WMJ 04 2009

G 20438
No. 4, December 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 :
Mural painting in the Cultural Administration
Complex of the University Campus, Caracas,
Venezuela. Painter: Narváez Francisco.
Photographer: Eliseo Sierra.
Date of photograph 2009.
Publisher
The World Medical Association, Inc. BP 63
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ISSN: 0049-8122
Dr. Dana HANSON
WMA President
Fredericton Medical Clinic
1015 Regent Street Suite # 302,
Fredericton, NB, E3B 6H5
Canada
Dr Masami ISHII
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
Prof. Ketan D. Desai
WMA President-Elect
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
I.M.A. House
India
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. Yoram BLACHAR
WMA Immediate Past-President
Israel Medical Assn
2 Twin Towers
35 Jabotinsky Street
P.O. Box 3566
Ramat-Gan 52136
Israel
Dr. Jens Winther Jensen
WMA Chairperson of the Medical
Ethics Committee
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Denmark
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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Healthcare and the Economic Crisis
Eastern European countries, especially those that were formerly
parts of the Soviet Union, are in the midst of a serious economic
crisis. The countries most significantly affected are Lithuania, Lat-
via, Romania, Bulgaria and Hungary (members of the European
Union), as well as Ukraine, Moldavia and Azerbaijan. In these
countries the gross national product has fallen from 10% to 25%,
the national debt has increased dramatically,the unemployment rate
has reached up to 20%, wages have decreased, the budget for health
care and welfare have been cut, and money for heating and even
subsistence is lacking in some areas.
An economic crisis somewhere in the world is nothing new. In the
early 1990s the economies of Eastern Europe overall dropped 32
% to 75% of their previous level and medical facilities were faced
not only with insufficient funds, but also with a lack of medicines
and bandages, while also working in out-dated facilities and with
imprecise laboratories. In the 1990s, during the military crisis in
Yugoslavia and the Nagorono-Karabakh conflict, the countries in-
volved did not expend any money at all for the health care of its ci-
vilians. At the turn of the century the economies of the “Southeast
Asian tiger” countries fell by more than 25%, and the health care
expenditures of Thailand, Laos and Vietnam were significantly re-
duced. But, the situation that is most analogous to the current crisis
in Eastern Europe occurred in Argentina and other South Ameri-
can countries, whose economies collapsed at the beginning of this
decade. It is interesting that almost all these countries that were
faced with economic recession and decline in health expenditures
have reacted to the crisis with political sensitivity.
To avoid risk of offending colleagues in other countries,I will confine
my comments to the situation in Latvia, though I am familiar the
way the crisis was handled in Lithuania, Ukraine and Byelorussia.
There is a great deal of interest in crises,and how they affect medical
care. Conferences have been held to search for solutions on how to
prevent economic crises from disrupting health care. For example,
the conference “Health in the times of global economic crisis: im-
plications for the WHO European Region” that was held in Oslo,
Norway from April 1-2, 2009 came up with recommendations for
European countries*. The fifth recommendation stated: “Protect
cost-effective public health and primary healthcare services. If
spending on health is reduced: a) protect spending on public health
programmes; 2) protect spending on primary health care; 3) reduce
spending on the least cost effective services. These will normally be
found among the most high-technology, high-cost services in hos-
pitals. 4) delay investment plans for high-cost facilities and promote
the use of generic drugs.
Unfortunately,this resolution was not heard in Latvia. When health
care financing was reduced, the first programmes to be cut were: 1)
the Public Health Service which is the only authorized institution
in Latvia responsible for disease prevention and prophylaxis . We
are not an isolated country, and the potential spread of infectious
disease could have an effect on others. 2) The expenditure for med-
ical care in prisons was cut threefold – raising the prospect that our
prisons could become a breeding ground for resistant tuberculosis
in Europe. (3) Elective surgery, such as arthroplasty, cardiac valve
replacement and cataract surgery was severely curtailed because of
lack of funding, resulting in the departure of many physicians from
the Baltic countries to work in Great Britain, Scandinavia, Canada
and New Zealand where they can receive higher wages and bet-
ter job security. In 1990s almost every hospital in Latvia acquired
new technology, such as magnetic resonance imaging and digital
angiography. It was easy to make the transition to modern medicine
and to achieve a standard comparable to the rest of Europe – going
backwards is not so easy. This year, when a true financial deficit hit:
the health care budget was cut by 20% in the first half of the year
and 40% in the second half. The State could no longer reimburse for
expensive diagnostic methods and costly medications. It appears
that it is not possible to turn back the clock: doctors would sooner
go to work elsewhere than resume using cheap and ineffective treat-
ment methods. The plunge in doctors’ salaries has led to depression
amongst physicians and their loss of faith in the future. In Eu-
rope, physicians have traditionally been respected citizens and role
models. Seeing the doctors depressed spills over to the rest of the
population.
It is not enough to look at the adverse effects of an economic crisis
upon the health care of a nation. We must also look at the funda-
mental underlying causes of the problem. In Latvia, the money for
health care is under the direct control of the politicians. The signifi-
cance of politicians having direct control over health care expendi-
tures cannot be ignored. If Latvia had introduced a self-governed
and contribution-financed social insurance system, this health care
disaster might not have happened! Furthermore, the functioning
health care sector would be a stabilizing element for the economy
instead of a drag on the economy. Unfortunately, in Latvia, health
care has become the victim of bad politics.
Respected colleagues throughout the world! An economic down-
turn can hit any country. Latvia was not ready for these chang-
es. We would like others to learn from our experiences so you do
not repeat our mistakes. A WMA conference focusing on how to
prevent, prepare for and deal with the health care problems that
are associated with economic crises would be an excellent way to
achieve this and could be organised in Latvia.
Peteris Apinis, MD,
Editor in Chief, WMJ
Editorial
* “Recommendations of the meeting” available at
http://www.euro.who.int/document/HSM/Oslo_crisis_mtg_rec.pdf
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128
WMA news
More than 200 delegates from 46 National
Medical Associations (NMAs) attended
the annual General Assembly held at the
LaLit Hotel, in New Delhi, India from
14-17 October 2009.
The four-day event, hosted with Bollywood
flamboyance by the Indian Medical Associ-
ation, was notable for the attendance of the
President of India Madam Pratibha Patil,
to officially open the Assembly, as well as
the unopposed election in his own country
of Dr. Ketan Desai, President of the Indian
Medical Council, as President Elect of the
WMA, and the adoption of no less than 16
new or revised policy statements on issues
ranging from climate change and stem cell
research, to professionally-led regulation
and task shifting.
