraging those
who are residing irregularly to leave. There
is debate surrounding not only the ethics
of this trend, but also the notion of health
care as a “pull factor“.What role does access
to healthcare have in the decision-making
process of migrants? There is fear that equal
access to health care for undocumented
migrants would trigger a wave of irregular
immigration that would overwhelm west-
ern health care systems. Non governmental
organization PICUM argues that the belief
in health care as a “pull factor”is poorly sub-
stantiated [8, 9].
It is the opinion of some that immigration
policy should be kept entirely separate from
health care. According to Dr. Henry As-
cher of the Nordic School of Public Health
based in Sweden, it is inappropriate for
doctors to function as part of the immigra-
tion control system. He illustrated his point
with the example of a physician working in
an emergency ward giving treatment to a
group of young people who have been in-
jured following a street gang ﬁght. It is not
the physician’s role to make judgments in
regard to which of his or her patients acted
as aggressors and which were victims in the
ﬁght, and then proceed to give care based
on these judgements. These judgments are
the responsibility of the justice system. The
physician should proceed by administering
treatment based on severity of the condi-
tion. Similarly, requiring physicians to con-
sider the residency status of patients forces
physicians to assume a role that is not theirs
and asks them to compromise their ethical
obligations to the patient.
Dr. Ascher stresses the importance of pre-
serving public trust in health care providers.
Just as the public should have trust in the
justice system to defend the right to rep-
resentation and a fair trial, patients should
have security in knowing that doctors will
evaluate their condition and administer ap-
propriate treatment based on no consider-
ation beyond that of their health status.
A role for the WMA
The World Medical Association could play
a key role in identifying the role of national
medical associations in addressing access
to health care of undocumented migrants.
The WMA could encourage medical asso-
ciations to support physicians as they hon-
our their ethical obligations to patients. In
conformity with WMA policy, this would
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98
Medical Ethics, Human Rights and Socio-medical aﬀairs
demonstrate WMA’s dedication to reduce
health inequality through the development
of integrated and non-exclusionary health
care systems around the world.
WMA survey
The WMA recently created and sent a sur-
vey to member medical associations that
looked into undocumented migrant access
to health care. Among the 18 participat-
ing medical associations, 12 are within the
European Union. 70% reported they were
aware that undocumented migrants were
experiencing diﬃculty in accessing health-
care and 50% reported that they had taken
some form of action to address the issue.
These initiatives vary in nature and scale.
82% reported that they considered insuﬃ-
cient entitlements and lack of health liter-
acy as barriers that prevent undocumented
migrants from accessing care.
References
1. Hamborg Institute of international Economics,
Database on Irregular Migration, http://irregular-
migration.hwwi.net/Europe.5248.0.html
2. Médecins du Monde European Observatory on
Access to Health Care, European survey on undoc-
umented migrants access to health care, 2007, avail-
able at http://www.mdm-international.org/IMG/
pdf/rapportobservatoireenglish.pdf
3. PICUM (Platform for International Cooperation
for Undocumented Migrants), Access to Health
Care for Undocumented Migrants in Europe, 2007,
available at http://www.picum.org/data/Undocu-
mented%20Children%20in%20Euorpe%20EN.pdf
4. Averroes Project, Health for Undocumented Mi-
grants and Alyssum Seekers Network, http://www.
huma-network.org
5. UN Oﬃce of the High Commissioner for Hu-
man Rights, Fact Sheet No. 31, The Right to Health,
June 2008, No. 31, available at: http://www.unhcr.
org/refworld/docid/48625a742.html
6. Paul Hunt, Report of the Special Rapporteur
on the right of everyone to the enjoyment of the
highest attainable standard of physical and men-
tal health “Mission to Sweden”, 2008, available at
http://www2.essex.ac.uk/human_rights_centre/rth/
docs/sweden.pdf
7. Médecins du Monde, Rapport 2005 de l’obser-
vatoire de l’Accès aux Soins de la Mission France
de Médecins du Monde, 2005, avalable at http://
www.medecinsdumonde.org/thematiques/l_obser-
vatoire_de_l_acces_aux_soins
8. Robinson. V and Segrott.J, Understanding the
decision making of asylum seekers,Home oﬃce Re-
search Study, Home oﬃce Research, Development,
and Statistics Directorate, 2002, available at http://
www.homeoﬃce.gov.uk/rds/pdfs2/r172.pdf
9.Albrecht,H.J Fortress Europe? Controlling illegal
immigration, European Journal of Crime, Criminal
Law and Criminal Justice, Volume 10, Number 1,
2002 , pp. 1-22(22); 2002.
Lauren Storwick, WMA Secretariat
Most people would not knowingly buy
goods produced by children in dangerous
conditions, earning less than US $2 a day.
Yet unfair and unethical working condi-
tions are behind the supply of some medi-
cal products and services to health systems
throughout the world.
An article in the British Medical Journal
in August 2006 reported concerns in the
manufacture and supply of surgical instru-
ments from Sialkot, northern Pakistan, to
healthcare markets in the developed world.
The 50,000 skilled manual labourers who
manufacture instruments in Sialkot typically
earn less than US $2 per day, have no secure
income, and are exposed to a wide variety of
occupational hazards. Furthermore,there are
an estimated 5,800 children employed in the
industry,mostly working full-time,and some
as young as seven years old. Research by
Swedish NGO,Swedwatch,conﬁrmed these
problems in supply chains to health systems
in Europe and the United States.
Surgical instrument manufacture is not the
only industry where labour abuses are a con-
cern. Research has also identiﬁed problems
in the production of textiles for healthcare
from India and Pakistan. A risk assessment
by the Ethical Trading Initiative suggests
that a signiﬁcant number of goods and ser-
vices for healthcare are at risk of abuse of
labour standards,and one report identiﬁed a
number of medical products manufactured
in South and South-East Asia that may be
subject to unethical trade practices.
Talking to suppliers to the UK and Swe-
den, we know that their products end up in
hospitals and clinics around the world. As
these are global supply chains, with manu-
facturers supplying multiple markets, it is
reasonable to assume that the same prod-
ucts supply markets in the rest of Europe,
the United States, Canada, Australasia and
other regions and countries.
So what does this mean for medical asso-
ciations? The British Medical Association
(BMA) has been working closely with part-
ners to investigate and address these issues.
The BMA formed the Medical Fair and
Bringing Fair Trade to Health Systems:
What You Can Do
Olivia Roberts Mahmood Bhutta Eva Nilsson Bågenholm
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99
Medical Ethics, Human Rights and Socio-medical aﬀairs
Ethical Trade Group (MFETG), which is
an independent group with membership
from fair trade groups, industry associations
and government bodies.The MFET Group
is coordinated by the BMA International
Department and the promotion of fair trade
in healthcare goods is a key objective for the
BMA’s work on improving global health.
The Group aims to promote fair and ethi-
cal trade in the manufacture and supply of
medical commodities. Recent successes in-
clude a code of conduct for all major suppli-
ers of healthcare goods to the UK, and the
development of guidance by the NHS Pur-
chasing and Supply Agency – the group re-
sponsible for national purchasing decisions.
These tools enable the UK health system to
question suppliers about whether they have
adhered to basic labour rights in the produc-
tion and supply of their goods. The British
Medical Association will be engaging with
its members and other health professionals
to help them learn to ask the right questions
and bring change to these industries. An-
other exciting eﬀort is supporting the devel-
opment of product lines that may represent
especially good practice in fair and ethical
trade, including fair trade and environmen-
tally friendly rubber for surgical gloves, and
fair trade cotton for healthcare textiles.
In Sweden, the three largest authorities for
health care have jointly produced a Code of
Conduct for fundamental social responsi-
bility in procurement contracts with suppli-
ers, and there are plans to make the Code
apply nationally in the near future. Recently
signed contracts will be monitored annually,
and suppliers asked how they comply with
the contract. If problems are discovered,
further steps include requesting the supplier
to contact the producing factory or to un-
dertake independent audits to assess labour
conditions.
Both the guidance in England and the
Swedish Code of Conduct contain the fol-
lowing points as key principles of develop-
ing fair and ethical trade:
Suppliers shall respect principles of fun-•
damental social responsibility in business
deals.
All products shall be produced accord-•
ing to ILO and UN fundamental labour
conventions and shall be related to health
and safety legislation in the manufactur-
ing country.
Discrimination, forced labour or child la-•
bour must not occur.
Wages shall be paid as agreed directly to•
workers.
Remuneration must not be below nation-•
al statutory minimum wage.
Weekly working hours must not exceed•
legal limit and overtime is to be paid for.
Working environment shall correspond•
to international guidelines.
When combined, the policies in the UK
and Sweden have the potential to aﬀect bil-
lions of dollars of health service contracts
per year. However, this is still only a small
percentage of healthcare expenditure: the
UK and Sweden together account for only
7% of hundreds of billions of dollars global
purchasing of medical devices. If guidance
and policies were developed in other coun-
tries throughout the world,the impact could
be much more signiﬁcant. But this will only
happen if key partners work together, and
with suppliers, to identify problems and ﬁx
them.
We are now working with other medical
associations in Europe and recommend the
following actions for all medical associa-
tions:
Contact the British Medical Association•
for advice (email fairtrade@bma.org.uk).
Contact your members about this issue to•
get their support.
Contact your national health service pur-•
chasing agency or regional body to ask
them to engage on this issue.
Contact your local industry association•
and ask them about their supply chains.
We need you to join us to mobilise health
professionals throughout the world to insist
that their health system treats the world
fairly.
References
British Medical Association [homepage on the1.
Internet] [cited 2009 September 11]. Available
from: www.bma.org.uk/fairtrade
Bhutta MF. Fair trade for surgical instru-2.
ments. British Medical Journal [serial on the
Internet] [cited 2009 September 11]. Avail-
able from: http://www.bmj.com/cgi/pdf_
extract/333/7562/297?rss=
Impactt – supply chain strategy organisa-3.
tion [homepage on the Internet] [cited 2009
September 11]. Available from: http://www.
impacttlimited.com/2008/12/09/nhs-pasa-
publish-%E2%80%98ethical-procurement-
for-health%E2%80%99-to-develop-ethical-
trade-for-health-supplies/
Ethical procurement for health guidance. NHS4.
[homepage on the Internet] [cited 2009 Sep-
tember 11]. Available from: http://www.pasa.
nhs.uk/PASAWeb/NHSprocurement/Sustain-
abledevelopment/Ethicalprocurement/
Purchasing and Supply Agency Sustainabil-5.
ity reports. NHS [homepage on the Internet]
[cited 2009 September 11]. Available from:
http://www.pasa.nhs.uk/PASAWeb/NHSpro-
curement/Sustainabledevelopment/
Bjurling K. The dark side of healthcare. 2007.6.
Swedwatch [homepage on the Internet] [cited
2009 September 11]. Available from: http://
www.swedwatch.org/swedwatch/in_english/
reports
The Stockholm County Council, Västra Göta-7.
land Region and Region Skåne. Sustainable
procurement [homepage on the Internet] [cited
2009 September 11]. Available from: http://
www.skane.se/upload/Webbplatser/MASkane/
Dokument/Socialt_ansvar_Hallbar_upph_
en.pdf
Department of Health.K Global Health Strat-8.
egy 2008-13 [homepage on the Internet] [cited
2009 September 11]. Available from: : http://
www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/
DH_088702
Olivia Roberts,
British Medical Association
Dr. Mahmood Bhutta,
Medical Fair and Ethical Trade Group
Dr. Eva Nilsson Bågenholm,
Swedish Medical Association
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100
Medical Ethics, Human Rights and Socio-medical aﬀairs
The 2nd
Geneva Conference on Person-cen-
tred Medicine in May 2009 followed the
inaugural Geneva Conference of May 2008,
both as landmarks in a process of building
an initiative on medicine for the person
through collaboration of major global med-
ical and health organizations and a growing
group of committed individuals.
The Conference took place on 28 and 29
May 2009 under the auspices of the Uni-
versity of Geneva Medical School and the
University Hospitals of Geneva organized
by the World Medical Association (WMA),
the World Organization of Family Doctors
(Wonca), and the International Network
for Person-centred Medicine, in collabora-
tion with the Council for International Or-
ganizations of Medical Sciences (CIOMS),
the World Federation for Mental Health
(WFMH), the World Federation of Neu-
rology (WFN), the World Association for
Sexual Health (WAS), the International As-
sociation of Medical Colleges (IAOMC),
the World Federation for Medical Educa-
tion (WFME), the International Federation
of Social Workers (IFSW),the International
Council of Nurses (ICN),the European Fed-
eration of Associations of Families of People
with Mental Illness (EUFAMI), the Inter-
national Alliance of Patients’ Organizations
(IAPO), and the Paul Tournier Association.
The editor-in-chief of the World Medical
Journal was in attendance and invited the
preparation of this report.
The Conference had as its aims: to examine
and discuss key concepts of person-centred
medicine and practical approaches for its
implementation, to elicit useful initiatives
on person-centred medicine, and to engage
international medical and health organiza-
tions on the Conference’s theme.
The Conference Core Organizing Commit-
tee was composed of J.E. Mezzich (World
Psychiatric Association President 2005-
2008), J. Snaedal (World Medical Asso-
ciation President 2007-2008), C. Van Weel
(World Organization of Family Doctors
President 2007-2010), and I. Heath (World
Organization of Family Doctors Executive
Committee Member at Large). The Con-
ference Secretariat was based at the Inter-
national Centre for Mental Health, Mount
Sinai School of Medicine, Fifth Ave &
100th Street, Box 1093, New York, New
York 10029-6574, USA.
Financial or in-kind support for the Con-
ference was provided by the University of
Geneva, the Paul Tournier Association of
Geneva, Person-centred Medicine & Psy-
chiatry Programs, Conference registration
fees, and the International Network for
Person-centred Medicine.
The Conference was opened by the Rector
of the University of Geneva and the Vice-
Dean of its Medical School, as well as by
the members of the Conference Core Orga-
nizing Committee.All remarked on the tra-
dition that was emerging engaging Geneva
as encounter point for the development of
person-centred medicine.
The 1st
scientiﬁc session involved presenta-
tions of leaders and representatives of the
International Alliance of Patients’ Organi-
zations, the International Network for Per-
son-centred Medicine, the World Health
Organization, the World Medical Asso-
ciation, the World Organization of Family
Doctors, the Council of International Or-
ganizations of Medical Sciences, and the
International Council of Nurses. The pre-
sentation of policy statements and relevant
institutional programs reﬂected the value
ascribed by these organizations to person-
centred medicine. Details on the presenta-
tions made in this session and the following
sessions can be found in the abstracts pre-
sented at the SGCPCM Report at www.
personcenteredmedicine.org.
Eight special initiatives relevant to person-
centred care were presented in the 2nd
ses-
sion. The presentations were made by rep-
resentatives of several major organizations
collaborating in the Second Geneva Con-
ference and other prominent work groups.
The diverse experiences presented from a
range of ﬁelds revealed a number of sub-
stantive achievements and promising op-
portunities for a medicine of the person.
Concepts and meanings of person-centred
medicine were the subject of the 3rd
session.