The ceremonial session of the Assembly was
addressed by both the President of India
and the Health Minister Mr. Ghulam Nabi
Azad. In her welcome address the President
Madam Pratibha Patil called on the medical
community to work for the ideal of medical
care for all.
She said:“The question of equitable medical
care to all people is a big human and ethi-
cal question. In India, we are conscious of
this and through policies and programmes,
efforts are underway to reach populations
including those in rural areas that face the
highest degree of deprivation in terms of
health facilities. All governments have re-
sponsibilities to take action, but global in-
stitutions also have a crucial role.The World
Health Organization and other internation-
al organizations like yours are major stake-
holders in this endeavour. I would call on all
of you present here today, to contribute, to
further the cause of medical care for all.”
Union Health Minister, the Honourable
Shri Gulam Nabi Azad, told the Assembly
about the proposed new alternative model
for medical education in his country, aimed
primarily at rural health manpower. He
pointed out that because of the concentra-
tion of health care professionals in urban
and semi-urban areas there was a huge gap
in availability of manpower at the grassroots
level.
Dr. Yoram Blachar, in his valedictory ad-
dress as outgoing President of the WMA,
said that Association statements carried
great weight in most national and interna-
tional discussions on health. In recent years
the WMA had taken more active roles in
promoting health care and had initiated or
taken part in a number of projects in the
areas of public health, such as an internet
course on TB and the project of talking
books which enabled information to be
brought to parts of the world where there
was illiteracy.
The WMA also had an important role in
advocacy as the voice of the profession rep-
resenting millions of doctors around the
world.The partnerships and alliances of the
Association were vital to its success.Through
its relationships the WMA promoted and
defended the basic rights of patients and
physicians, helped physicians to continu-
ously improve their knowledge and skills,
developed public health policy and projects
such as tobacco control and immunisation,
assisted with human resource planning for
health care services and encouraged democ-
racy building for new medical associations,
especially in new or developing democra-
cies.
The installation then took place of the new
WMA President for 2009-2010, Dr. Dana
Hanson, former President of the Canadian
Medical Association.In his inaugural speech
he criticised Governments of the world for
paying too little attention to the effects of
climate change on population health and its
huge impact on health services.
“We know that the climate affects local and
national food supplies, air and water quality,
weather, economics and many other criti-
cal health determinants. Climate change
represents an inevitable, massive threat to
global health that will likely eclipse the ma-
jor known pandemics as the leading cause
of death and disease in the 21st century. Yet
why do we hear so little or no discussion by
our governments of the effects of climate
change on population health and its huge
impact on health services?”
Dr. Hanson, a dermatologist from
Fredericton, New Brunswick, said he hoped
the WMA would be granted observer sta-
tus in Copenhagen in December when
192 United Nations member states will
meet to create a plan of action around the
UN Framework Convention on Climate
Change.
“There is no other organisation that can
bring the message of human health protec-
tion and preservation – untainted by na-
tional political and economic agendas – to
the climate change debates.There is no oth-
WMA General Assembly, New Delhi 2009
President of India Madam Pratibha Patil
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WMA news
er organisation whose members view each
and every citizen as a cherished patient to
whom we owe a professional duty and feel a
personal commitment.”
Dr. Hanson said that traditionally the
WMA’s work had focused almost exclusively
on the development of its body of policy, as
it sought to promote the highest standards
of medical ethics,professional responsibility
and patient care.
“These standards reflect the cumulative,
global experience and understanding of the
world’s physicians and constitute a rich col-
lection of resources for which the WMA is
known among physicians and many of our
allied organizations. Some of our policies,
such as the Declaration of Helsinki and
the Declaration of Tokyo, among others,
are known far beyond WMA and our close
friends and, indeed, are recognised glob-
ally as the gold standard of policy on their
respective subjects.”
He added: “I believe that our work is rel-
evant – indeed vital – far beyond our own
membership and our historic allies and
partners and it is time to elevate advocacy
to a higher priority for the WMA. With
the growth of our membership, the addition
of project work to our portfolio, and our
professionalised staff structure, the WMA
is now positioned to add a stronger, more
dynamic advocacy dimension to our work.
Ours is a unique advocacy voice in the world
today – that of the world’s physicians – and
it is by activating this voice to its fullest ca-
pacity that we will ensure WMA’s vision
and policies are truly promoted worldwide
and that our expertise and experience can be
effectively accessed by those whose interests
intersect with our own.”
Finally Dr.Hanson spoke of physicians’own
well being. “At the same time that we ad-
vocate for the health, safety and well-being
of our patients, we must also channel our
advocacy efforts in support of these quali-
ties for ourselves and our colleagues all over
the world. Poor and dangerous working en-
vironments, inadequate pay and overwork,
institutional and even physical violence are
experienced by far too many physicians.
And while many persevere, continuing their
dedicated service to patients and their com-
munities despite these conditions, many
others move on in search of better circum-
stances – sometimes even leaving medicine
entirely for other professions.”
“I think this is a vital component of our on-
going work on health and human resources.
It is a subject that is often marginalised in
the international medical workforce discus-
sion, but we at the WMA know that it has
a profound effect on physicians, patients
and entire health systems. The importance
of advocacy by the profession for our fellow
doctors in this context cannot be overstated
and the WMA must and will continue to
shine a light on this endemic problem.”
At the plenary session of the Assembly
Dr. Ketan Desai was elected unopposed as
President Elect of the WMA. Dr. Desai,
President of the Medical Council of India
and former National President of the In-
dian Medical Association, will take up his
post at the General Assembly meeting in
Vancouver, Canada in October 2010.
The Assembly, under the chairmanship of
Dr. Edward Hill, adopted several new and
revised policies, many of them the result of
the Association’s ongoing revision of poli-
cies.
Climate Change
A new Declaration was adopted – entitled
the Declaration of India – setting out mea-
sures to bring health to the forefront of the
climate change debate and to mitigate the
serious health risks facing the world (see full
text p. 137). Dr. Ruth Collins-Nakai, from
the Canadian Medical Association, who
chaired the WMA’s climate change working
party, said: “We should recognise that most
initiatives, which improve the impact of cli-
mate change, also improve individual and
population health – that what is good for
the environment is also good for health.”
Following the meeting an advocacy kit was
circulated to NMAs, including a factsheetDr. Ketan D. Desai
Dr. Yoram Blachar
Dr. Dana Hanson
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WMA news
on the impact of climate change on health
and a model letter to send to health minis-
ters and to the UNFCCC national contact.