They focused on the role and worth of the
person in medicine,the cruciality of a sense of
identity,empathy and engagement for optimal
clinical care, and the value and impact of life
experiences for the development in each indi-
vidual of personalized medicine and health.
The 4th
session presented and discussed
procedures for person-centred diagnosis.
The Second Geneva Conference on
Person-centred Medicine
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101
Medical Ethics, Human Rights and Socio-medical aﬀairs
Particularly covered were the signiﬁcance
of multilevel explanations and diagnosis in
medicine, the key features of a person-cen-
tred integrative diagnosis addressed to ap-
praise whole health using standardized and
narrative descriptions reﬂecting interactions
among clinicians, patient and family, as well
as the prospects for person-centred diagno-
sis in general medicine.
A panel on programmatic contributions for
person-centred medicine in a 5th
session
oﬀered an opportunity for the presenta-
tion of brief statements by representatives
of the twelve collaborating organizations
and groups from across the world. They at-
tested to the relevance of person-centred
approaches to medicine for an ample range
of medical, health and social institutions.
The 6th
session, at the beginning of the sec-
ond day of the Conference, discussed pro-
cedures for person-centred treatment and
health promotion. These included general
features of person-centred integrative care,
the prospects for a person-centred medi-
cal home in the United States, and WHO
perspectives on person-centred healthiness,
social determinants, and health promotion.
Person-centred medicine for children and
older people was discussed in the 7th
session
of the Conference. Such vulnerable popula-
tions represent particular challenges and op-
portunities from scientiﬁc and ethical view-
points. The uniqueness and developmental
sensitivity of the child were highlighted.
Also pointed out were the complexity of
health conditions in older people and the
imperative need to attend to their values
and perspectives.
Training and research on person-centred
medicine was the subject of the 8th
ses-
sion. Speciﬁc topics included the develop-
ment of pertinent guidelines and curricula
for person-centred clinical care, the assess-
ment of a epistemologically based person
centred medicine at Ambrosiana University
in Milan, training and research on commu-
nication for person-centred outcomes, and
broad programmatic features and objectives
of research on person-centred clinical care.
The 9th
session of the Conference reviewed
person-centred health systems and policies.
WHO’s new focus on persons for the de-
velopment of more promising global health
policies and systems, as aﬃrmed by the
latest World Health Assembly, was given
pointed attention. Also discussed was the
role of health informatics for the construc-
tion of personalized medicine and complex
health care systems. Last but not least was a
review of the role and documented value of
the person for the conduction of health care,
training and research
The ﬁnal 10th
session presented a confer-
ence summary and outlined next steps.
Among the general conclusions were:
a commitment to the importance of per-•
son-centred medicine for the health of
people, noting the participation of a vast
array of important medical and health or-
ganizations, a wish to share and collabo-
rate, and an understanding of the impor-
tance of grasping opportunities;
the growing availability of resources,includ-•
ing general concepts and procedures as well
as teaching materials and research tools;
the importance of ﬁtting the above re-•
sources into health care systems and into
particular health care encounters, with
particular attention to person-centred-
ness as an intrinsic quality rather than as
an additional commodity,and the value of
comprehensiveness,continuity,and atten-
tion to context as crucial features of good
clinical care.
Proposals for future conferences included
the need to build bridges to the various
specialties in medicine, the participation of
diﬀerent patient groups, and the inclusion
of representatives of additional health dis-
ciplines.Emphasis was made on consolidat-
ing the ideas from the ﬁrst two conferences,
and to use that for further work to enhance
person-centred medicine.
Anticipated next steps include the following:
Completion of a joint editorial to be pub-•
lished in a wide circulation international
journal.
Preparation of a 2• nd
Geneva Conference
Summary Report.
Publication of a monograph containing•
the papers presented at the 2nd
Geneva
Conference.
Collaboration with WHO on Person-•
centred Medicine topics related to the
2009 World Health Assembly Resolu-
tions.
Organization of scientiﬁc events rel-•
evant to person-centred medicine, such
as a prospective New York Conference on
Well-Being and Person in Medicine and
Health.
Organization of a 3• rd
Geneva Conference
on Person Centred-Medicine in early
May 2010, prospectively focused on a
team approach across specialties and dis-
ciplines.
Establishment of a clearinghouse of Per-•
son-centred Medicine documents.
Upgrading an internet platform to sup-•
port our archival, informational, commu-
nicational, and programmatic needs.
Development of an International Network•
for Person-centred Medicine to stimulate
the above activities and to organize ini-
tiatives on conceptual and ethical bases,
diagnosis, clinical care, training, research,
health systems, and public policies.
The 2nd
Geneva Conference was distinctly
perceived by its participants as a stimulat-
ing success in terms of food for thought and
shared commitment to build a paradigmatic
shift in medicine and health care. A 3rd
Ge-
neva Conference is widely anticipated as
the next landmark in this unfolding process
with the emerging International Network
for Person-centred Medicine as the collab-
orative and ﬂexible structure to co-ordinate
and move forward our vision and program-
matic eﬀorts.
Juan E. Mezzich
WPA President 2005-2008
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102
Medical Ethics, Human Rights and Socio-medical aﬀairs
James Appleyard
Each child is a unique individual. Each
child is conceived within and delivered
from their mother. Each child is inﬂuenced
uniquely by their father, the wider family,
the culture of the local community and the
nation state. The infant grows and develops
through childhood and adolescence into an
adult within ﬁve areas – mentally, physically,
intellectually emotionally and spiritually.
In those children nurtured in an environ-
ment of love, joy and peace, their spiritual
dimension will widen. They are more likely
to survive the journey to adulthood and the
signiﬁcantly diﬀerent physiological,psycho-
logical and pathogenic features which occur
at the diﬀerent ages.
The paper looks at how this person centred
paradigm eﬀects the individual child and the
community in which he or she lives and the
harmful consequences of “depersonalization”.
At ﬁrst thought such a paradigm seems vague
and without much scientiﬁc credibility.
But in a comparative study by Cigdem
Kagitcibasi and colleagues, the motivations
for child rearing by 20,000 parents from
9 countries were assessed as “valuable” in
three domains – economic, social and psy-
chological [1]:
the• “economic” reason which involved the
material beneﬁts that children may bring
both when they are children and when
they grow up, to be a security in old age;
the• “Social” reasons which are related to
the general social acceptance that normal
adults are given when they have children,
and the desire for continuation of the
family;
the• “Psychological” intention for the ful-
ﬁlment of children – with love, joy, pride
and companionship.
In those countries whose mothers viewed
their children to fulﬁl their own individual
potential with love, joy pride and compan-
ionship had the best child survival rates
Poverty breeds disease and disease causes
poverty. Disease in just one family member
may have disastrous eﬀects on the children
through loss of care and reduced family in-
come, causing older children to leave school
to support the family. The tragedy of the
AIDS orphans is all too apparent in Africa.
Poor families compensate for children’s
deaths by having a large number of children,
with the expectation that suﬃcient will sur-
vive to care for the parents in their old age.
Large families simply cannot aﬀord educa-
tion and health care for each child. Con-
versely reduction in mortality can be a spur
to reducing fertility rates.The evidence link-
ing fertility levels to infants under the age of
1 yr and child mortality under 5 is powerful.
Countries who have infant mortality rates
of less than 20 have an average total fertility
rate of 1.7 children.In countries which have
infant mortality rates of over 100 have an
average total fertility rate of 6.2. children.
When children are valued in their own right
rather than for utilitarian purposes, family
size is smaller. This demonstrates the im-
portance given to each individual child on
the survival of the community
The mother’s education is clearly another
important factor but one which is also as-
sociated with the family’s increased earning
capacity. The clear message is that looking
after children means less and not more
mouths to feed, better education, healthier
adults and improved economic progress
Yet UNICEF’s statistics reveal that some
10 million children worldwide are not ad-
equately cared for [2]. They die under the
age of 5years, mainly unnecessarily, from
treatable illnesses and from lack of local,
national and international will to recognise
the importance of each child as an indi-
vidual person
At international level the overwhelming ma-
jority of countries have signed up to Article
24 of the 1989 United Nations Convention
on the Rights of the Child. This recognises
the right of the child to the enjoyment of
the highest attainable standard of health
and to facilities for the treatment of illness
and rehabilitation of health, and states that
Person Centred Pediatric Care
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103
Medical Ethics, Human Rights and Socio-medical aﬀairs
nations shall strive to ensure that no child is
deprived of his or her right of access to such
health care services.
Health care systems tend to respond by
identifying and measuring some measur-
able constituent parts of a child’s problem at
the expense of the child as a whole person
whose complex needs interact – the whole
child being more than the sum of the in-
dividual components. What counts for
each child may not be counted and what is
counted may not count.
This reductionist approach has fostered the
move towards greater specialisation and the
relative deskilling in primary care at which
level it is practical to look at a child in the
family and community setting.
A target culture has grown up in the un-
derstandably cost conscious management
environment of most health care providers,
where individual episodes of care are mea-
sured in isolation of a child’s overall needs
.The overall costs to the child, the family
and the local community are not measured.
What appears to be a “saving” may shift the
cost to another sector and create an even
greater burden for the family
This culture of isolated short episodes of
care has had an eﬀect, that of the physicians
working “shifts” within the health provider
system. The concept of any continuing duty
of care by the physicians towards their child
patient is vanishing.
At individual level such professional care for
a child is crucial – the child must be treated
as a person. This is only possible when the
attending physician is an independent pro-
fessional and inspires trust.
A profession is deﬁned as “a vocation in
which knowledge of some department of
science or learning”, or “the practice of an
art founded upon it is used in the service of
others” [3].
A profession is characterized as having a
code of ethics reﬂecting the integrity and
morality of its members, a complex body of
knowledge which should be used altruisti-
cally in the service of others as an autono-
mous professional person yet accountable to
a professional association and through the
code of ethics to society in general.
The code of ethics from the time of Hippo-
crates that should govern the behaviour of
members of the medical profession is based,
in my opinion [4], on seven principles:
1. The prime importance of the person
seeking help from a physician – patients
and their individual autonomy;
2. Beneﬁcence – to do good and act in
their best interests;
3. Non malfeasance – to limit any harm;
4. Fidelity – the duty of care;
5. Truthfulness – the need for transpar-
ency;
6. Conﬁdentiality – it is essential to keep
the patients “secrets”;
7. Justice – to be fair to all.
These principles need to be inscribed into
the conscience of the physician as part of
the medical ethical culture [5].They provide
the ethical “compass” to navigate through
the complex issues that confront physicians
throughout their professional lives.
A physician’s personal ethics and his integ-
rity – his conscience – form the most impor-
tant and safest resource in medical practice
worldwide. It is the basis of the trust be-
tween the physician and his or her patient.
That is what makes the art of medicine so
challenging and at the same time rewarding.
There is no one right answer. Just the right
answer, based on the best judgment for the
individual.
Within the medical care of children, it is
the child who is the person central to the
physician’s attention.
The World Medical Association’s current
Declaration of Ottawa (1998) provides an
important ethical framework [6].
It states:
“The health care of a child,whether at home
or in hospital, includes medical, emotional,
social and ﬁnancial aspects which interact
in the healing process and which require
special attention to the rights of the child
as a patient”.
“The wishes of each child need be taken
into account in any clinical decision. These
wishes should be given increasing weight
dependant on her/his capacity of under-
standing.The mature child, in the judgment
of the physician, is entitled to make her/his
own decisions about health care.”
From this person centred paradigm, as Staf-
ford Beer’s work in the ﬁeld of cybernetics
has illustrated, a viable system model can be
constructed so that knowledge sharing and
decision making can evolve without hierar-
chical control [7] to further the best inter-
ests of each child in every community.
References
1. Kagitcibasi C.The value of children: a key to gen-
der issues. Int Child Health. 1998; 9: 15-24.
2.The United Nations Children’s Fund.The state of
the world’s children 2007. UNICEF, 2006.
3. The shorter Oxford English dictionary. 3rd
ed.
Oxford: Oxford University Press, 1944.
4. Appleyard W.J. ‘Professionalism’ Icelandic Medi-
cal Association. Laeknaping, 2004.
5.Vikstrom J.‘Service of humanity’ Pro humanitate.
Finnish Medical Association , 2000.
6. World Medical Association Declaration of Ot-
tawa on the rights of the child to health care. Ot-
tawa, 1998.
7. Kawalek P. Athenaeum Forum Exchange, 2009.
James Appleyard MD FRCP FRCPCH
Children’s Physician
Past President , WMA.
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104
Medical Ethics, Human Rights and Socio-medical aﬀairs
The earliest roots of person-centred medi-
cine can be found in ancient civiliza-
tions, both Eastern (such as Chinese and
Ayurvedic) and Western (particularly an-
cient Greek),which tended to conceptualize
health broadly and holistically. This notion
is reﬂected in the encompassing deﬁnition
of health inscribed in the constitution of the
World Health Organization (WHO,1946).
Also noticeable in medical traditions from
those early civilizations is a personalized
approach to health care.
The modern development of medicine has,
however,neglected the above considerations
and privileged conceptual reductionism,
paid absorbed attention to disease, super
specialization and fragmentation of services
as well as commoditization and commer-
cialism in the ﬁeld. This has interfered with
attentiveness to the whole person and his/
her ill- and positive-health as the natural
focus of medical science and practice and
to the ethical imperatives connected to pro-
moting the autonomy, responsibility, and
dignity of every person involved.
Endeavors to refocus medicine on the per-
son of the patient, the clinician and the
members of the community at large have
been distinctly noted in the past century.
Illustratively, Paul Tournier, a Swiss general
practitioner discovered the transformational
value of critical interpersonal experiences
and of attending to the whole person and the
biological,psychological,social and spiritual
aspects of health.He presented his vision on
Medicine de la Personne (Tournier,1940) and
19 other books translated to over 20 lan-
guages. Around the same time, American
psychologist Carl Rogers demonstrated the
signiﬁcance of open communication and of
empowering for individuals to achieve their
full potential (Rogers, 1961) and proceeded
to develop a person-centred approach to ther-
apy, counseling and education.
During the second half of the 20th
Cen-
tury, Frans Huygen in the Netherlands,
Ian Mc Whinney in the UK and Canada,
and Jack Medalie in the United States and
Israel struggled with the ongoing limita-
tions of modern medicine noted above and
committed themselves to promote a broad
and contextualized understanding of health
with high concern for their patients’ well-
being. They went on to develop a generalist
medical specialty under the terms of gen-
eral practice and family medicine (Huygens,
1978; McWhinney, 1989), which has char-
acteristically focused on patient-centred care.
Sustained eﬀorts to establish a person-cen-
tred medicine program on epistemological
grounds and to build a corresponding medi-
cal school and clinical teaching method have
been undertaken by Giuseppe Brera (1992),
rector of Ambrosiana University in Milan.
Another inspirational medical ﬁgure has
been Finn psychiatrist Yrjo Alanen, who
engaged patients by paying careful attention
to the meaning of their experiences and the
nature and signiﬁcance of their needs, and
artfully combined pharmacological and psy-
chosocial therapeutic techniques. His need-
adaptive assessment and treatment approach
(Alanen, 1997) has impressed not only pro-
fessional colleagues but even critical patient
groups.