Professionally-led Regulation
A rewritten Declaration of Madrid on Pro-
fessionally-led Regulation was adopted (see
full text p. 140). The Declaration, a revision
of the 2005 Declaration on Professional
Autonomy and Self Regulation, resulted
from a White paper on Professionalism and
the Medical Association, written by Dr. Jeff
Blackmer from the Canadian Medical As-
sociation.
Child Health
The 1998 Declaration of Ottawa on Child
Health was revised and adopted to in-
clude new broader guidelines on improving
the health of the world’s children (see full
tex p. 140). Dr. Ruth Collins-Nakai, who
chaired the WMA working group on child
health, said: “The world’s children are worse
off today than they were two decades ago
and it is important that in proposing this
broader policy we make physicians aware of
just how tenuous the status of children is in
the world.”
Task Shifting
A new Resolution on Task Shifting was
adopted, expressing a series of concerns
about the global development of task shift-
ing (see full text p. 141).
The Resolution prompted lengthy debates
both in Council and Assembly following
criticism from several delegates that its
tone was too negative. However, others ar-
gued that this was a document relating to
physicians and it was important that it was
published.A call to refer back the document
was defeated.
Iran
In an Emergency Resolution, National
Medical Associations were urged to speak
out in support of the rights of patients and
physicians in Iran (see full text p. 143). This
followed a report from the German Medical
Association. Dr. Frank Montgomery, from
the German Medical Association, said:
“Physicians serve people not governments.
They must be able to fulfil their duties with-
out government harassment. Physicians will
not participate in torture or degrading treat-
ment. They are the “whistleblowers” of such
criminal acts committed by governments. I
call upon the Iranian Government to reaf-
firm the position that independent, free
medicine is a cornerstone of democracy.”
Medical Workforce
The Assembly agreed to amend the 1998
Resolution on the Medical Workforce (see
full text p. 144).
Inequalities in Health
A Statement was adopted calling on NMAs
to influence national policy to reduce health
inequalities, advocate for the abolishment
of financial barriers to obtaining needed
medical care, and to advocate for equal ac-
cess for all to health care services irrespec-
tive of both geographic and economic dif-
ferences (see full text p. 145).
Improved Investment in Public Health
With many countries planning to cut their
health budgets as a result of the economic
recession, the Assembly revised its Reso-
lution on Improved Investment in Public
Health (see full text p. 146).
Conflict of Interest and
Commercial Enterprises
A Statement on Conflict of Interest was
adopted, the first time the WMA has is-
sued guidelines on physicians’ behaviour on
issues of conflict of interest. The guidelines
identify areas where a conflict of interest
might occur during a physician’s day-to-day
practice of medicine, and seek to assist phy-
sicians in resolving such conflicts in the best
interests of their patients.
The Association’s Statement Concerning
the Relationship between Physicians and
Commercial Enterprises was also revised
with advice to physicians on receiving spon-
sorship or gifts when attending conferences
or conducting research and on their affilia-
tions with commercial entities.
Stem cell research
A Statement was adopted expressing sup-
port for stem cell research being carried out
with appropriate regulation to prevent un-
acceptable practices.The Statement,initially
prepared by the Icelandic Medical Associa-
tion, declared that regulation according to
established ethical principles was likely to
alleviate public concerns, especially if asso-
ciated with careful policing. Whenever pos-
sible, research should be carried out using
stem cells that were not of embryonic ori-
gin. However there would be circumstances
where only embryonic stem cells would be
suitable for the research model. Research on
stem cells, regardless of their origin, must
be carried out according to agreed ethical
principles.
Dr. Vivienne Nathanson, from the British
Medical Association, who chaired the
WMA’s stem cell working party, said: “This
is cutting edge science and may lead to the
development of new treatments for chronic
illnesses such as diabetes and Parkinson’s,
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WMA news
which would enormously lessen human suf-
fering. We must make sure that good, ethi-
cal research goes ahead, and see if we can
reap the benefits of this exciting science.”
Telehealth
New guiding principles for the use of tele-
health for the provision of health care were
adopted. Among the areas covered by the
Statement were legal responsibilities, com-
munication with patients,standards of prac-
tice and quality of clinical care, quality indi-
cators, patient confidentiality and consent.
Nicaragua
An Emergency Resolution called on the
Nicaraguan government to repeal legisla-
tion criminalising abortion. It said the leg-
islation was having a negative impact on the
health of women in Nicaragua and could
result in preventable deaths of women and
the embryo or foetus. The legislation also
placed physicians at risk of imprisonment if
they broke this law and at risk of suspen-
sion from medical practice if they failed to
follow government protocols, which some-
times required treatment of a pregnant
woman contrary to the legislation.
The 1997 Declaration on Guidelines for
Continuous Quality Improvement in
Health Care was revised as part of the
WMA’s review of policy documents and
amendments were also made to the 1999
Statement on Patenting of Medical Proce-
dures,which was renamed the Statement on
Medical Process Patents, and to the 2005
Statement on Genetics and Medicine.
Human Rights
Ms. Clarisse Delorme, the WMA’s advoca-
cy advisor, and Dr. Herman Reyes, from the
International Committee for the Red Cross,
gave a presentation to the Assembly about
the role of physicians in the prevention of
torture and ill treatment in places of deten-
tion. They spoke about the Optional Proto-
col to the UN Convention against Torture
and how national medical associations had
an important role in monitoring the Na-
tional Prevention Mechanisms where they
had been set up in their countries.
Dr. Otmar Kloiber, secretary general of
the WMA, said this was not a problem for
other countries. It was a problem for all
countries.
Associates
The Associate Members meeting debated
a report from Dr. Masami Ishii, Chair of
the Work Group on Reform of Associate
Membership. It was agreed that proposals
for increasing the merits of membership
should be circulated for further discussion.
New Member
The Assembly approved an application for
membership from the Society of Medical
Doctors in Malawi.
Other Business
The Assembly adopted the audited Finan-
cial Statement for the year ended December
2008 and adopted the Budget for 2010.
Open Session
During the “open session”, giving delegates
an opportunity to present any profession-
specific problem, policy or project they be-
lieved the WMA should know about, the
meeting heard from several NMA repre-
sentatives.
Dr.Cecil Wilson,from the American Medi-
cal Association, reported on the controversy
surrounding America’s health care reform
proposals. He said the AMA was proud of
the health care that was provided to the citi-
zens of the US and proud of the country’s
dedicated physicians. The problem was that
that health care was not universal. Some
46 million Americans or 16 per cent of the
population did not have health insurance.
The AMA was committed to health care
reform and was working very closely with
President Obama and with Members of
Congress on proposals for reform,but it was
not an easy task. He added that the AMA
shared the concern about the vitriolic tone
of the debate and had called for calm.
Scientific session
The theme of the scientific session was
“Multi-Drug Resistant Tuberculosis and
Lessons Learned from this Epidemic.” Ex-
perts from across the world spoke about
guidelines for treatment and infection con-
trol, with a particular emphasis on the expe-
rience in India.
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At the same time, the WMA launched a
new online refresher course for physicians,
providing basic clinical care information for
TB including the latest diagnostics, treat-
ment and information about multidrug-
resistant TB. The new course was written
for the WMA by the New Jersey Medical
School Global Tuberculosis Institute, USA.
It incorporates key strategies of interna-
tionally accepted strategies for management
and control of TB, will link to the WMA’s
MDR-TB course which has been running
for the past two years.
Dr. Julia Seyer, medical adviser at the
WMA, said: “When we started an online
multidrug-resistant tuberculosis (MDR-
TB) training course in 2006, we discovered
that many physicians were missing the most
basic knowledge about normal TB. With
the disappearance of the disease from large
parts of the world, many physicians from
the developed world had never even seen
a case of TB and had no basic training in
diagnosing and treating what is a prevent-
able disease. Now that TB has re-emerged
as a serious global disease, it is vital that
physicians around the world regain the ba-
sic knowledge they once had. The course
will be useful in developing countries,where
the majority of TB cases are, and will serve
as a refresher of what physicians may have
learned some time ago.”
The course is free of charge and can be used
by physicians in private practice, as well
as in the public. Physicians will be able to
receive credits for completing the course
as part of their continuing medical educa-
tion programme. Although the course is
available only in English at the moment,
it will be translated into Spanish, French,
Russian and Chinese.The new course is be-
ing financed by an unrestricted educational
grant by the Lilly MDR-TB Partnership,
which comprises several other organisations
working together to improve tuberculosis
control worldwide.
Secretary General’s Report
Dr. Otmar Kloiber reported on significant
activities and developments during the year.
A train-the-trainer course in MDR-TB
had been developed to create champions in
the field of TB on a local level. Physicians
who were experts in TB received training
in adult learning and accelerated learning
principles in order to better teach their col-
leagues. The first of a series of workshops
took place in Pretoria, South Africa in
November 2008 in co-operation with the
Foundation of Professional Development.
A further workshop was due to take place
in New Delhi before the Assembly together
with the Indian Medical Association.
The WHO was in the process of developing
a policy on ethics in the TB setting, with
a goal for its adoption at the World Health
Assembly in 2010. The WMA was invited
to address the issues related to health pro-
fessionals in the policy.
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 ran high and
could dissuade health providers from ac-
cepting 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 prac-
tices and recommendations. The WMA,
in collaboration with the South African
Medical Association and the ICN, IHF
and ICRC, organised the first workshop
in Cape Town South Africa in November
2007. The second one took place together
with the Brazilian Medical Association in
Rio De Janeiro, Brazil in March 2009, and
the third one was in Durban, South Africa
in June 2009.
The WMA joined the implementation pro-
cess of the WHO Framework Convention
on Tobacco Control (FCTC) http://www.
who.int/tobacco/framework/en/, the interna-
tional treaty that condemned tobacco as an
addictive substance,imposed bans on adver-
tising and promotion of tobacco, and reaf-
firmed the right of all people to the highest
standard of health. The first international
treaty negotiated under the auspices of the
WHO, the FCTC entered into force in
2005 and was 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 in No-
vember 2008 to discuss articles of the treaty
and receive reports of the working groups
created for specific articles. The WMA was
a member of the working groups on Article
12 – Education, Communication, Training
and Public Awareness and Article 14: Mea-
sures Concerning Tobacco Dependence and
Cessation.
The WMA continued its close involve-
ment in the Positive Practice Environ-
ment Campaign (PPE). This global five-
year campaign – spearheaded by WHPA
members together with the World Con-
federation for Physical Therapy and the In-
ternational Hospital Federation – aimed to
ensure high-quality healthcare workplaces
worldwide. The appointment last March of
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a full-time coordinator,in charge of running
the campaign on behalf of the organisation
members, allowed the PPE to kick off in
three selected countries: Uganda, Morocco
and Zambia.Taiwan would also be involved
in the PPE as a self-funded country. With
the support of the PPE coordinator, health
professionals’ organisations from the select-
ed countries were in the process of setting
up national structures (national coordinator
and steering committee) for the running of
the campaign.
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
from in March, 2009. The 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 included ideas to
facilitate WMA policy development in this
area.The WMA Advocacy Working Group
was considering these proposals and explor-
ing follow-up opportunities, such as map-
ping relevant work and research undertaken
on task shifting.
In early March, the WMA was invited to
take part in the planning process of the
next Conference on Workplace Violence
in the Health Sector, scheduled to take
place from 27-29 October 2010 in Amster-
dam. The event is supported by the Glo-
bal Health Workforce Alliance (GHWA),
WHO, International Labour Organisation
(ILO), the International Council of Nurses
(ICN), Public Services International (PSI)
and other relevant health organisations.
The WHO was developing guidelines on
retention strategies for health profession-
als in rural areas, which should be adopted
at the World Health Assembly 2010. The
objective was to ensure access to health
care for people living in rural areas, thus
improving the health outcomes, including
those outlined in the Millennium Develop-
ment Goals (MDGs).The guidelines would
be based on three pillars: educational and
regulatory incentives, monetary incentives
and management, environment and social
support.The WMA,as the secretariat of the
World Health Professions Alliance, was a
member of the core expert group develop-
ing the guidelines.
WMA staff, Dr. Julia Seyer, as secretariat
of the WHPA, had been invited to join an
independent merit review panel organised
by the Global Health Research Initiative.
The panel would review research propos-
als submitted in response to a competition
launched in January 2009 by the “Africa
Health Systems Initiative Support to Af-
rican Research Partnerships” program
(AHSI-RES). AHSI-RES was a 5-year
research program (2008-2013) that formed
one component of the Africa Health Sys-
tem Initiative (AHSI) supported by the Ca-
nadian International Development Agency
(CIDA). AHSI was a 10-year initiative
focused on strengthening national-level
health strategies and architecture, ensur-
ing appropriate human resources for health,
strengthening front-line service delivery,
and building stronger health information
systems – all with special attention to equity
considerations.