Noteworthy too are the emerging responses
from a number of global medical and health
organizations. The World Health Organiza-
tion, which incorporated in its constitution
the above mentioned comprehensive deﬁni-
tion of health, has recently introduced the
term dynamic, meaning interactive, to char-
acterize the relationship among dimensions
of well-being and has started discussions on
the possibility of adding a spirituality dimen-
sion. Furthermore, for the ﬁrst time WHO
is placing people/person at the center of
healthcare and public health, as reﬂected on
the resolutions of the World Health Organi-
zation’s 2009 World Health Assembly.
Linked to person-centred care perspec-
tives is an ethical frame of reference that
The International Network for
Person-centred Medicine:
Background and First Steps
Iona HeathJuan Mezzich Jon Snaedal Chris van Weel
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105
Medical Ethics, Human Rights and Socio-medical aﬀairs
seeks to assure equal opportunities for all,
particularly in terms of access to care, with
an emphasis on the rights of individuals in
need of health care (www.wma.net/policy).
The triad of caring, ethics, and science are
reaﬃrmed as the enduring traditions of
the medical profession (Coble, 2005). The
physicians’ obligation to respect human life
rather than to extend it blindly has been
cogently argued (Snaedal, 2007). This has
been incorporated by the World Medical
Association (WMA) into the Declara-
tion of Helsinki for Medical Research and
the International Code of Medical Ethics
(www.wma.net/press releases).
The renaissance of family medicine after the
Second World War was informed by holistic
perspectives which grounded the role of the
general practitioner/family physician in an
integrated approach to the care of patients
and their families in the context of a spe-
ciﬁc local community (Mc Whinney, 1989).
The World Organization of Family Doctors
(Wonca) has recorded its commitment to
persons and community in its basic con-
cepts and values – continuity of care, care
for all health problems in all patients within
a societal context (www.woncaeurope.org).
The tension between the disease and the per-
son experiencing the disease is particularly
tangible in mental health care. In fact, as
documented by Garrabe (2008), the begin-
nings of the World Psychiatric Association
(WPA) in 1950 already revealed interest on
the concept of the person as central to the
ﬁeld. That interest evolved to the point that
in 2005 the WPA General Assembly estab-
lished an Institutional Program on Psychia-
try for the Person. This program sought to
articulate science and humanism to promote
a psychiatry of the person, for the person, by
the person, and with the person (Mezzich,
2007). Among its signal conferences were
those organized in London (October 2007)
in collaboration with the UK Department
of Health and in Paris (February, 2008) in
cooperation with the WPA French Mem-
ber Societies. In addition to a number of
journal papers, monographs have been pre-
pared on the Conceptual Bases of Psychia-
try for the Person (Mezzich, Christodoulou
& Fulford, in press) and on Psychiatric Di-
agnosis: Challenges and Prospects (Salloum
& Mezzich, 2009).
Geneva Conferences on
Person-centred Medicine
The Geneva Conferences on Person-centred
Medicine took place at the Geneva Uni-
versity Hospitals on May 29-30, 2008 and
May 28-29, 2009 as landmarks in a process
of building an initiative on medicine for the
person through the collaboration of major
global medical and health organizations and
a growing group of committed individuals.
The institutions formally involved in either
or both Conferences included the World
Medical Association (WMA), the World
Organization of Family Doctors (Wonca),
the WPA Institutional Program on Psychia-
try for the Person (IPPP), the International
Network for Person-centred Medicine, the
Council for International Organizations
of Medical Sciences (CIOMS), the World
Federation for Mental Health (WFMH),
the World Federation of Neurology
(WFN), the World Association for Sexual
Health (WAS), the International Asso-
ciation of Medical Colleges (IAOMC), the
World Federation for Medical Education
(WFME), the International Federation of
Social Workers (IFSW), the International
Council of Nurses (ICN), the European
Federation of Associations of Families of
People with Mental Illness (EUFAMI), the
International Alliance of Patients’ Organi-
zations (IAPO), the University of Geneva
School of Medicine, and the Paul Tournier
Association.
The 1st
Geneva Conference on Person-cen-
tred Medicine was aimed at presenting and
discussing the experience on person-centred
principles and procedures gained through a
Person-centred Psychiatry Program,explor-
ing the conceptual bases of person-centred
medicine, and engaging interactively major
international medical and health organiza-
tions. It included sessions on international
organization perspectives on person-centred
medicine, related special initiatives, con-
ceptual bases of person-centred medicine,
personal identity, experience and meaning
in health, a review of Paul Tournier’s vision
and contributions, person-centred health
domains, clinical care organization, person-
centred care in critical areas, and person-
centred public health. The upgraded papers
presented at the Conference are being pub-
lished as a supplement of the International
Journal of Integrated Care (Mezzich, Snae-
dal, van Weel & Heath, in press)
The 2nd
Geneva Conference was aimed at
probing further key concepts of person-
centred medicine and reviewing a number
of practical approaches for the implementa-
tion of this approach through a collaborative
eﬀort with an enlarged number of interna-
tional health organizations. Through nine
sessions, it covered institutional perspec-
tives and activities on person-centred medi-
cine, other relevant initiatives, concepts and
meanings of person-centred medicine, pro-
cedures for diagnosis, treatment and health
promotion in medicine for the person,
person-centred medicine for children and
older people, as well as training, research,
health systems and policies on person-
centred medicine. Among the conference
conclusions were a wide commitment to the
importance of person-centred medicine for
the health of persons and populations,clari-
ﬁcation of the availability of conceptual, ed-
ucational and research tools,and the need to
ﬁt these into health encounters and systems,
aﬃrming person-centredness as an intrinsic
quality rather than an additional commod-
ity. There was consensus on organizing a 3rd
Geneva Conference where emphasis would
be placed on building further bridges to the
specialized sphere of medicine, other health
professions, and various patient groups.
Among additional next steps are the orga-
nization of relevant scientiﬁc events such
as a New York Conference on Well-Being
and the Person, publication of a joint edito-
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106
Medical Ethics, Human Rights and Socio-medical aﬀairs
rial in an international journal, preparing
a monograph with the papers presented at
the Second Geneva Conference, respond-
ing positively to requests from WHO for
collaboration on people-centred care strat-
egies adopted by the 2009 World Health
Assembly, and further development of the
International Network for Person-centred
Medicine to help move forward collabora-
tively an optimized vision for health care.
Constructing the International
Network for Person-centred Medicine
The International Network for Person-cen-
tred Medicine (INPCM) is a non-for-proﬁt
educational, research, and advocacy organi-
zation emerging from the above outlined
Geneva Conferences process and aimed at
developing opportunities for a fundamental
re-examination of medicine and health care
to refocus the ﬁeld on genuinely person-
centred care.
Person-centred medicine is dedicated to
the promotion of health as a state of physi-
cal, mental, social and spiritual wellbeing
as well as to the reduction of disease, and
founded on mutual respect for the dignity
and responsibility of each individual per-
son. To this eﬀect, the INPCM seeks to
articulate science and humanism in a bal-
anced manner, engaging them at the service
of the person. The purposes of the INPCM
may be further summarized as promoting a
medicine of the person (of the totality of the
person’s health, including its ill and posi-
tive aspects), for the person (promoting the
fulﬁllment of the person’s life project), by
the person (with clinicians extending them-
selves as full human beings with high ethi-
cal aspirations), and with the person (work-
ing respectfully, in collaboration, and in an
empowering manner).
The expected INPCM activities include the
following:
Organization of conferences and other•
scientiﬁc meetings promoting person-
centred care in medicine at large and in
its various specialties and related health
ﬁelds;
Preparation of person-centred clinical•
practice guidelines relevant to diagnosis,
treatment, prevention, rehabilitation and
health promotion;
Preparation of educational programs, in-•
cluding curricula, aimed at the training of
health professionals on person-centred
care;
Conduction of studies and research proj-•
ects to explore and validate person-cen-
tred care concepts and procedures;
Preparation of publications to dissemi-•
nate and advance the principles and prac-
tice of person-centred medicine;
Development of advocacy forums and ac-•
tivities to extend and strengthen person-
centred medicine with the participation
of clinicians, patients and families, as well
as members of the community at large;
Establishment of an internet platform to•
support archival, informational, commu-
nicational, and programmatic eﬀorts on
person-centred medicine.
All organizations and individuals who
have participated actively in relevant pro-
grammatic activities, such as the Geneva
Conferences, will be invited to participate
in the INPCM. It will be organizationally
developed and guided initially by a board
of ﬁve to eight persons with a clear track
record of work on person-centred medicine
and who are committed to the promotion
of the fundamental purposes of the orga-
nization. Additional structures to be con-
sidered are an advisory council (composed
of eminent experts and representatives of
major collaborating organizations) and an
operational council (composed of leaders
of emerging INPCM Programs, i.e., con-
ceptual and ethical bases, diagnosis, clinical
care, training, research, health systems, and
public policies).
Support for the INPCM and its activities is
expected to come, as it has been for its ini-
tial steps, from academic institutions, pro-
fessional societies, governmental organiza-
tions,foundations,person-centred medicine
and psychiatry non-proﬁt program funds,
and conference registration fees. Any sup-
port from industry sources will be accepted
provided it is transparent and unrestricted.
Further information on the INPCM can be
obtained at www.personcenteredmedicine.
org.
Colophon
Early scientiﬁc and ethical eﬀorts coalesced
through the First and Second Geneva Con-
ferences, and are ﬁnding fruition in the
International Network for Person-centred
Medicine. Encouragement is aﬀorded by
the wide array of collaborating organiza-
tions, the scholarly dedication of commit-
ted individuals, and the conviction that the
greatest asset of any community is its capac-
ity to organize itself.
References
Alanen YO. Schizophrenia: its origins and1.
need-adaptive treatment. London: Karnak,
1997.
Brera GR. Epistemological aspects of medical2.
science. Medicine and mind, 7: 5-12, 1992.
Coble Y, ed. Caring Physicians of the world.3.
World Medical Association, Ferney-Voltaire,
France, 2005.
Garrabe J. Historical views on psychiatry4.
for the person. Paris Conference on Person-
centered psychiatry; World Psychiatric Asso-
ciation, French Member Societies Association,
2008 Feb. 6-8.
Huygen FJA. Family medicine, the medical life5.
history of families. New York: Brunner Mazel,
1982.
McWhinney IR. A textbook of family medi-6.
cine. Oxford: Oxford University Press, 1989.
Mezzich JE. Psychiatry for the person: articu-7.
lating medicine’s science and humanism.World
Psychiatry. 2007; 6: 1-3.
Mezzich JE, Christodoulou G, Fulford KWM,8.
editors. Conceptual bases of psychiatry for the
person. Psychopathology. In press.
wma 7-2.indd 106wma 7-2.indd 106 9/29/09 5:25:12 PM9/29/09 5:25:12 PM
107
Point of View
Mezzich JE, Snaedal J, van Weel C, Heath I,9.
editors. Conceptual explorations on person-
centered medicine. International Journal of In-
tegrated Care. In press.
Rogers CR. On becoming a person: a thera-10.
pist’s view of psychotherapy. Boston: Houghton
Miﬄin, 1961.
Salloum IM, Mezzich JE, editors. Psychiatric11.
diagnosis: challenges and prospects. Chichester,
UK: Wiley-Blackwell, 2009.
Snaedal J. Presidential Address. World Medical12.
Journal, 2007; 53: 101-2.
Tournier P. Medicine de la personne. Neucha-13.
tel: Delachaux et Niestle, 1940.
World Health Organization. WHO Constitu-14.
tion. Geneva: WHO, 1946.
Juan Mezzich,
WPA President 2005-2008.
Jon Snaedal,
WMA President 2007-2008.
Chris van Weel,
Wonca President 2007-2010.
Iona Heath,
Wonca Executive Committee.
Nariman Safarli
Azerbaijan as Muslim country. Azerbai-
jan, an oil-rich republic of 8.1 million on
the shores of the Caspian Sea, has seen a
revival of Muslim faith since it became in-
dependent with the collapse of the Soviet
Union in 1991. Approximately 93.4 to 96
percent of the population of Azerbaijan is
nominally Muslim. Azerbaijan at the same
time is a secular country, Article 48 of its
Constitution ensures the liberty of worship
to everyone. According to paragraphs 1-3
of Article 18 of the Constitution religion
acts separately from the government, each
religion is equal before the law and the pro-
paganda of religions, abating human per-
sonality and contradicting the principles of
humanism is prohibited. At the same time
the state system of education is also secu-
lar. The law of the Republic of Azerbaijan
(1992) “On freedom of faith” ensures the
right of any human being to determine and
express his or her view on religion and to
execute this right.
As a Muslim physician. In my paper I
add information about the responsibilities
and duties, basic norms and values, which a
Muslim doctor in particular and any doctor
in general must adhere to while delivering
his or her services in the society.
I know that the most important thing for
a Muslim doctor is to be interested in the
basic values and principles of Islam.This in-
terest will be in the foreground of his or her
duties and responsibilities which will bestow
loyalty and wisdom upon his or her profes-
sion, as well as cast his or her perceptions
upon a strong foundation of our religion so
that he or she may perform his or her duties
as a real faithful believer.
Most of this information was extracted
from the Islamic Code of Medical Ethics
Kuwait Document published by the Inter-
national Organization of Islamic Medicine
in 1981 and from FIMA Year Books which
are published regularly by the Federation of
Islamic Medical Association. Some of these
recommendations were taken from the pa-
per – “The Medical Ethics – An Islamic
Perspective” written by Dr. Mohammad
Iqbal Khan and from the paper -“Medical
Ethics from Islamic Law” written by the
Prof. Omar Hassan Kasule, and some of
this information I collected during my par-
ticipation at various professional workshops
and seminars held in Malaysia, Jordan, and
the USA.
Ethics, morality and law are vitally impor-
tant in our world. Ethical, moral, and legal
responsibilities are at the heart of a physi-
cian’s competent professional behaviour and
scientiﬁc undertakings.
Islamic and Secularized Ethics. The main
task of Islamic ethics is to understand and
expound the ethos of Islam as conceived in
the Qur’an and elaborated in the Sunnah of
the Prophet.
In Muslim countries, in any discussion of
ethics, there is a tendency to look towards
religion. Islam is believed to be able to fully
restore the harmony between religion and
science. Ethics in Muslim countries is in-
separable from religious jurisprudence.New
regulations and guidelines on ethics were
compiled and put into practice using the
Islamic point of view as the basis.
Islamic bioethics is intimately linked to
the broad ethical teachings of the Qur’an
and the tradition of the Prophet Muham-
mad (s.a.w.), and thus to the interpretation
of Islamic law. Bioethical deliberation is
inseparable from the religion itself, which
emphasizes continuities between body and
mind, the material and spiritual realms
Ethical , Moral, and Legal Responsibilities of
Physicians: an Islamic Perspective
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108
Point of View
and between ethics and jurisprudence. The
Qur’an and the traditions of the Prophet
have laid down detailed and speciﬁc ethical
guidelines regarding various medical issues.
The Qur’an itself has a surprising amount
of accurate detail regarding human em-
bryological development, which informs
discourse on the ethical and legal status of
the embryo and foetus before birth.