The WMA participated as a member of the
steering group in the Mobility of Health
Professionals research project. The objec-
tive of the project was to assess the current
trends of mobility of health professionals to,
from, and within the European Union, in-
cluding their reasons for moving. Research
would also be conducted in non-European
sending and receiving countries, although
the focus lay on the EU.
In January 2011 the Global Health Work-
force Alliance is organising the 2nd Global
Forum on Human Resources in Health
(HRH) in Thailand. The WMA is part
of the thematic focus committee for this
event. In a first meeting, two main themes
is proposed: improving quantity and quality
of health workforce for equitable access to
primary health care within a robust health
system and financing HRH in the light of
the global financial crisis.
Counterfeit medicines were drugs manu-
factured below established standards of
safety, quality and efficacy and therefore
risked causing ill health and killing thou-
sands of people every year. Experts esti-
mated that 10 per cent of medicines around
the world could be counterfeit. The phe-
nomenon had grown in recent years due
to increasing sophistication of counterfeit-
ing methods and the increasing amount of
merchandise crossing borders. At the last
Executive Board Meeting of the WHO in
January 2009, the report and draft resolu-
tion on counterfeit medical products were
“Speeking book” opening
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discussed and all member states stressed
the importance of protecting public health
against risks caused by counterfeit medica-
tions. An intense debate took place on the
definition of counterfeits versus substand-
ard medicines. So far WHO has focused
on counterfeits while largely ignoring the
broader – and more politically sensitive –
category of substandard drugs.
The World Health Report from 2008
“Primary Health Care – Now More Than
Ever”- critically assessed the way that
health care was organised, financed, and
delivered in rich and poor countries around
the world. The WHO report documented
the failures and shortcomings over the last
decades that had left the health status of dif-
ferent populations, both within and among
countries, dangerously out of balance. The
report urged the importance of an holistic
health care approach where primary health
care played an important role as a facilitator
between prevention, secondary and tertiary
care.The report focused health care systems
on four pillars: universal coverage, people-
centred health care, leadership reform to
make health authorities more accountable
and to promote and protect public health in
general.
The Executive Board of the WHO in
January 2009 discussed a draft resolution
on primary health care, including health
care system strengthening. On behalf of
the World Health Professions Alliance,
the WMA made a public statement dur-
ing the Executive Board session. Further
debate took place during the World Health
Assembly in May 2009. The WHO invited
the WMA to take part in a global consul-
tation on the contribution of health pro-
fessions to primary health care and the
global health agenda in June 2009. As one
of the outcomes the WHO was develop-
ing implementation guidelines to support
governments in setting up primary health
care teams in a holistic health care system,
which would be sent out soon for comments.
The WHO saw physicians as a strong pillar
in this approach and was pleased to work
closely with WMA.
In May 2008, the World Health Assembly
adopted a resolution requiring the WHO to
intensify its work to curb the harmful use
of alcohol. Members States called on the
WHO to develop a global strategy for this
purpose. The resolution also requested the
WHO Director-General to consult with
intergovernmental organisations, health
professionals, nongovernmental organisa-
tions, and economic operators regarding
ways in which they could contribute to re-
ducing the harmful use of alcohol. In line
with the WMA Statement on Reducing
the Global Impact of Alcohol on Health
and Society, the WMA secretariat moni-
tored the drafting process of the WHO
strategy, informed WMA members on a
regular basis of relevant developments in
this area and had developed contacts with
relevant WHO officials and civil society or-
ganisations to collaborate in the process.
In October 2008, the WMA Advocacy
Advisor, Ms. Clarisse Delorme, moderated
an NGO briefing on reducing the glo-
bal harm caused by alcohol, organised by
GAPA (Global Alcohol Policy Alliance).
The objectives of the briefing were to un-
derstand the WHO process related to the
strategy, to begin discussions on substantive
and political proposals to promote an ef-
fective, evidence-based global strategy, and,
finally, to develop further working relations
between civil society actors involved in this
area.
In November 2008, Dr. Kloiber, and Ms.
Delorme, participated in the WHO round-
table meeting with representatives of
NGOs and health professionals on ways
they could contribute to reducing harmful
use of alcohol. This was an opportunity to
raise,amongst others issues,the WMA’s de-
sire that medical associations and individual
physicians be fully involved in the WHO
strategy on alcohol.
The World Medical Association had
developed, together with the Geneva Social
Observatory, a Workplace Strategy on Di-
abetes and Wellness. This was a guideline
for employers and employees to educate and
raise awareness about diabetes, and provide
examples of healthier lifestyles during work.
The aim was to mitigate the ill effects of
diabetes on personal health, workplace pro-
ductivity, and health care costs.
The WMA Workgroup on Health and
the Environment, chaired by the Canadian
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 would focus on environmental
degradation and the built environment.
Following the adoption by the 2008 General
Assembly of the WMA Statement on Re-
ducing the Global Burden of Mercury, the
WMA joined the UNEP Global Mercury
Partnership to contribute to the partner-
ship goal to protect human health and the
global environment from the release of
mercury and its compounds.
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:
Two Egyptian doctors, Raouf Amin al-•
Arabi and Shawqi Abd Rabbuh, were
sentenced to 15 and 20 years in prison
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and 1500 and 1700 lashes respectively in
Saudi Arabia for having facilitated the
addiction of a patient to morphine after
prescribing the medicine for her pain
relief following an accident (December
2008). The WMA sent letters calling on
the authorities of Saudi Arabia to review
the case or send it for retrial and to ensure
that any such procedures were undertaken
in accordance with international fair trial
standards.
Dr. Arash Alaei and Kamiar Alaei (Re-•
public of Iran) were sentenced to six and
three years of imprisonment respectively
for “co-operating with an enemy govern-
ment”, specifically with US institutions
in the field of HIV & AIDS prevention
and treatment (January 2009). In letters
to the Iranian authorities, the WMA ex-
pressed its serious concerns on the pro-
ceedings falling far short of international
standards for fair trial and asked for the
immediate release of the two physicians,
as their imprisonment appeared to be po-
litically motivated.
Three government employed doctors,•
Dr.T.Sathiyamoorthy,Dr.T.Varatharajah
and Dr. Shanmugarajah, who had been
working in the conflict zone in northeast-
ern Sri Lanka until 15 May 2009, were
held under emergency regulations by the
Sri Lankan government for providing
“false information“ to foreign journalists.