The main principles of “western” bioethics
(autonomy, beneﬁcence, non-malfeasance
and justice) are acceptable according to Is-
lam, but interpretation of them can diﬀer.
For example, there is a limit on autonomy;
sometimes the interests of the society is
preferred to individual rights.Also the main
principles of the Hippocratic oath are ac-
knowledged in Islamic bioethics, although
the invocation of multiple gods in the origi-
nal version, and the exclusion of any god in
later versions, have led Muslims to adopt
the Oath of the Muslim Doctor, which
invokes the name of Allah. It appears in
the 1981 Islamic Code of Medical Ethics,
which deals with many modern biomedical
issues such as organ transplantation and as-
sisted reproduction.
Some physicians in Westernized Muslim
countries say that to strictly apply Islamic
medical ethics to modern medicine is tanta-
mount to a reactionary movement of a return
to subduing science under the hegemony of
religion. They say that modern medicine is
embarking on new unprecedented frontiers
of cloning, genetic engineering and hu-
man spare parts generated by stem cells. It
should be given full freedom to develop and
experiment without any religious restric-
tions or hindering rigid ethical codes.These
physicians believe that the ‘non-religious’
rational ‘versatility’ of medical ethics is a
more suitable moral guide to modern medi-
cine. Such physicians share with their west-
ern colleagues a negative approach towards
the role that religion can play in moulding
medical ethics and practice. In eﬀect they
are opposed to the whole ﬁeld of the Islam-
ization of western sciences, often discussing
this subject with mockery and ridicule.
To the average Muslim doctor and to those
who show respect to their religion, such
statements can only come from a person
who is ignorant about Islam as a religion
and world view and one who lacks depth
of knowledge about the religious aspects of
medical ethics. One does need neither to
defend Islam as a way of life nor the ﬂexibil-
ity of its usul al ﬁqh in creating a spiritually
guided modern medical ethics. It encour-
ages every new development, discovery or
innovation in the ﬁeld of science and medi-
cine, but within the framework of the spiri-
tual honour Bestowed on man by his Great
Creator.The impressive literature published
by the Federation of Islamic Medical Asso-
ciation (FIMA) and other Islamic medical
organizations and universities is quite con-
vincing to any unbiased scientist.
Islamic Ethics are derived from religious
convictions and traditions and are therefore
constant and will remain so for all time. On
the other hand, secular ethics are framed by
a society which is ﬁckle,inconsistently ruled
by a majority vote and devoid of religious
restrictions. For example, one has seen the
change from a total prohibition of abortion
to the current “abortion on demand” by the
patient accepted by society.
Similarly, Euthanasia (Mercy Killing),
which was illegal and still is in most coun-
tries in the west is “quietly”acceptable to so-
cieties where elderly people, with children
not prepared to look after them, opt for
ending their lives with the cooperation of
their doctors while the Governments look
the other way!
In much the same way, at ﬁrst artiﬁcial in-
semination involved egg and sperm fertiliza-
tion of legally wedded couples, then sperm
“banks” resulted in children with unknown
fathers and now with surrogate motherhood
the children may not know either their real
father or mother! These are the result of sci-
entiﬁc advancement; and what cloning may
produce will be an ethical nightmare. The
conceptual and moral problems of secular-
ized medicine has some paradigms that we
do not accept as Muslims. Death is rejected
as a natural phenomenon and resources are
wasted in terminal illnesses. Aging is also
not accepted as a normal process. There is
no consideration of balance and equilibrium
in selecting treatment modalities with the
result that an unacceptably high number of
patients are being treated for side eﬀects of
modern therapeutic agents. Too much nar-
row specialization leads to lack of a holistic
approach to the patient. The physician be-
haves as a technician and turns a blind eye
to the moral and social issue of the day that
aﬀect the health of his or her patients and
claims that his or her responsibility is medi-
cal care only. Secularized medicine has no
consistent set of ethics regarding malprac-
tice, fraud, and bias in research. Accepting
only empirical knowledge and negating
other sources of knowledge had also created
new problems. By denying a religious and
moral dimension, secularized medicine op-
erates in a presumed moral vacuum. It is a
gross mistake to attempt to solve social and
medical problems of a moral or spiritual na-
ture by use of technology. At the time when
the ﬁrst discussions among Islamic scholars
were held about organ transplants, attitudes
were more divided than they are today.There
have always been those against and those for
transplantation. A belief from earlier times
has been passed on, i.e., that it is permit-
ted to transfer not only tissues, but also a
bone from an animal whose meat is edible.
By analogy, the possibility of transplanting
an organ from a non-Muslim to a Muslim
and vice versa is pointed out. A Muslim
physician is obliged to give the same aid, or
medical care, both to a non-Muslim, as well
as to a Muslim.
But when the patient deteriorates and real-
izes that he or she is being terminal, it is the
Islamic responsibility of the Muslim doctor
to council the patient and to convince him
or her that all his or her agony will wash
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109
Point of View
away his or her sins, and his or her patience
will surely secure for him or her the plea-
sure of Allah. But if the patient is actually
dying, then spiritual words of optimism
about the forgiveness of our Merciful Lord
and happiness in life after death can have
unequalled positive eﬀects on the patient
and much reward to the doctor. Repeating
the creed to those whose soul has already
reached their throat is again an act of great
Islamic importance particularly for those
poor Muslims who die alone in a hospital
bed. For the Muslim doctor to ask the nurse
about a dying person, give a quick glance at
his or her medical reports and just go away
without contemplation or du’a’ or feelings
about the angels around the death bed or
the unseen pleasures and punishments
round the corner, is the action of a secular-
ized physician.
Islamic Law (Shariat ) is comprehensive
and encompasses moral principles directly
applicable to medicine.It is noteworthy that
there is a wide overlap between Islamic eth-
ics,the Islamic rulings and law,so that some
religious principles such as eternity of life or
seeking perfection could be very important
in ethical decision-making in an Islamic
setting.
Secularized Law denied moral consid-
erations associated with “religion” and
therefore failed to solve issues in modern
medicine requiring moral considerations.
The medical profession and society at large
were not ready to face the new challenges.
The existing positive secular laws are lack-
ing in moral spine. It becomes necessary to
develop secular ethics as a new discipline to
deal with the challenges.
Moral responsibilities of Muslim doctors. A
Muslim doctor is a Muslim even before he
or she becomes a doctor, but after becoming
a doctor his or her responsibilities increase
manifold. During his or her professional
duties, he or she comes into contact with
a large number of people. To them all, his
or her character is like a model. He or she,
therefore,should exhibit good character and
Islamic way of life, keeping his or her life
in accordance with the teachings of Islam.
There should be no controversy in the prac-
tical life of a Muslim physician and he or
she must be a living example of the Islamic
way of life and should never exhibit any ac-
tion contrary to his or her beliefs.Only then
physicians can be sources of inspiration for
others and only then they can link their pa-
tients with The Lord.
But what is it that makes a Muslim doctor
diﬀerent from other non- Muslim doctors?
From the technological and scientiﬁc points
of view, all doctors fall in one category.
However, when it comes to practice, the
Muslim doctor ﬁnds him or herself bound
by particular professional ethics plus his or
her Islamic directives issuing from his or
her belief. In fact, the Muslim doctor—i.e.,
a doctor who tries to live his or her Islam
by following its teachings all through—is
expected to behave diﬀerently in some oc-
casions and to meet greater responsibilities
than other non-Muslim doctors.
A Muslim physician should be a good role
model. He or she must present him or her-
self as a person of high moral character.
He or she must be polite, humble dutiful,
honest, truthful and trustworthy. He or she
should be performing his or her duties with
excellence as the rewards of excellence are
excellence “Could the reward for excellence
be anything but excellence”(Qur’an- 55:60).
One can only provide the excellent service if
he or she excels in professional knowledge,
expertise and strength of personal character.
Prophet Mohammad PBUH said, “I was
sent down by Almighty Allah for the per-
fection and excellence in morality” (Hadith
Ibne Majah).
A Muslim doctor has a two-fold of moti-
vation to remain ethical and maintain good
moral characters i.e. he or she is answerable
to the society, profession and has to abide
the law of the land, but a Muslim doctor
has the added motivation to remain ethi-
cally correct due to his or her beliefs, his
or her piety and his or her Islamic obliga-
tions. This second motivation which might
or might not be observed by others is the
most powerful tool to keep a Muslim doctor
ethical and God fearing.
An important demand of academic honesty
is that a doctor should continue throughout
his or her life to develop his or her scientiﬁc
knowledge and keep him or herself updat-
ed about new researches. Allah Almighty
taught this prayer to the Prophet: O My
Lord! Advance me in knowledge (Qur’an-
20:114).
A ﬁeld of knowledge that deals with human
life warrants even more careful attention
and continued expansion. Regular weekly
or monthly meetings of doctors at the local
level for discussion on diﬃcult and interest-
ing cases may also be an eﬀective means for
increasing one’s knowledge. Meeting other
doctors from time to time or to seek their
advice about patients is another means of
adding to one’s knowledge. Allah has said
in the Qur’an: If you do not know, ask those
who are knowledgeable (Qur’an-16:43).
Before commencing medical practice, it is
obligatory for a Muslim physician to ob-
tain the required knowledge and skill, and
to remain at the cutting edge in his or her
ﬁeld of interest in medicine. It is further
stressed in another Hadith “That a Muslim
performs his duties with excellence”. One
cannot achieve excellence in his or her pro-
fessional skills without constant eﬀort and
desire to excel in his or her profession.
The Muslim doctor is obliged to acquire the
best possible knowledge and expertise and
has to deliver his or her services to ailing
humanity without any discrimination and
without any worldly gain. If a patient can
pay for the consultation, it is fair enough to
take the fee. But if he or she is unable to
pay, the physician cannot refuse his or her
services. If a physician refuses to give his or
her services because he or she is not being
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110
Point of View
paid, he or she is committing sin. One of
the several rights which a Muslim has on
another Muslim is, “Whenever he falls ill
he is being visited by other Muslim; when-
ever he is consulted for some matter he
must impart his consultation with the best
of knowledge and taqwa”. A medical pro-
fessional is directly responsible to his or her
fellow human beings.
Muslim physician strongly believes that he
or she is not only accountable for all his
or her deeds, but he or she is quite hope-
ful that while he or she is abiding by the
divine guidelines he or she shall never go
astray. “Surely it is for us to give guidance”
(Qur’an 92-12).
However, honesty includes academic hon-
esty, but it is being mentioned separately
because of its importance. It is a must for
a doctor to acquire adequate knowledge
about the profession he or she has studied
and adopted as a career. The Holy Prophet
has said,“The one, who treats patients with-
out enough knowledge, will be answerable
before Allah for the harm he might cause”
(Hadith: Abu Dawud).
Apart from many other rights of a Muslim
on another Muslim, two important aspects
of this act of Ibada are directly related to
medical profession. A doctor has to provide
medical consultation to his or her patient
whether paid or unpaid. If a person is un-
able to pay the consultation fee of a doctor,
a Muslim doctor has to provide consulta-
tion free of cost according to the best of
his or her knowledge and expertise.Though
charging consultation fee is permissible
within limits.
When Muslim doctor deals with a patient,
he or she seeks Allah’s pleasure through it.
Immediate and material gains are not his
or her objective, though Allah accepts his
or her eﬀorts and gives health to his or her
patients. Beneﬁts, material gains, name and
fame are all a reward, but these are of only
secondary importance to a Muslim doctor
who seeks Allah’s pleasure.
A Muslim physician must be honest in all
of his or her dealings, especially when pro-
viding necessary care and advice to his or
her patients and their concerned relatives.
He or she must honestly evaluate his or her
capabilities and practice those sections of
medicine over which he or she has gained
mastery. He or she should not hesitate to
consult a specialist in a particular ﬁeld for the
best handling and management of his or her
patients. According to the Qur’anic injunc-
tions and the Sunnah “one must not indulge
himself in matters about which he does not
have knowledge and expertise”. You shall
not follow any one blindly in those matters
of which you have no knowledge, surely, the
use of your ears and the eyes and interpreta-
tion – all of these,shall be questioned on the
day of Judgment (Qur’an- 17:36).
Prophet PUH said “ Those who practice
medicine without having its proper knowl-
edge and expertise will be responsible for
their acts” (Nisai; Ibne Majah). Those who
will cause damage to the body or soul of
their fellow human beings, due to lack of
knowledge or expertise, will fall in this cat-
egory of ignorance and negligence. One
must also not discriminate between the
patients irrespective of their social status or
economic backgrounds. “No white has any
superiority over a black or a black over a
white except on the basis of Taqwa (God
consciousness). A doctor is supposed to de-
liver his or her services and expertise by the
best possible means and ways irrespective of
what is he or she going to get out of it in
terms of money. One should not discrimi-
nate between his or her private and oﬃcial
practice.A person who is unable to pay does
not deserve an inferior quality or obsolete
treatment options.
The deeper a doctor feels for humanity
and considers him or herself a healer ap-
pointed by the Creator,the greater he or she
would strive for removing sorrow.The Holy
Prophet has said that Allah loves a person
who performs whatever he does in the best
manner (Hadith: Abu Dawud).
The Holy Prophet has told us: He who
gives wrong advice to his brother commits
dishonesty (Hadith: Mishkat). If there are
more than one way for treating a patient,
then beneﬁts and harms of every treatment
should be explained to the patient besides
giving the honest opinion as to which treat-
ment is best for him or her. The decision,
then, should be left to the patient and see
what he or she opts for. If another doctor
has a better treatment, you should refer the
patient to him or her without hesitation. It
would be dishonest to keep the patient as a
source of income.
The Physician is truthful whenever he or she
speaks, writes or gives testimony. He or she
should be invincible to the dictates of greed,
friendship or authority that might pressur-
ize him or her to make a statement or tes-
timony that he or she knows is false. Testi-
mony is a grave responsibility in Islam.
Legal responsibility of Muslim physicians.
More than any other professional, the Mus-
lim medical doctor is confronted more fre-
quently with questions regarding the Islam-
ic legitimacy of his or her activities. There
are almost daily controversial problematic
issues on which he or she is supposed to
decide: e.g. birth control, abortions, oppo-
site sex hormonal injections, trans-sexual
operations, brain operations aﬀecting hu-
man personality, plastic surgery, extra-uter-
ine conception, and so forth. The Muslim
doctor should not be guided in such issues
merely by the law of the country in which
he or she is residing (which may be non-
Muslim). He or she must also ﬁnd the Is-
lamic answer and rather adopt it as much as
he or she can. To ﬁnd the answer is not an
easy matter, especially if the doctor him or
herself has no reasonably solid background
in the ﬁeld of Islamic teachings. Yet, to gain
such knowledge is very simple and would
not consume as much time as generally
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111
Point of View
presumed. In general, every Muslim must
have a preliminary knowledge of what is
reprehensible and what is prohibited. One
has to admit that our early education as in-
dividuals is very deﬁcient in this regard. But
this does not justify our ignorance of the es-
sentials of our religion and our indiﬀerence
towards its injunctions.There is no diﬃculty
nowadays to obtain a few reference books
about our Shari’ah and to ﬁnd out the an-
swers to most, if not all, our medical que-
ries. The importance of Islamic knowledge
becomes conspicuous when the subject of
the issue is purely technical and thus lies
beyond the reach of the normal religious
scholar. Besides, there are many secondary
questions that arise in the course of deal-
ing with patients where the personal judg-
ment of the doctor is the only arbiter.There,
as always, the doctor needs a criterion on
which he or she can build his or her code of
behaviour and the ethics of his or her medi-
cal procedure. The Practice of Medicine is
lawful only to persons suitably educated,
trained and qualiﬁed, fulﬁlling the criteria
spelt out in the Law. A clear guidance is the
Prophet’s tradition: “Who-so-ever treats
people without knowledge of medicine, be-
comes liable”.
After medical graduation, though a doctor
has legal right to treat all patients, but it is
neither practically possible nor morally per-
missible for every doctor to start treatment
for every ailment or try to do that. This is
why a doctor has to limit the area of his
practice. In this limited area, it is his or her
duty to acquire comprehensive knowledge
about the ailments, and keep updated. It is
also because the knowledge about ailments
and their treatment has grown so vast that it
is almost impossible for one person to have
a grasp over the entire ﬁeld of knowledge.
This is how, long ago, the idea of special-
ization in diﬀerent areas of medical sciences
started. Now, specialization is required al-
most in every ﬁeld.
Morality, ethics and law are not the same.
Morality refers to standards of behaviours
by which people are judged and ethics en-
compasses the system(s) of beliefs that sup-
port a particular view of morality. Ethical
concepts and principles are used to criticize,
evaluate, propose, or interpret laws. Soci-
eties use laws to enforce widely accepted
moral standards. Societies use laws to regu-
late conﬂicts over ethical issues in order to
guarantee social stability and democratic
order. Legal systems often illustrate nation-
al morality. Ethical systems are enforced
and codiﬁed for the “public good.”Laws are
based on the ethical system of a society. Be-
cause laws change slowly, the morality of a
society can and often does conﬂict with the
codiﬁed ethics of the society. Moral systems
begin with the individual, based on a sense
of “good” and “evil” in some cases. Religious
morality often conﬂicts with social ethics,
especially when a religion’s morality con-
ﬂicts with existing laws and greater social
ethics.
Achieving the holistic balance is only pos-
sible where action in medical practice has its
moral, ethical and legal basis.
To clearly understand what is the relation-
ship and interrelatedness between ethics,
morality and the law in an Islamic setting I
would like to illustrate ethics, morality and
law as a basis of medical practice from view-
point of Muslim doctors with very simply
three overlapping circles in iconic model – a
simple Venn Diagram as below. Any action
in medical practice must be ethical, moral
and legal (ethical, moral and legal spheres
overlap each other equally and completely).
We suggest that ethical, moral and legal
concepts as a basis of medical practice must
be present in every medical curriculum, if
we want that medicine may play in the fu-
ture its decisive role in shaping a civilized
world concerned for the respect of the hu-
man person. Increasing interrelation of
medicine, religion, ethics and law requires
greater understanding and analysis of medi-
cal ethics issues and the provision of cultur-
ally-adapted solutions.
To conclude, the role of the Muslim doc-
tor is brieﬂy to put his or her profession in
service of the pure religion Al-Islam.To this
end, he or she must know both: medicine
and Islam.
References
Mohammad Iqbal Khan. Medical Ethics – An1.
Islamic Perspective, FIMA Year Book 2004
Kasule, Sr., Omar Hasan. Medical ethics from2.
Maqasid al Shariat : Presented at the Interna-
tional Scientiﬁc Convention jointly organized
by the Jordan Society for Islamic Medical Stud-
ies,JMA and the Federation of Islamic Medical
Associations at Amman, Jordan 15-17 July .
The Islamic code of medical ethics. World Med3.
J 1982;29(5):78-80
Athar,S., Fadel,H.E.,Ahmad,W.D. et al. Islam-4.
ic Medical Ethics: The IMANA Perspective. J
Islam Med Assn 2005;37:33-42
Abdallah S. Daar and A. Khitamy “Bioethics5.
for clinicians: 21. Islamic bioethics CMAJ –
January 9, 2001; 164 (1).
Islamic Code of Medical Ethics – Kuwait Doc-6.
ument – published by International Organiza-
tion of Islamic Medicine -1981, revised 2004.
International Ethical Guidelines for Biomedi-7.
cal Research involving Human Subjects ( An
Islamic Perspective)- prepared by Islamic orga-
nization for Medical Sciences-2004
Nariman Safarli MD, President of the
Azerbaijan Medical Association, Chairman
of Forum for Medical Ethics in Azerbaijan
(FMEA), Fellow of Fogarty International
Centre and NIH on Research Ethics
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Medical Ethics, Human Rights and Socio-medical aﬀairs
Introduction
Global burden of diseases especially in the
developing parts of the world is a threat to
human existence. Low income, poor infra-
structures, inadequate skilled manpower to
contain the controllable diseases in Africa
and other developing nations make the situ-
ation pitiable[1, 2].
The millennium development goals (MDG)
of the United Nations (UN) [3] and World
health Organization Programs had iden-
tiﬁed these problems; however, a lot still
needs to be done in the areas of supportive
initiatives to assist the developing nations
achieve these goals. The collaborative ef-
forts of international organizations, donor
agencies, are very much needed to help de-
velop adequate work force and infrastruc-
tural know how to tackle this challenge.
The beneﬁt from such eﬀorts on our health
institutes on short and long term basis
could be unimaginable as will be illustrated
in this presentation. Yet there are so many
unexplored areas of human health develop-
ment. To this end, we focus on illustrating
the positive multiplier eﬀects on manpower
and community development a well orga-
nized and coordinated collaborative eﬀort
in highly skilled surgical specialties (Oph-
thalmology, Plastic Surgery and Otorhi-
nolaryngology) and the need to expand to
other areas like Pediatric Otolaryngology
where hearing loss is a common problem as
observed in the UCH.
Speech, a social attribute unique to man
is invariably a product of good hearing.
Therefore early evaluation and subsequent
hearing conservation and rehabilitation are
necessary. Unfortunately, the cost of achiev-
ing this is prohibitive making international
Collaboration indispensable especially in
the developing nations of the world.
It is on this concept we highlight the im-
portance of international collaboration.
Reviewed records on
collaborative activities
Other major collaborative institutes in Ni-
geria include:
Ebonyi State University Teaching Hospi-•
tal Abakiliki
Military Hospital Ikoyi lagos•
Jos University Teaching Hospital Jos•
University of Nigeria Teaching Hospital•
Enugu
Federal Medical Centre Owerri•
Lagos State university Teaching Hospital•
lagos
Murtala Muhammad Specialist Hospital•
Kano
Specialist Hospital Bauchi•
Furthermore, applications from many more
medical centers in Nigeria were being con-
sidered by the smile train.
The burden of Cataract and blindness
The most recent global data on the preva-
lence of blindness estimates that about 37
million people are blind while another 124
million are visually impaired [4, 5]. The
WHO estimates that about 75% of global
blindness is avoidable and over 90% of
blind people live in developing countries
[6].Cataract is responsible for about 48% of
global blindness [4] and 33-70% of blind-
ness in Nigeria [7-13]. Majority of those
International collaborative initiative surgical
Manpower development: a plea to do more in
low –income-countries
Collaborative Surgical Manpower Development
Titus S Ibekwe
Adeyinka O Ashaye
Bolutife A Olusanya
Onyekwere GB Nwaorgu
Paul A Onakoya
Odunayo M Oluwatosin
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113
Medical Ethics, Human Rights and Socio-medical aﬀairs
aﬀected have little or no access (geographic
and ﬁnancial) to health services [14, 15].As
a result the quality of lives of these patients
deteriorates and fewer patients present to
the hospitals. The low volume of patients
undergoing cataract surgery had a negative
impact on the training capacities of the eye
care training centers available in Nigeria.
Collaborative remedial
eﬀorts and outcome
International Council of Ophthalmology
(ICO) conducted site visits to a number of
eye care facilities in Nigeria in April 2004.
Training and infrastructural deﬁciencies in
the delivery of eye care services in Nigeria
were found and this resulted in the initiative
to establish a model regional ophthalmic
training center in West Africa. The Oph-
thalmology Department of the University
College Hospital Ibadan, Nigeria was cho-
sen for this purpose. The initiative was co-
sponsored by the International Agency for
Prevention of Blindness (IAPB) and Carl
Zeiss Company. The main aim was to im-
prove ophthalmic training through imple-
menting initiatives to increase patients’
volume, focus on subspecialty training, pro-
vision of infrastructure and strengthening
of management / operational systems.
An initial take-oﬀ boost was given by Dr.
El-Margaby, the then president of Middle
East African Council (MEACO)], who
donated consumables for 500 cataract sur-
geries. The surgical programme started in
September 2006. The patient load for cata-
ract surgeries increased by 247.9% within
the year (table 1). A positive impact was
also felt on the residency training as regards
the increased number of cataract surgeries
(211.1%) performed by the senior resident
Doctors as primary operators.
Despite the increase in the volume of sur-
gical turnover, the quality of surgeries were
not compromised rather the frequent expo-
sure and hands-on experience of the resi-
dent doctors made room for good quality
assurance in the patients management. This
was demonstrated by a signiﬁcant increase
in the proportion of patients with good
visual outcome deﬁned at Visual Acuity
(VA) 6/18 or better after cataract surgery.
An increment from 68.4% to 85.5% was re-
corded. This is close to the WHO standard
of about 90% record of VA 6/18 or more.
Again, the insertion of intraocular lens after
the cataract extraction has been perfected
by the trainees and is now the standard
practice in the hospital. The impact of the
initiative on the social lives of the patients is
currently being evaluated, however, the goal
of VISION 2020: the right to sight is being
achieved in no small way.
Cleft lips and palate disorders
and collaborative remedies
Cleft lip and /or palate are major problems
of the developing nations where millions of
children carry their clefts un-repaired due
to economic and infrastructural impover-
ishment [16, 17]. Apart from the distorted
cosmesis, feeding and speech are usually
impaired and is often associated with social
stigmatization [18, 20]. As a result, inte-
gration in schools, work places and social
gatherings are seriously hampered .The
surgical time for the repairs of cleft could
be as short as 45 minutes and the cost as
Table 1.
Cataract surgeries and ICO initiatives
Parameters Pre ICO
Initiative
(2006)
Post ICO
Initiative
(2007)
Percentage
(%)Increase
Z-test @ 95% conﬁ-
dence
Interval
(Z-values)
Average Cataract sur-
gery load per Annum
282 699 247.9 12.03
Average cataract
extractions per senior
Resident Dr.
45 95 211.1 3.85
Table 2.
Established centers for the smile train cleft repair initiatives in Nigeria and activities in
2008/2009
Institutes Proposed no of
free repairs /year
Achieved no of
free repairs / year
Lagos University Teaching Hospital 100 90
National orthopaedic Hospital Enugu 100 75
University College Hospital Ibadan 60 20
Univ. of Maiduguri Teach. Hospital 50 61
Obafemi Awolowo Teach. Hosp. Ile Ife 50 50
Fed Med Center Gombe 50 48
National hospital Abuja 40 25
Ladoke Akintola Univ.Teach Hosp. Osogbo 40 23
Ahmadu Bello University Teaching
Hospital Zaria
40 47
Usman Danfodio UTH Sokoto 33 13
Aminu kano Univ.Teach. Hospital kano 25 40
Univ. of Ilorin Teach. Hospital 20 15
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114
Medical Ethics, Human Rights and Socio-medical aﬀairs
low as $250.00 [21, 22]. However, bearing
in mind that most developing countries of
the world, including Nigeria, live below the
poverty line (per capita income less than
USD$ 826) [17] it stands to reason why this
is not readily aﬀordable. Since March 2000,
a non-governmental organization called
“Smile Train” has oﬀered free cleft surger-
ies for 280,738 children worldwide. The
mission was to focus on cleft lip and palate
repairs, empower local doctors in develop-
ing countries with the skills and resources
through collaborative training to achieve
best safety/quality rewards among cleft
charities at lowest possible costs [21].
The University College Hospital (UCH)
Ibadan Nigeria is one of the centres in Ni-
geria where the Smile Train services are
oﬀered. This is mainly a plastic and recon-
struction teams’ work, however, a multi-
disciplinary management of the patient is
necessary.The ENT surgeons, speech thera-
pists/pathologists,maxillofacial surgeons are
members of the team in the UCH, Ibadan.
As shown on table 2 above, UCH center has
one of the highest renewable quotas of 60
cleft repairs.The contract was signed in De-
cember 2006 and ﬁrst installment of pay-
ment for sponsorship of the repairs made
in January 2007. Within the ﬁrst quarter of
the year, 33.0% of the target per year has
been achieved with good outcome (devoid
of signiﬁcant anesthetic or surgical compli-
cations). Apart from the social beneﬁts to
the patients and the relations, it is also an
avenue for exposure and training of the resi-
dent doctors in this ﬁeld of endeavor.
Beneﬁts and other area of need
Like the ICO surgical initiative, the pro-
gram helps to pool the cases of cleft to the
designated centers. This enhances skill and
exposure of the trainee surgeons and as
noted by the co-coordinator of the program
in UCH Ibadan, the exposure to the trainee
doctors has been worthwhile. A similar ob-
servation was also made by the trainees.
Regional workshops and trainings are also
held regularly on the cleft repairs. A bi-
monthly and quarterly academic conference
by the members of the multidisciplinary
team is being integrated into the program
in UCH Ibadan. This will ensure proper
evaluation, auditing and a high standard of
practice.
A close evaluation of the above two proj-
ects resulting from international surgical
initiatives and collaborations had revealed
a tremendous improvement on the train-
ing of resident doctors in skill acquisition
and manpower development. It has also
improved the health and social lives of the
populace especially the less privileged in the
developing countries who cannot aﬀord the
surgical fees. It is in this light we identiﬁed
SNHL among children (excluding acute or
chronic otitis media) as an important area
that has constituted a burden to the Oto-
rhinolaryngologists in a developing country
like Nigeria.
Sensorineural hearing loss in children
The disease burden posed by this ailment in
our environment deserves an urgent atten-
tion including assistance from donor agen-
cies just like the ICO/IAPB ‘Cataract’ and
the ‘Smile train cleft repair’ initiatives. In
1995 , the WHO indices showed that about
12 million people world wide had disabling
hearing loss (>40dB) and that warranted a
declaration by the World Health Council
that all member countries should prepare
action plan for early detection of hearing
loss through screening tests for newborn,
toddlers and infants [24]. Ten years later
(2005), statistics showed that this “hidden
handicap” had aﬀected about 250 million
people, out of which about 75% live in the
developing countries and 25% were of early
childhood onset [25].
From the above review, Sensorineural hear-
ing loss among children constituted about
14.6% of all pediatric cases seen in ORL
Department out of which about 72.0% fall
within the under 5 age group. Regrettably,
the actual onset and possible etiologies in
most of these cases are not known. This is
in consonance with the ﬁndings in earlier
studies in Nigeria, Ghana, Sierra Leone and
the Gambia which revealed that 21-36.5%
of cases of Sensorineural hearing losses
were either of unknown cause or suspected
congenital causes [26-30]. In fact, presen-
tations are mostly dependent on when the
parents feel that there is undue prolonged
poor cognitive response. Most times these
patients are presented to the hospital be-
yond the critical period of the acquisition
of speech, language and cognitive functions
(within the 1st
year of life) [31,32].