At the end of May, the WMA sent letters
urging the Sri Lankan authorities to give
to the three doctors immediate and unre-
stricted access to lawyers of their choice
and that they be promptly brought before
an independent court. Access to medical
treatment and permission for family visits
were also required. They were released on
the 24 August 2009, but with restricted
liberty, required to report regularly to the
authorities. Amnesty International con-
tinued to have serious concerns, given the
unclear process for their bail and possible
ongoing trial. The WMA Secretariat was
in regular contact with Amnesty and was
ready to take further actions, if appropri-
ate.
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 emphasised
in letters to Iran authorities that, according
to international medical standards, it was
unacceptable to involve physicians in this
inhuman and degrading treatment.
The WMA was actively involved in
developing the “Right to Health as a
Bridge to Peace in the Middle East” joint
seminar, which was due to take place in
October 2009 in Turkey. The seminar was
being organised by the International Fed-
eration of Health and Human Rights Or-
ganisations (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 facilitate the
communication among health professionals
in the participating nations.
The 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 rights to the highest attainable
standard of health.
In August 2008, Clarisse Delorme, WMA
advocacy advisor, was elected as indepen-
dent expert on the Council of the Interna-
tional Rehabilitation Council for Torture
Victims (IRCT) 2009-2012.
In September 2009, the WMA secretariat
together with the Danish Medical Asso-
ciation contacted the Danish permanent
Representative in Geneva to discuss po-
tential follow-up from the resolution on
the Role and Responsibility of Medical
and other Health Personnel in Relation
to Torture, adopted by the Human Rights
Council last March at its 10th session.
Based on their concerns that the resolu-
tion adopted did not include references to
WMA core policies in this area, nor did it
highlight the positive role of physicians and
other health personnel in preventing and
condemning torture and other inhuman
treatments, the WMA and DMA suggest-
ed that the Permanent Representative work
with the Danish government on a further
resolution highlighting the positive role of
physicians and other health personnel in
preventing and condemning torture and
other inhuman treatments.
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 addressed global
health through social determinants, i.e.,
the structural determinants and conditions
of daily life responsible for a major part of
health inequities among and within coun-
tries, and proposes a new global agenda for
health equity.
On the occasion of the 124th
session of
WHO Executive Board (January 2009),
the 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-
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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 to the inequalities health professionals
face in their daily work.
Clinical research involving human subjects
had proliferated in developing countries in
the recent past, increasing concerns about
ethical and legal implications of misconduct
and violations of subjects’human rights and
welfare due to inadequate scientific and
ethical review of protocols or as a result
of poor or absent drug regulatory systems.
The 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 expertise and expe-
riences between national and international
institutions, on the issue of protection of
human participants in biomedical research.
Participants stressed the importance of
building capacity in biomedical ethics re-
views in developing countries by supporting
education and training curricula of health
professionals and community health work-
ers, in order to facilitate the creation of in-
stitutional Research Ethics Committees.
The Caring Physicians of the World
(CPW) Initiative (Leadership Course)
began with the Caring Physicians of the
World book, published in October 2005
in English and in Spanish in March 2007.
Regional conferences were held in Latin
America, Asia-Pacific and Africa regions.
The CPW Project was extended to in-
clude a leadership course organised by the
INSEAD Business School in Fontaineb-
leau, France, in December 2007, in which
32 medical leaders from a wide range of
countries participated. The second Leader-
ship Course was held at the same place in
December 2008 for one-week with 30 par-
ticipants, with continued successful results
and positive feedback.The third Leadership
Course at the INSEAD Business School
would be held in Singapore, 8-13 February
2010. The curriculum included 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.
The World Health Professions Alliance
was now a decade old. The context within
which it was working had evolved with its
continued development, and so had the or-
ganisations that made up the alliance. The
WHPA had revised its strategy and priori-
ties for the next few years and would focus
mainly on human resources in health, pa-
tient safety, public health, counterfeit medi-
cal products and human rights in health.
The World Federation for Medical Edu-
cation (WFME) brought together medical
faculties and the profession. During recent
years it had focused on describing global
standards for basic and post-graduate edu-
cation of physicians, as well as for Continu-
ing Professional Development. The WMA
General Assembly, Tokyo 2004 endorsed
these standards.
Currently, the WFME worked on encour-
aging and supporting countries and medical
schools to further develop, or to improve,
their accreditation. Although not itself an
accrediting body, the WFME – together
with WHO – strongly supported the use of
accreditation as a method of documenting
and improving the quality of education and
achieving comparability in the international
arena.
Based on a mutual agreement with the
WHO, the WFME together with the Uni-
versity of Copenhagen (which hosted the
WFME office), had taken over from WHO
Headquarter the register of institutions
for higher education in health care. The
WFME now developed this register in an
online database called Avicenna Directories,
which would not only list the institutions as
named by their governments, but also pro-
vide information about their accreditation
status and the accrediting body.
In January 2009, the WMA signed a con-
tract with DGN Services to develop and
install a new web portal for the WMA.The
new web portal, launched in October 2009,
would provide the platform for co-operation
with the members of WMA, allow online
payments for meetings, books and associate
membership dues, and, most of all, it would
facilitate more timely presentation of con-
tent on the public website.
Speaking book on clinical trials
One of the fringe events of the Assembly
was an evening presentation of an Indian
perspective of the WMA’s Speaking Book
on Clinical Trials, aimed at patients and
their relatives who do not read and write
sufficiently well to understand what a clini-
cal trial is for and how it works.Representa-
tives from the WMA, the Indian Medical
Association, the Indian Council of Medical
Research and Pfizer,spoke about the launch
of the English-Hindi books and Ms. Zane
Wilson,from Books of Hope and the South
African Depression and Anxiety Group,
spoke movingly about the developments of
the project.
WMA Public Relations Consultant
Mr. Nigel Duncan
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Declaration of Delhi on Health
and Climate Change
Adopted by the WMA General Assembly,
New Delhi, India, October 2009
PREAMBLE
The purpose of this document is to provide a response by the WMA
on behalf of its members to the challenges imposed on health and
healthcare systems by climate change.
Although governments and international organizations have
the main responsibility for creating regulations and legislation to
mitigate the effects of climate change and to help their populations
adapt to it, the World Medical Association, on behalf of its national
medical association members and their physician members, feels an
obligation to highlight the health consequences of climate change
and to suggest solutions.The 4th Assessment Report of the Interna-
tional Panel on Climate Change (IPCC) contains a full chapter on
human health impacts (AR4 Chapter 8 Human Health*
), includ-
ing a range of possibilities regarding the potential effects of climate
change. The following introduction includes the most likely effects
of climate change from the IPCC report.