In the past these late presentations were at-
tributed to socio-cultural and superstitious
beliefs of the parents [27, 33]. However,
emerging facts have shown that this trend
is changing and most parents are becoming
aware but the impending limitation is in the
aﬀordability of the medical bills [26, 34].
Again, most of the medical facilities in Ni-
geria and indeed most developing countries
lack the needed infrastructures and man-
power to tackle the challenges. The intense
investigative (genetic, audiological and im-
aging) and rehabilitative tools required for
the eﬀective management of these patients
are lacking.
Genetic/familial factors are recognized
world wide as strong links to immediate or
late manifestations of Sensorineural hearing
loss [35]. Syndromic and non-Syndromic
forms have equally been identiﬁed. Sickle
cell anemia, predominant in black race,
has been identiﬁed by several authors as
a predisposition to Sensorineural hearing
loss probably through the vaso-occlusive
eﬀect on the microvasculature of the co-
chlea of the young infants [36-38]. Apart
from Sickle cell anemia and probably Con-
nexin 26 (detected in Ghana through col-
laborative eﬀorts by Brobby et al) [39, 40],
other hereditary causes are poorly studied
and hardly detected early in our sub region.
Necessary manpower for hearing genetic
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115
Medical Ethics, Human Rights and Socio-medical aﬀairs
studies in Africa is needed in designated
centers to ﬁll in this gap.
Obstacles to remedy
The basic universal hearing screening for
the newborn, infants and pre-school aged,
which is the expected standard worldwide
[41 – 43], has a great set back in Nige-
ria. The tools needed for this purpose like
Otoacoustic emission (OAE), Automated
Brain Response (ABR), Screening and
diagnostic Audiometers and Tympa-
nometers are lacking. These are not read-
ily available in specialists’ centres not to
talk of the other health facilities where
birth deliveries are taken. OAE and ABR,
which are automated machines designed
for the purpose of hearing screening in
children costs about USD$3,000.00 and
$8,000.00 respectively. At least two each
are needed in designated screening centres
to enhance maintenance and sustainability
of this program. As correctly observed by
Olusanya et al , government contributions
to health in developing countries (as low
as 24%) are far cries compared to devel-
oped countries (as high as 81%)and this
translates to nearly 90% out of pocket ex-
penses for the populace in the developing
countries within their limited income.
This means that at best the government
role in these countries could only be facil-
litatory –i.e. sensitization and creation of
awareness among the populace on the ex-
isting programme. Therefore, sponsorship
of such programs in developing nations
like Nigeria will largely depend on Inter-
national collaborations with professional
organizations, donor agencies through
private public partnerships [44].
Rehabilitative technologies through hear-
ing aids and cochlear implants are either too
expensive or non-existent in Nigeria. Most
families cannot aﬀord hearing aids. Up to
date, only two cases of cochlear implanta-
tion carried out in Jos, Nigeria, in 2005 at
ECWA missionary hospital in collabora-
tion with House Institute USA has been
recorded. Temporal bone surgeries and
Otology training in Nigeria needs urgent
attention from international surgical and
Otorhinolaryngological initiatives. Basic
and functional temporal bone laboratories
are few amongst our ORL training centers
in Nigeria.
Conclusion and way forward
As observed on the impact in these special-
ties, eﬀorts need to be improved, sustained
and expanded to other ﬁelds to avoid a
skewed eﬀect where other areas are neglect-
ed with the anticipated consequences as ex-
empliﬁed in the Pediatric Otolaryngology
specialty.
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Cooper RS, Osotimehin B, Kaufman JS, et al.34.
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Han B, Dai P, Qi QW, et al. Prenatal diagnosis35.
for hereditary deaf families assisted by genetic
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Mgbor N, Emodi I. Sensorineural hearing loss36.
in Nigerian children with sickle cell anemia. Int
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Odetoyinbo O,Adekile A. Sensorineural hear-37.
ing loss in children with sickle cell anemia. Ann
Otol Rhinol Larngol.1987;96:258-260.
Onakoya PA, Nwaorgu OGB, Shokunbi WA.38.
Sensorineural hearing loss in adults with sickle
cell anemia. Afr.J Med Med Sci. 2002;31:21-24.
Brobby GW, Muller-myhsok B, Horstmann39.
RD. Connexin 26R143W mutation associated
with recessive non-syndromic Sensorineural
deafness in Africa. N England J Med.1998;
338:548-550.
Hamelmann C, Amedofu GK, Albrecht K,40.
et al. Pattern of connexin 26(GJB2) mutaions
causing Sensorineural hearing impairment in
Ghana. Human Mutat. 2001;18:84-85.
Grill E, Hessel F, Siebert U, et al. Comparing41.
the clinical eﬀectiveness of the diﬀerent new
born hearing screening strategies. A decision
analysis. BMC Public Health.2005;5:12.
Ptok M. Early Diagnosis of hearing im-42.
pairment in children. Z Arztl fortbild
Qualitatssich.2004;98:265-270.
Universal newborn hearing screening ﬁne-43.
tuning the process. Curr opin Otorhinolaryngol
Head and neck surg.2003;11:424-427.
Olusanya BO, Swanepoel DW, Chapchap MJ,44.
et al. Progress towards early detection services
for infants with hearing loss in developing
countries. BMC Health Serv Res. 2007;7:14.
Dr. Titus S Ibekwe, MBBS (Nig),
FWACS, FMCORL, ENT Division,
Department of Surgery, College of Health
Sciences, University of Abuja Nigeria.
Dr. Bolutife A Olusanya, MBBS (Ib),
FWACS, Department of Ophthalmology
University College hospital Ibadan.
Dr. Paul A Onakoya MBBS (Ib), FWACS,
FMCORL Department of ORL University
College Hospital Ibadan Nigeria.
Dr. Adeyinka O Ashaye MBBS, FMCOph,
FWACS, Department of Ophthalmology
University College hospital Ibadan.
Dr. Onyekwere GB Nwaorgu, MBBS (Ib),
FWACS, FMCORL, Department of ORL
University College Hospital Ibadan Nigeria.
Prof. Odunayo M Oluwatosin MBBS
(Ib), FMCS, FWACS, Division of Plastic
Surgery, Department of Surgery University
College Hospital Ibadan Nigeria.
About a year ago, a crisis related to devel-
oped countries’ housing markets contrib-
uted to a global ﬁnances collapse and led to
the worst world economic crisis since 1929.
Years of equity wealth in world market cap-
italization have been destroyed and millions
have lost their jobs. An additional twelve
million people more than expected before
the crisis will fall below the $2-a-day pover-
ty line this year and seven million more than
expected will experience “absolute poverty”
($1.25 a day). The pandemic H1N1 threat-
ens to make things even worse while major
lingering contributing crises to health prob-
lems (demographics, environment, energy)
have not been resolved. Billions have been
invested in rescuing banks and funding re-
covery programs, the revenue base of social
protection is shattered and debt may jeop-
ardize the economic prospects of coming
generations.
The World Health Organization is coor-
dinating the health response. A high-level
consultation on “Financial Crisis and Glob-
al Health” was held in Geneva in January
2009. The April 2009 meeting on “Health
in Times of Global Economic Crisis” in
Oslo and the 62nd
World Health Assembly
in May were also crucial. The 59th
Europe-
an Regional Committee in September will
hold further discussions.
What are the likely implications for health
in Europe? No “scientiﬁc” predictions can
be made. I will brieﬂy review what is known
about the determinants of health (including
available evidence from previous economic
crises) and issues related to regional health
services access.
There is consensus about the causes for the
improvement in world health in recent dec-
Re-thinking Means and Ends: Economic Crises,
Health and Access to Health Services in Europe
Nata Menabde
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117
Medical Ethics, Human Rights and Socio-medical aﬀairs
ades. In 2008 both the report of the Com-
mission on Social Determinants of Health
and the European Ministerial Conference
on Health Systems, Health and Wealth
conﬁrmed that in a context of declining fer-
tility, improvements were due to combined
interventions at social level (nutrition,hous-
ing, education, etc) and at the health system
level (population and personal services,such
as care of the newborn, vaccines, treatment
of injuries, etc.).
However severe equity gaps persist. World-
wide, 42 countries account for 90% of total
child deaths. In the European Region there
is a diﬀerence of 35-40 years in average life
expectancy between rich people in Luxem-
bourg and poor people in Tajikistan; a child
born in the Commonwealth of Independent
States is three times as likely to die before
the age of ﬁve as a child born in the Eu-
ropean Union (EU); maternal mortality in
Central Asian Republics double the region-
al average. Problem exists even within the
EU: men in Latvia and Lithuania live 14
years less than in Sweden and Ireland (65
versus 79 years); in Slovakia, infant mortal-
ity from respiratory diseases in 2001 was
8.34 per 1000 live births, while the median
in the European Region was 1.6.
Do previous recessions oﬀer clues about the
likely evolution of health in Europe in the
future?
Diﬀerent negative health impacts were re-
ported: low income countries experienced
increases in infant and child mortality and
micronutrient deﬁciency, plus anemia in
women; in higher income countries, prob-
lems included mental health problems and
suicides, with occasional crisis duration-
related increases in adult male mortality.
Spain in the 1980s and Finland in the 1990s
showed no noticeable negative impact; al-
though perhaps the adverse consequences
of recession took longer to manifest, or only
appeared within marginalised subgroups.
State welfare institutions, including health
systems, seem crucial, i.e., whether or not
government spending fell and rapid action
was taken even if revenues decreased. If so,
capital expenditure -infrastructure, equip-
ment- was usually delayed. Imported medi-
cines and technologies became more expen-
sive if the local currency was devalued.
Whenever household incomes fell,domestic
health spending (especially private) also fell.
Utilisation of health facilities that charged
for services always declined, with people
switching to government and subsidised
(e.g. NGO) facilities.
This leads to the issue of comparative health
service utilization in Europe. Clearly, uni-
versal access to health services is an eﬀective
and eﬃcient way to reduce poverty and social
inequalities by ensuring the positive eﬀects
of preventive, therapeutic and care related
action and preventing the catastrophic ex-
penses attached to health services utiliza-
tion.
Beyond that broad objective, squaring
health service accessibility in Europe raises
enormous challenges. First, access indica-
tors have little comparability; if outpatient
contacts per person were used as standard,
for example, the baseline in the WHO Eu-
ropean Region would rank from more than
15 (Czech Republic) to 1.5 (Albania). If
hospital admissions as a percent of the pop-
ulation were used instead, the range would
go from 26% (Austria) and 23% (Russia) to
5% (Azerbaijan) or 8% (Netherlands).
Second, such “contacts”reveal little in terms
of services to the population because of the
diﬀerent input combinations each country
uses in producing them.For example,health
professionals’ density is three times higher
in Germany (46.5/1,000 inhabitants) than
in Portugal (13.5/1,000 inhabitants) and
indeed those numbers are split diﬀerently
among professional categories (doctors,
nurses, etc); Ireland for example has 15.5
nurses/1,000 inhabitants,which is ﬁve times
more than Turkey’s 3.1/1,000 inhabitants.
Third,there are huge diﬀerences in ways that
resources are spent, ranging (at purchasing
power parity (PPP)) from US$ 5,686 per
person per year in Luxembourg to US$ 93
in Tajikistan. The fractions spent by the
public versus the private sectors, collected
as pre-paid insurance versus as direct out-
of-pocket payments, etc., are enormously
varied as well.
Fourth and most importantly, comparing
quality (“ﬁtness for use”) would require a
deeper understanding of health needs (bur-
den of disease and equity), context (values,
expectations,socioeconomic situation,tech-
nological development, political climate)
and health systems (“the ensemble of all
public and private organizations, institu-
tions and resources mandated to improve,
maintain or restore health within the po-
litical and institutional framework of each
country: it encompasses personal and popu-
lation services as well as activities to inﬂu-
ence policies and actions of other sectors
addressing the social, environmental and
economic determinants of health”). Health
intelligence for policy making and better as-
sessing health system performance is mostly
“work in progress”at the moment and needs
to be further developed.
In summary, overcoming this economic cri-
sis requires well targeted,timely investments
in health systems as part of economic stimu-
lus packages because it is good for health, social
stability and the economy. Improved access
is a particularly critical objective. The crisis
however calls for doing things diﬀerently,
avoiding duplication, fostering partnership,
strengthening health governance and im-
proving performance assessment, as stated
in the “Tallinn Charter”from the European
Ministerial Conference on Health Systems,
Health and Wealth in June 2008.
Dr. Nata Menabde
Deputy Regional Director,
World Health Organization
Regional Oﬃce for Europe
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WMA news
Jens Winther Jensen
The WMA has entered into the debate on
climate and health. Recently, the WMA
and the Danish Medical Association held
a seminar in Copenhagen to discuss the
WMA draft Statement on Health and Cli-
mate Change and the state of the climate
in the world today. Immediately after the
seminar the WMA issued a statement de-
claring that health should be given a much
greater priority at the UN Global Climate
Change Conference in Copenhagen in De-
cember 2009. You can access this statement
on the Danish Medical Association website
www.laeger.dk.
The purpose of the WMA-DMA spon-
sored Copenhagen, seminar which took
place 1 September 2009, was to gather the
knowledge on the present global situation
and provide input to the WMA Statement
on Health and Climate Change. The state-
ment will inspire National Medical As-
sociations to take action to prevent health
related consequences of climate change.
The Statement is being edited and will be
presented for adoption at the upcoming
WMA General Assembly in New Delhi in
October, Thereafter, the statement will be
directed at the United Nations Conferences
of the Parties – COP15 in December 2009
also to be held in Copenhagen.
However, the initiative to get health on the
global agenda must begin now.
At the seminar we learned that global warm-
ing will have very serious consequences on
health. Everybody will feel the consequenc-
es in their daily lives and the consequences
are irreversible.
All signals of melt-down – waters rising,
droughts, heat waves, ﬁres, desert spread-
ing – are well described and were explained
again at the seminar by presenters from
Asia, Africa, Australia, Europe and North
America.
Not so widely understood are the conse-
quences for the respective physicians and
the health care systems all over the world.
How will climate changes aﬀect health pro-
fessionals and the ability to provide health
care? Do we need to adjust health infra-
structures now – and if so, how?
The presenter from the WHO expressed
bewilderment that we have been discussing
climate change for so long, but only within
the last couple of years have we begun to talk
about the health aspects and consequences
on health of the global change in climate.
Are we reacting too late? Time will tell.
There are many regional diﬀerences in the
eﬀects of climate change and the reaction
of authorities. France is the ﬁrst western
country to give the health aspect top pri-
ority when discussing climate change.
Maybe this is related to the fact that France
has experienced heat waves that have cost
lives, mainly of elderly people. Besides this
fact, former French colonies in Africa will
probably experience some of the worst con-
sequences of global warming.
There are also huge diﬀerences in the fa-
cilities that greatly impact how the country
deals with dramatic changes in the climate.
These facilities relate to infrastructure.
In South Africa 40 percent of all hospitals
are without clean water and water shortages
are critical. It will be the responsibility of
governments to ensure that strategies on in-
frastructure are implemented to avoid the
most severe consequences of climate change
and do not increase inequality in the access
to health care.
The climate changes will further accentuate
inequalities in health if we do not react in
time.
The good news is that there is strong correla-
tion between what is good for our health and
what will beneﬁt the climate. Get out of the
cars and hop on a bike! This will lower the
CO2 emission. The consumption of salads
and vegetables instead of beef will also ben-
eﬁt the climate,since a lot of CO2 is used in
the production of meat. In these and many
other ways, the preventive meassures of ill
health and climate change coincide. One of
the positive outcomes of the Copenhagen
seminar was the statement: ”What is good
for the climate is good for health.” Now, we
all must begin working to change habits and
inﬂuence our governments.
Dr. Jens Winther Jensen
Climate Changes and Health –
There is Some Good News…
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Ongoing global warming is caused by hu-
mans’ increasing emission of greenhouse
gases, this warming is causing global cli-
mate changes, and these changes have local,
regional and global health implications.The
seminar in Copenhagen was an opportunity
to review the state of the art concerning
health implications of climate change, and
to comment on the proposed WMA posi-
tion statement.
The health consequences of climate change
could, according to Colin D. Butler (The
Australian National University), be under-
stood using a classic health model: primary,
secondary and tertiary health impacts. The
primary health impacts include heat waves,
injuries after ﬂoods or ﬁres, infrastructure
collapse; secondary consequences are vec-
tor-borne diseases, food and water-borne
infections, and allergies; and the tertiary
consequences would be famine,local and re-
gional conﬂicts, displacement, refugees, and
developmental failure. Dr. Butler stressed
that tertiary consequences would cause the
greatest health impacts in this century.
Education is crucial, though not suﬃcient
to solve these problems. Dr. Butler empha-
sized the need for changes in university and
professional education. In particular, educa-
tion at the undergraduate and postgraduate
levels needs to focus on sustainability and
limits to growth.
Ms. Francesca Racioppi Acting Head of Rome
Oﬃce, (WHO) noted that when we think
about the trends created by the ﬁnancial cri-
sis, we can quickly understand that a crisis
caused by climate change would similarly
weaken our capacity to respond.We need to
think in the medium and long term and not
just about the next election.
Dr. Mike Gill (Professor Public Health, Uni-
versity of Surrey, UK) proposed that health
professionals became more aware of certain
and immediate health beneﬁts of climate
change mitigation. Life style changes, such
as active transportation will mitigate climate
change and will have a positive inﬂuence on
obesity, heart diseases, diabetes, cancer, re-
spiratory diseases, road traﬃc injuries, and
osteoporosis. As those in wealthier coun-
tries change their lifestyles, they will also
bring about equity.
The WHO estimates that the prevalence
of preventable disease in high income and
low-income countries due to environmen-
tal degradation is, respectively, 17% vs. 25%.
Understanding and surveying for the socio-
economic determinants of health are es-
sential to developing eﬀective public policy.
Dr. Maura N. Ricketts (Director, Oﬃce for
Public Health, Canadian Medical Association)
concluded that an understanding is not
achieved without an emphasis on research.
Ms. Susan Wilbum (Dep. of Public Health
and Environment, WHO) urged physicians,
medical associations and countries to work
collaboratively to develop systems for event
alerts to ensure that health care systems
and physicians become aware of high risk
climate events as they unfold, and receive
timely accurate information regarding the
management of emerging health events.
In Asia, the most populous continent, the
marine and coastal ecosystems are likely to
be aﬀected by sea-level rise and temperature
increase, as is agriculture. The risk of hun-
ger and water resource scarcity is growing,
reported Professor Dongchun Shin. The Hi-
malayas provide water to a billion people.
South Asian countries must prepare for the
impacts of global warming, melting glaciers
and subsequent loss of potable water.
Even without climate change Africa is al-
ready suﬀering severely from public health
problems that are exacerbating morbidity
and mortality more than in other continents,
Drs. Sandrine Segovia-Kueny and Louis-Jean
Calloc’h summarized. WHO estimates that
climate change is already claiming 150,000
human lives annually and most of this hap-
pens in Africa. Climate change (and global
warming) is creating climatic instability,
which interferes with the rainfall patterns
and aﬀects domestic agricultural produc-
tion. Minister for Development Corporation,
Mrs. Ulla Toernaes in her closing remarks
reminded us that the poorest countries are
the most vulnerable to the negative impacts
of climate change and thus that those who
have contributed least to the problem are
facing the most severe consequences. WMA
General Secretary, Dr. Otmar Kloiber further
contributed to this perspective by his clos-
ing remark that “we owe our possibilities (to
act, mitigate and adapt) to those who don’t
have them”.
Øjvind Lidegaard, Professor, Rigshospitalet,
Dept. of Obstetrics & Gynaeocology,
University of Copenhagen, Denmark
Maura N. Ricketts, Director,
Oﬃce for Public Health, Canadian
Medical Association, Canada
Climate Change and Health Care –
a Summary of the Sessions at the
WMA Seminar held in Copenhagen
on September 1st
, 2009
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WMA news
Mike Gill
”I believe that climate change will ride across
this landscape as the ﬁfth horseman. It will in-
crease the power of the four horsemen that rule
over war, famine, pestilence, and death – those
ancient adversaries that have aﬀected health
and human progress since the beginning of re-
corded history” (Dr. Margaret Chan, Director
General World Health Organisation,The 2007
David E. Barmes Global Health Lecture)
The welter of arguments to justify immedi-
ate action to mitigate climate change is now
well known. Increasingly the arguments
linking climate change to global health are
being loudly articulated. Indeed, Dr. Mar-
garet Chan, Director-General of the World
Health Organisation, two years ago de-
scribed climate change as the deﬁning issue
for public health during this century. „With
impoverished populations in the develop-
ing world the ﬁrst and hardest hit, climate
change is very likely to increase the number
of preventable deaths. The gaps in health
outcomes we are trying so hard to address
right now may grow even greater.” (David
E. Barmes Global Health Lecture 2007) .
Since then two major publications have
set out the detail of the impact of climate
change on humans and on human health [1,
2] (see Figure 1). There is no getting away
from the facts that climate change is now
having huge impacts on human health, that
these will become greater if no action is
taken, and that the most vulnerable are the
world’s poorest, already most vulnerable to
poor health and premature death, and least
responsible for greenhouse gas emissions.
This growing threat has to be added to the
other major threats to the health of poor
people across the world. Chronic diseases,
for example, now impose their heaviest
burden in low- and middle-income coun-
tries.They place enormous strains on health
systems. In many parts of the world the
additional burden of climate change will
break them. Some of
its eﬀect will be direct
– for example through
increased insect-borne
disease, food poisoning,
and injury and infectious
disease from ﬂooding.
Much larger though will
be its indirect eﬀects.
Crop failures will cause
famine, water shortages
will cause conﬂict, as
will mass migration and
economic collapse. All
will cause death.
These are perhaps the
most obvious reasons
why health professionals
should be clamouring
for ﬁrm global action to
control greenhouse gas
emissions to mitigate
climate change, and to
provide suﬃcient re-
sources for middle and
low-income countries to
increase their adaptive
capacity, in other words
to become more resilient
to the threats to which they are already ex-
posed or which are now unavoidable.
There is also a very diﬀerent set of argu-
ments which health professionals in general,
and doctors in particular, need to state, and
which politicians and negotiators from the
rich countries may ﬁnd easier to hear and act
on. These arguments are based on the size
of the beneﬁts to population and individual
health which arise from mitigation actions.
Actions in the energy sector, for example
how we choose to generate electricity, in the
transport sector, for example through the
promotion of active transport, in the built
environment, for example how energy- ef-
ﬁcient buildings are, and in the food sector,
for example through adjustments in our
meat and diary product consumption, all
Is Climate Change the Fifth Horseman?
Figure 1
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WMA news
these may have a profound eﬀect on health
in both rich and poor countries.
Mitigation actions will halt the spread of
many of those chronic diseases borne of
urbanisation – increasingly unhealthy di-
ets, sedentary lifestyles, and obesity. These
are already putting health and health sys-
tems under intolerable strain, often in the
poorest countries.In Cambodia for example
one in ten adults has diabetes and one in
four hypertension. Cardiovascular disease
accounts for 27% of deaths in low-income
countries (often at a younger age than in
higher-income countries). The combined
deaths from malaria, tuberculosis and HIV/
AIDS account for only 11% [3, 4].
So on top of the arguments rooted in social
justice – that we should end poverty and re-
duce global inequalities in health – it is clear
that health is no longer a mere consumer of
resources. It is also a producer of economic
gains, as a result of those very actions being
considered to avoid runaway climate change.
One of the most important of these is in
the realm of transport, a major and increas-
ing source of greenhouse gas emissions. As
well as the important eﬀects on road-traﬃc
injuries, urban air pollution, energy-related
conﬂict, and environmental degradation,
there are signiﬁcant
health gains associ-
ated with replacing
fossil-fuel based
transportation with
walking and cycling.
For example the eco-
nomic cost of obesity
to the UK by 2050
has recently been
projected to reach
£50 billion at today’s
prices, in addition to
the £10 billion direct
cost to the NHS [5]
. On the other hand
Woodcock and col-
leagues have mod-
elled the potential
health gains for an average car-driving
women, age 35-44 years, changing to rid-
ing a bicycle in London, where almost three
quarters of car trips are less than eight kilo-
metres. They conclude she would lose 15g
fat tissue per day, the equivalent of 5.6kg
fat tissue per year. She would rapidly reduce
her risk of premature mortality by 20–40%,
breast cancer risk by 25%, all cancer risk by
more than 20%, and risk of developing dia-
betes mellitus by more than 30% [6].
Interventions to curb the current global in-
crease in meat consumption, which is ﬁve
times what it was ﬁfty years ago (see Fig-
ure 2), are similarly likely both to reduce
greenhouse gas emissions (agriculture is re-
sponsible for 22% of total global emissions,
more even than transport) and to beneﬁt
health, especially in high-income countries
mainly through reducing the risk of ischae-
mic heart disease (especially related to satu-
rated fat in domesticated animal products),
obesity,colorectal cancer,and,perhaps,some
other cancers[7].
Currently 2.4 billion people depend on tra-
ditional biomass for cooking. This has major
health eﬀects: about 1.6 million people die
every year from the eﬀects of exposure to high
levels of indoor air pollution, largely in low-
income countries [8]. It also generates large
quantities of black carbon, now known to be
the second strongest contribution to global
warming after carbon dioxide emissions [9].
A mitigation action essential to controlling
climate change – addressing the lack of ac-
cess to clean energy for such large numbers
of people in low-income countries – will thus
also confer huge health beneﬁts.
Realizing these potential health beneﬁts re-
quires public and political support for the
mitigation actions that will induce them.
To achieve this, health professionals must
make both politicians and the public aware
of the scale of those beneﬁts. In this task so
far we have not done well. A recent article
by a doctor in the Times newspaper in the
UK likened climate change to cholera in the
nineteenth century. Just as fear of cholera
outbreaks that killed rich and poor in Vic-
torian times led to vast sums being spent on
sewers and ensuring clean water supplies,
the physician asserted, so „the medical pro-
fession should be in the vanguard of this
new revolution in public health” [10] (see
Figure 3). The responses to this call to ac-
tion were revealing: as well as bringing out
the frank „climate change deniers’ in force,
there was a strong theme of „doctors should
stick to their own area of expertise”. While
those who respond to newspaper articles are
not a scientiﬁcally random sample, this re-
sponse nontheless supports the impression
that there is much work to be done before
the public in the UK understands the dual
Figure 2
World meat production (1950-2006)
Figure 3
The Times
May 25, 2009
Climate change is the cholera of our
era
The medical profession needs to wake
up: we should be in the vanguard of the
green revolution
Muir Gray
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WMA news
beneﬁts of low carbon living. With this un-
derstanding comes a critical reduction of the
political risk associated with promoting and
supporting an equitable global agreement to
control greenhouse gas emissions.The health
beneﬁts of low carbon economies and low
carbon lifestyles provide powerful impetus
to politicians in terms of being able to carry
their electorates with them along what is an
irreducibly radical path if the global agree-
ment is to achieve its objectives.
The stakes are high and so the level of our
eﬀorts must be commensurate with what
we have to gain by achieving our goals.
We must leverage the public’s trust of the
medical profession, which endures despite
global health crises and occasional bad pub-
licity [11,12]. We need to do a better job
of illustrating the clear links between envi-
ronmental strategies and improved health,
clearly articulating the major beneﬁts of ap-
propriate action. Where possible we should
lead personal life styles which are climate-
friendly, and encourage our patients to do
the same. And we should hone our advo-
cacy, ensuring that politicians, as well as the
public, get the message.
At a time when health systems across the
world face signiﬁcant ﬁnancial constraints,
this message is one of the few „good news”
stories around. Health systems based on
strategies that facilitate low carbon living
and deliver health care using low-carbon
approaches and technologies, will indeed
deliver better health outcomes, save money
and protect our planet.
Until now the voice of the health professions
has been virtually silent in the UN negotia-
tions and conferences on the environment.
This is in contrast to the business sector,
which in 2007 produced, for example, the
Bali communiqué [13]. The Climate and
Health Council is working to rectify this.
This Council is an organization led by doc-
tors with the aim of mobilising health pro-
fessionals across the world to tackle climate
change. They have mounted an ambitious
global campaign, designed to ensure that
the voice of the health profession is heard
before and during the forthcoming interna-
tional Climate Conference in Copenhagen
in December 2009. By the commencement
of the conference, the objective is to have
gathered hundreds of thousands of health
professional signatories from across the
world to apply pressure on governments to
sign a meaningful agreement in Copenha-
gen. For the Council, „meaningful” means
that the deal should be based on the follow-
ing three principles.
a) A scientiﬁcally-assessed and globally•
binding commitment to cap and reduce
carbon emissions to avoid atmospheric
concentrations greater than 450ppm ,rec-
ognising that this target may be subject
to revision in light of further scientiﬁc
information.
b) A mechanism for ensuring that re-•
sources are transferred to those countries
where both living standards and fossil
fuel use have been low. These resources
include those needed to enable popula-
tion stabilisation.
c) An approach to development which,•
by giving people the capability of mak-
ing low carbon choices, minimises green
house gas emissions.
For more information, please visit the Cli-
mate and Health Council website at (www.
climateandhealth.org). All health profes-
sionals are encouraged to sign the pledge,
which can be found at (www.climateand-
health.org/pledge).
References
The anatomy of a silent crisis: the human impact1.
report. Global humanitarian forum. Geneva,
2009 [homepage on the Internet] [cited 2009
September 11]. Available from: : http://www.
ghf-geneva.org/OurWork/RaisingAwareness/
HumanImpactReport/tabid/180/Default.aspx
Costello A, Abbas M, Allen B, Ball S, Bell S,2.