INTRODUCTION
The response of world leaders to the impact that humans are having
on climate and the environment will permanently alter the livability
of this planet.
1. The UN International Panel on Climate Change (IPCC) states
“Even the minimum predicted shifts in climate for the 21st century
are likely to be significant and disruptive”.**
1.1 The minimum warming forecast for the next 100 years is more
than twice the 0.6° C increase that has occurred since 1900.
1.2 Extra-tropical storm tracks are projected to move toward the
poles, with consequent changes in wind, precipitation, and tem-
perature patterns.
1.3 Sea levels have already risen by 10 to 20 cm over pre-industrial
averages, and will continue to rise due to the time scales associ-
ated with climate processes and feedbacks.
* Confalonieri, U., B. Menne, R. Akhtar, K.L. Ebi, M. Hauengue, R.S. Kovats,
B. Revich and A. Woodward, 2007: Human health. Climate Change 2007:
Impacts, Adaptation and Vulnerability. Contribution of Working Group II to
the Fourth Assessment Report of the Intergovernmental Panel on Climate
Change, M.L. Parry, O.F. Canziani, J.P. Palutikof, P.J. van der Linden and C.E.
Hanson, Eds., Cambridge University Press, Cambridge, UK, 391-431.
** United Nations Framework Convention on Climate Change. http://unfccc.
int/2860.php downloaded 1 September 2008
1.4 Projections point to continued snow cover contraction, and
widespread increases in thaw depth over most permafrost re-
gions, now including Antarctica.
1.5 A future of more severe storms and floods along the world’s
increasingly crowded coastlines is likely.
1.6 Increases in the amounts of precipitation in high latitudes and
precipitation decreases in most sub-tropical land regions are
predicted.
1.7 Regional / local effects may differ but a reduction in potential
crop yields is expected in most tropical / sub-tropical regions –
causing further disruptions in global food supply.
1.8 Salt-water intrusion from rising sea levels will reduce the quality
and quantity of freshwater supplies, and seawater will become
more acidic from dissolved CO2.
1.9 As many as 25% of mammals and 12% of birds may become ex-
tinct within the next few decades. Warmer conditions are alter-
ing the ecosystem and human development is blocking threat-
ened species from migrating.
1.10 Higher temperatures will expand the range of some vector-
borne diseases, such as malaria, which already kills 1 million
people annually, mostly children.
2. The IPCC authors begin with a review of the evidence and pro-
vide the following information (confidence levels as determined by
IPCC in brackets):
2.1 Climate change currently contributes to the global burden of
disease and premature deaths (very high confidence). At this
early stage the effects are small but are projected to progressively
increase in all countries and regions.
2.2 Emerging evidence of climate change effects on human health
shows that climate change has (confidence levels in brackets):
2.2.1 Altered the distribution of some infectious disease vectors
(medium);
2.2.2 Altered the seasonal distribution of some allergenic pollen
species (high);
2.2.3 Increased heat wave related deaths (medium).
3. In their thorough review, the IPCC authors’ project climate
change related human health impacts as follows (confidence levels
in brackets):
3.1 Increased malnutrition and consequent disorders, including
those relating to child growth and development (high).
3.2 Increased numbers of people suffering from death, disease
and injury from heat waves, floods, storms, fires and droughts
(high).
3.3 Continued change in the range of some infectious disease vec-
tors (high).
3.4 Mixed effects on malaria; in some places the geographical range
will contract, elsewhere the geographical range will expand and
the transmission season may be changed (very high).
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3.5 Increased burden of diarrheal diseases (medium).
3.6 Increased cardio-respiratory morbidity and mortality associated
with ground-level ozone (high).
3.7 Increased numbers of people at risk of dengue (low).
3.8 Social and health inequalities due to possible desertification,
natural disasters, changes in agriculture, feeding and water pol-
icy which will have consequences on both human health and
human resources in health.
4. The authors note that climate change could bring some benefits
to health, including fewer deaths from cold, although these will be
outweighed by the negative effects of rising temperatures world-
wide, especially in developing countries (high confidence).
5.The WMA notes that climate change is likely to amplify inequali-
ties in health and other existing problems within and between coun-
tries.
6.Early research suggests that mitigation of the effects of climate change
may have a link with prevention such that mitigation might have signifi-
cant health benefits for both individuals and populations*
STATEMENT
Given the consequences of global climate change on the health of
people throughout the world, the World Medical Association, on
behalf of its national medical association members and their physi-
cian members supports and commits to the following actions:
1. ADVOCACY to Combat Global Warming
1.1 The World Medical Association and National Medical Associa-
tions urge national governments to recognize the serious con-
sequences for health as a result of climate change and therefore
to strive for an intergovernmental agreement in Copenhagen in
December 2009 with the following components:
1.1.1 specific goals for reductions of climate altering emissions
(mitigation);
1.1.2 a mechanism to minimize the harms and health inequalities
that are globally associated with climate change (adaptation);
1.1.3 because climate change will exaggerate health disparities,
WMA recommends that resources transferred to developing
* In the context of this paper, Mitigation describes the actions to
reduce human effects on the climate system: principally strategies
to reduce greenhouse gas emissions (analogous to primary preven-
tion) while Adaptation is understood to refer to the adjustment in
natural or human systems taken in response to actual or expected
climate stimuli or their effects, and that moderate harm or exploit
beneficial opportunities (analogous to secondary prevention). (See
WHO EB122/4, Jan 08)
countries for climate change must include designated funds
to support the strengthening of health systems.
1.2 As a profession, physicians & their medical associations will
encourage advocacy for environmental protection, reduction of
green house gas production, sustainable development and green
adaptation practices within their communities, countries/re-
gions, especially for the right of safe water & sewage disposal
for all.
1.3 As professionals, physicians are encouraged to act within their
professional settings (clinics, hospitals, laboratories etc.) to re-
duce the environmental impact of medical activities, & to de-
velop environmentally sustainable professional settings.
1.4 As individuals, physicians will be encouraged to act to minimize
their impact on the environment, reduce their carbon footprint
and encourage those around them to do so.
2. LEADERSHIP: Help people to mitigate
climate damage & adapt to climate change
2.1 Support the Millennium Development Goals and commit to
work to attain them.
2.2 Support and implement the principles outlined in the WHO
Commission on the Social Determinants of Health report,
Closing the Gap in a Generation and in the World Health As-
sembly Resolution on climate change and health and work with
WHO and others to ensure implementation of the recommen-
dations.