Bellamy R, [et al.]. Managing the Health ef-
fects of climate change. Lancet and Univer-
sity College London Institute for global health
Commission. Lancet 2009; 373: 1693-733.
Anderson GF, Chu E. Expanding priorities—3.
confronting chronic disease in countries with
low income. N Engl J Med. 2007; 356: 209–11.
Neglected global epidemics: three growing4.
threats: chapter 6.In: World health report 2003:
shaping the future. Geneva: World Health Or-
ganization, 2003
Foresight – tackling obesities: future choices.5.
Foresight [homepage on the Internet] [cited
2009 September 11]. Available from: http://
www.foresight.gov.uk/OurWork/ActiveProj-
ects/Obesity/Obesity.asp
Woodcock J, Barister D, Edwards P, Prentice6.
AM, Roberts J. Energy and transport: series on
energy and health. Lancet. 2007; 370: 1078-88.
McMichael AJ, Powles J, Butler C, Uauy R.7.
Food, livestock production, energy, climate
change, and health. Lancet 2007; 370: 1253-
63.
Haines A,Smith KR,Anderson D,Epstein PR,8.
McMichael AJ, [et al ]. Policies for accelerat-
ing access to clean energy, improving health,
advancing development, and mitigating climate
change. Lancet 2007; 370: 1264-81.
Ramanathan V, Carmichael G.9. Global and
regional climate changes due to black carbon.
Nature Geoscience. 2008; 1: 221-27.
Muir Gray J. Climate change is the cholera10.
of our era. The Times [serial on the Internet].
2009 May 25 [cited 2009 September 11].
Available from: http://www.timesonline.co.uk/
tol/comment/columnists/guest_contributors/
article6355257.ece
Ipsos Mori. Trust in Professions [homepage11.
on the Internet] [cited 2009 September 11].
Available from:http://www.ipsos-mori.com/
researchpublications/researcharchive/poll.
aspx?oItemId=15&view=wide
American Medical Association. Which profes-12.
sionals does the public trust the most, and the
least? American Medical News [serial on the
Internet]. 2005 Jan. 3-10 [cited 2009 Septem-
ber 11]. Available from: www.ama-assn.org/
amednews/2005/01/03/prca0103.htm
Bali communiqué [homepage on the Internet]13.
[cited 2009 September 11]. Available from:
http://www.cpsl.cam.ac.uk/our_work/climate_
leaders_groups/clgcc/international_work/the_
bali_communiqu%C3%A9.aspx
Prof. Mike Gill, The Climate and
Health Council Board member,
University of Surrey, UK
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In memoriam
In 1955, at the age of 25, Angel Orozco fol-
lowed his father from his then poor home
country, Chile, to New York City. With the
ambition of ﬁnding a job in America and mak-
ing a living for himself, he left Chile by boat
and landed in Norfolk, Virginia. In Norfolk,
he bought a bus ticket northbound to New
York. Oblivious to the laws of segregation
in the American south, he was confused by
the stares of the other passengers as he made
his way to the back of the bus and sat down
among a group of black women. His neigh-
bours welcomed the friendly, buoyant young
man and Angel had found a group of friends
with whom he remained in contact for the rest
of his life.
At that time, the World Medical Association
was located at New York’s Columbus Circle.
There Angel found his ﬁrst and last employer
in the beginning of 1956. Though he probably
did not know it at the time, this job would take
him across the globe and back many times. He
began his WMA career as a helping hand and
ﬁnished it as the organization’s Executive Di-
rector – a position he occupied for more than
two decades.It was he and fellow staﬀ-member,
Thomas Kennedy, who took responsibility in
1975 for moving the WMA from New York to
the Geneva area to be closer to the WHO and
the heart of the international community. He
and Tom (who later moved to Denmark and
joined the staﬀ of the Danish Medical Associa-
tion) settled the oﬃce just outside of Geneva in
Ferney-Voltaire, a tiny French village with only
6,000 inhabitants. There were not even proper
oﬃce buildings in Ferney to house the WMA
at that time, so the WMA purchased a villa in
a residential area and this became home for the
WMA and its staﬀ for the next 25 years. Dur-
ing his many years in France, Angel remained
a legal resident of New York state and a US
citizen, an identity he cherished along with his
Chilean citizenship.
During most of Angel’s tenure as Executive
Director, the WMA did not have a full-time
Secretary General present in the oﬃce, but a
series of volunteer Secretaries General who re-
mained in their own countries and served pri-
marily as spokesmen for the organization.The
running of the oﬃce, the management of the
staﬀ, and the work of the WMA was Angel’s
responsibility – and one he took very seriously.
He rarely left the oﬃce until 7 or 8pm and of-
ten stayed late into the night. He helped lead
the WMA through, and beyond, its ﬁrst half-
century, a successful era marked by progress as
well as controversy. Through all of that, Angel
was wholly committed to serving the WMA
members and oﬃcers, no matter what level of
eﬀort was required. He was universally loved
by his staﬀ – an extreme rarity for the boss
of any organization. In a nutshell, working
with Angel was fun. He demanded a lot, but
his informal style, ﬁerce loyalty and protective
nature made him more than a boss to most
who worked for him. He was also a friend, a
conﬁdant and even a father ﬁgure to some of
his younger staﬀ.
Angel’s work with the WMA was full of ad-
venture – and the occasional misadventure!
He was arrested twice in relation to WMA
business: once due to false allegations and once
for transporting the registration fees from the
General Assembly in Venice with him on his
attempted return to France. Carrying that
amount cash over the Italian border was illegal
at the time. It never occurred to Angel that a
person could be prohibited from carrying his
own money with him – a law of which he be-
came aware only after being was arrested on
the train on the border Italian-Swiss border
and taken in custody. In both cases, Secretary
General Dr. André Wynen, bailed Angel out
of jail and brought him home.
Oﬃcially, Angel retired from the WMA in
1994 at the age of 65. He returned to his home
country, Chile, re-established himself with his
family in Viña del Mar, and bought a small
farm in the hills between the coast and Santia-
go. Despite his oﬃcial retirement,he remained
a consultant and a friend to the WMA until
last year, helping with annual meetings and
providing invaluable institutional memory in
every area, from process, to policy, to politics.
His ﬁnal meeting with WMA was in Divonne
in 2008. Although most of us probably did
not realize it beforehand, Angel had been bat-
tling cancer for many years already when he
ﬁnally he felt too tired to make the trip to the
2008 General Assembly in Korea.
For 54 years, Angel Orozco was a ﬁxture in the
World Medical Association. He was aﬀection-
ately considered by many to be the “godfather”
of the WMA. He was honoured by numerous
member associations for his service to orga-
nized medicine, including the German Medi-
cal Association’s Medal of Honour. However,
those who knew Angel know that he would
count as far more signiﬁcant than his profes-
sional accomplishments, the deep and lasting
friendships he developed and maintained un-
til the very end of his days. Those who treated
Angel with respect were rewarded with a life-
long friend, full of energy, entertainment and
humour. From the women on the bus in Nor-
folk to new WMA members who may only
have met him last year,Angel was quick to oﬀer
his friendship and steadfast in sustaining it.
Although we learned of the severity of his ill-
ness nearly a year before his death on April
20, 2009, the news of Angel’s passing came
as a terrible shock to all of his friends and
colleagues. The WMA will not be the same
without him. It was an immense pleasure to
work with him and a wonderful and enriching
experience to know him. Angel may be gone,
but his ideas and spirit will forever remain part
of our organization and our lives. He is deeply
missed.
Otmar Kloiber with Joelle Balfe
In memoriam: Angel Orozco
Angel Orozco
Born 4 September 1929 in Iquique, Chile
Died 21 April 2009 in Viña del Mar, Chile
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In memoriam
EDWARD R. Annis, M.D., died September
14, 2009 at his home in Miami with several
of his children and loved ones at his bedside.
He was predeceased by his wife, Betty McCue
Starck, to whom he was married for 64 years.
They raised 8 children.
In 2005 Dr. Annis was honored to be includ-
ed in the book Caring Physicians of the World,
which proﬁled 65 “caring physicians” from 58
countries around the world, exemplifying the
universal and enduring medical traditions of
caring, ethics and science. “The term “Caring
Physicians” immediately conjures up images
of those who spend their lives serving patients
in poor and disease-stricken environments.
There are however other types of caring phy-
sicians, with roles equally important. These
are the physicians whose caring is manifest by
working in the public arena to inﬂuence public
policy to meet the healthcare needs of patients
and the physicians who serve them.”
Dr. Annis excelled at caring for patients as a
practicing physician for many years. He began
his medical career in Tallahassee, Florida, be-
fore moving to Miami, Florida, where he be-
came Chief of Surgery at Mercy Hospital. Dr.
Annis was passionate about healthcare access
for all patients,and used his medical and social
leadership skills to advocate for patients and
the medical profession throughout the world.
He served as President of the American Med-
ical Association from 1963 -1964, and in the
same year as President of the World Medical
Association.
Dr. Annis was a gifted orator with an excep-
tional understanding of the advocacy pro-
cess for developing health policy. Despite
the emotion created by the complex issues,
Dr. Annis was always clear, constructive and
statesman like. He honed his oratory skills in
high school, at the University of Detroit and
Marquette Medical School in Milwaukee,
Wisconsin where he received his medical de-
gree in 1938. In his role as advocate for physi-
cians and patients, he made many appearances
on national television and radio, and spoke
with politicians and presidents including John
F. Kennedy and Senators Humphrey, McNa-
mara, Proxmire, Javits and Gore.
Dr. Annis was a strong critic of ineﬃciencies
and unnecessary bureaucracy in healthcare.
In 1962 he gave a famous speech in Madison
Square Garden, to a television audience of 30
million people, presenting the physicians’ re-
sponse to government dominated medicine.
Recently, this famous televised speech was
entered into the United States Congressional
Record. His book, Code Blue: Health Care in
Crisis, was published in 1993.
Regarded as one of the giants of American
medicine, Dr. Annis mentored and inspired
many and achieved much, receiving many
honors and ﬁlling many important leadership
positions over his lifetime. When asked what
had been his greatest achievement in life, his
answer speaks volumes for this caring physi-
cian: “My family”. When asked to explain his
passionate service to patients and medicine,
he responded, “My whole approach is that no
person in the nation should be denied medical
care if they need it, whether they can pay for
it or not.”
Dr. Yank D. Coble
In memoriam Pedro
Salomão Kassab
Pedro Salomão José Kassab, a Brazilian physi-
cian,grandson of Lebaneses immigrants,grad-
uated in medicine at University of São Paulo
(USP) in 1953 and specialized in dermatology.
He had highlighted activity on medical asso-
ciative aﬀairs. He served as general secretary
of the Brazilian Medical Association (AMB)
from 1963 to 1968 and between 1968-1981,
he became president of this association. In
1976 he was elected president of the World
Medical Association. He was the second Bra-
zilian doctor to hold this position.
Dr. Kassab was also a member of the consult-
ing council at the University of São Paulo,
School of Medicine. Beyond medicine, educa-
tion was another passion for him. In 1957 he
became director of one of the most important
and traditional schools of São Paulo, The Li-
ceu Pasteur. He was president of the Educa-
tion State Council in 2006-07 and he also
directed The Superior Education Chamber of
this organ.
Pedro Kassab passed away on 15th September
2009. He had seven sons and ten grandsons.
One of his son´s is the current mayor of São
Paulo.
The Brazilian Medical Association
In memoriam Edward R. Annis
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125
The British Medical Association (BMA)
has issued a report focusing on the damag-
ing eﬀects of alcohol marketing on young
people. The Association’s Science and Edu-
cation department and its Board of Science
has published the report “Under the inﬂu-
ence”, which is authored by Professor Ge-
rard Hastings and Kathryn Angus.
The report points out that alcohol consump-
tion in the UK has increased rapidly in re-
cent years,not just among young people,but
across society.The population is drinking in
increasingly harmful ways and the result is
a range of avoidable medical, psychological
and social harm, damaged lives and early
deaths. Alcohol marketing communications
have a powerful eﬀect on young people and
come in many forms. These include tradi-
tional advertisements on television through
ubiquitous ambient advertising to new me-
dia such as social network sites and viral
campaigns. The cumulative eﬀect of this
promotion is to reinforce and exaggerate
strong pro-alcohol social norms.
The report also points out that stakeholder
marketing by the alcohol industry, includ-
ing partnership working and industry fund-
ed health education, has served the needs of
the alcohol industry, not public health.
In it’s conclusions, BMA reports that “The
reality is that young people are drink-
ing more because the whole population is
drinking more and our society is awash with
pro-alcohol messaging, marketing and be-
haviour.”
The measures recommended by the BMA
include a comprehensive ban on all alco-
hol marketing communications; minimum
price levels; increase the level of excise duty;
and several other measures.
Although the report is based on the British
alcohol scene, it would be interesting read-
ing around the world.
The alcohol industry has protested against
the recommendations of the report.
The report may be downloaded from the
BMA web site: http://www.bma.org.uk/
health_promotion_ethics/alcohol/underthein-
ﬂuence.jsp?page=1
Under the Inﬂuence – the Damaging Eﬀect of
Alcohol Marketing on Young People
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
The 182nd
WMA Council Meeting . . . . . . . . . . . . . . . . . . . . . . . . . 85
Items from the 182nd
WMA Council meeting in Tel Aviv,
May 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Task Shifting On-Line Moderated Discussion. . . . . . . . . . . . . . . . 93
Shaping the Future of Health Professionals’ Regulation . . . . . . . . . 94
Accessing Health Care
for Undocumented Migrants – European observations. . . . . . . . . . 95
Bringing Fair Trade to Health Systems: What You Can Do. . . . . . 98
The Second Geneva Conference on Person-centred Medicine . . . 100
Person Centred Pediatric Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
The International Network for Person-centred Medicine:. . . . . . . 104
Ethical , Moral, and Legal Responsibilities of Physicians:
an Islamic Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
International collaborative initiative surgical Manpower
development: a plea to do more in low –income-countries . . . . . . 112
Re-thinking Means and Ends: Economic Crises,
Health and Access to Health Services in Europe . . . . . . . . . . . . . 116
Climate Changes and Health – There is Some Good News… . . . 118
Climate Change and Health Care – a Summary
of the Sessions at the WMA Seminar held in Copenhagen
on September 1st
, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Is Climate Change the Fifth Horseman? . . . . . . . . . . . . . . . . . . . 120
In memoriam Angel Orozco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
In memoriam: Edward R. Annis,
MD President, World Medical Association, 1963-64 . . . . . . . . . 124
In memoriam: Pedro Salomão Kassab. . . . . . . . . . . . . . . . . . . . . . 124
Under the Inﬂuence – the Damaging Eﬀect
of Alcohol Marketing on Young People . . . . . . . . . . . . . . . . . . . . 125
Contents
wma 7-2.indd 125wma 7-2.indd 125 9/29/09 5:25:20 PM9/29/09 5:25:20 PM
WMA news
Belgrade, 17th
to 19th
of September, ZEVA Meeting
WMA Conference on Climate Change, Copenhagen, 1st
of September
wma 7-2.indd 126wma 7-2.indd 126 9/29/09 5:25:20 PM9/29/09 5:25:20 PM

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