2.3 Work to create resilience within health systems to ensure that all
health care providers are able to adapt and can fully utilize their
capacity to provide care to those in need.
2.4 Urge local, national and international organizations focused on
adaptation, mitigation, and development to involve physicians
and the healthcare community to ensure that unanticipated
health impacts of development are minimized, while opportu-
nities for health promotion are maximized.
2.5 Work to improve the ability of patients to adapt to climate
change and catastrophic weather events by:
2.5.1 encouraging health behaviors that improve overall health;
2.5.2 creating targeted programs designed to address specific
exposures;
2.5.3 providing health promotion information and education on
self-management of the symptoms of climate-associated ill-
ness.
3. EDUCATION & CAPACITY BUILDING:
3.1 Build professional awareness of the importance of the environ-
ment and global climate change to personal, community and
societal health, and recognize that universal equitable education
improves health capacity for all.
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3.2 Physicians have obligations for the health and health care of
individual patients. Collectively, through their national medical
associations, and through WMA they also have obligations and
responsibilities for the health of all people.
3.3 Work with others to educate the general public about the im-
portant effects of climate change on health and the need to both
mitigate climate change and adapt to its effects.
3.4 Add or strengthen routine health training on environmental
health/medicine and public health for all students in health re-
lated disciplines.
3.5 The WMA and NMAs should develop concrete actionable
plans/practical steps as tools for physicians to adopt in their
practices; health authorities and governments should do the
same for hospitals and other health facilities.
3.6 Incorporate tools such as a patient environmental impact assess-
ment and encourage physicians to evaluate their patients and
their families for risk from the environment and global climate
change.
3.7 Advocate that governments undertake community climate
change health impact assessments, widely disseminate the re-
sults, and incorporate the results into planning for mitigation
and adaptation.
3.8 Encourage recruitment of physicians for work in public health
and all roles in emergency planning & response to extreme cli-
mate change, including the training of other physicians.
3.9 Urge colleges and universities to develop locally appropriate
continuing medical and public health education on the clinical
signs, diagnosis and treatment of new diseases that are intro-
duced into communities as a result of climate change, and on
the management of long-term anxiety and depression that often
accompany experiences of disasters.
3.10 Urge governments to provide training for climate-change-re-
lated emergency response to physicians, particularly those living
in relatively isolated regions.
3.11 Work with policy makers on the development of concrete ac-
tions to be taken to prevent or reduce the health impact of cli-
mate-related emissions,in particular those initiatives,which will
also improve the general health of the population. This would
include initiatives to stop the privatization of water.
4. SURVEILLANCE AND RESEARCH:
4.1 Work with others, including governments, to address the gaps
in research regarding climate change and health by undertaking
studies to:
4.1.1 describe the patterns of disease that are attributed to cli-
mate change, including the impacts of climate change on
communities and households;
4.1.2 quantify and model the burden of disease that will be
caused by global climate change;
4.1.3 describe the effects of poorly treated wastewater used for
irrigation and
4.1.4 describe the most vulnerable populations, the particular
health impacts of climate change on vulnerable populations,
& possible new protections for such populations.
4.2 Advocate for the collection of vital statistics and the removal of
barriers to the registration of births & deaths, in recognition of
the special vulnerability of some populations.
4.3 Report diseases that emerge in conjunction with global climate
change, and participate in field investigations, as with outbreaks
of infectious diseases.
4.4 Support and participate in the development or expansion of sur-
veillance systems to include diseases caused by global climate
change.
4.5 WMA will and encourages all NMAs to collaborate in the col-
lection and sharing of local or regional health information with-
in and between countries in order to encourage the adoption of
best practices and proven strategies
5. COLLABORATION: Prepare for climate emergencies
5.1 Collaborate with governments, NGOs and other health profes-
sionals to develop knowledge about the best ways to mitigate
climate change, including those adaptive and mitigation strate-
gies that will result in improved health.
5.2 Encourage governments to incorporate national medical as-
sociations & physicians into country & community emergency
planning & response.
5.3 Work to ensure integration of physicians into the plans of civil
society, governments, public health authorities, international
NGOs and WHO.
5.4 Encourage WHO and countries of the World Medical Assem-
bly to review the International Health Regulations and Plan-
ning for Pandemic Influenza and obtain the perspective of clini-
cians in community practice to ensure that there are appropriate
responses by practicing physicians to emergency alerts, and to
make recommendations regarding the most appropriate educa-
tion, and tools for physicians and other healthcare workers.
5.5 Call upon governments to strengthen public health systems in
order to improve the capacity of communities to adapt to cli-
mate change.
5.6 Prepare physicians, physicians’offices, clinics, hospitals and oth-
er health care facilities for the infrastructure disruptions that
accompany major emergencies, in particular by planning in ad-
vance the delivery of services during times of such disruptions.
5.7 Urge physicians, medical associations and governments to work
collaboratively to develop systems for event alerts in order to
ensure that health care systems and physicians are aware of
climate-related events as they unfold, and receive timely accu-
rate information regarding the management of emerging health
events.
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5.8 Call upon governments to plan for environmental refugees
within their countries.
5.9 In collaboration with WHO,produce locally adapted fact sheets
on climate change for national medical associations, physicians,
and other health professionals.
5.10 WMA will work with others to identify funding for specific re-
search programs on mitigation and adaptation related to health,
and the sharing of information/research within and between
countries and jurisdictions.
Declaration of Madrid on
Professionally-led Regulation
Adopted by the WMA General Assembly,
New Delhi, India, October 2009
The collective action by the medical profession seeking for the1.
benefit of patients, in assuming responsibility for implement-
ing a system of professionally-led regulation will enhance and
assure the individual physician’s right to treat patients without
interference, based on his or her best clinical judgment. There-
fore, the WMA urges the national medical associations and all
physicians to take the following actions.
Physicians have been granted by society a high degree of profes-2.
sional autonomy and clinical independence, whereby they are
able to make recommendations based on the best interests of
their patients without undue outside influence.
As a corollary to the right of professional autonomy and clinical3.
independence,the medical profession has a continuing responsi-
bility to be self-regulating. Ultimate control and decision-mak-
ing authority must rest with physicians, based on their specific
medical training, knowledge, experience and expertise
Physicians in each country are urged to establish, maintain and4.
actively participate in a legitimate system of professionally-led
regulation. This dedication is to ultimately assure full clinical
independence in patient care decisions.
To avoid being influenced by the inherent potential conflicts of5.
interest that will arise from assuming both representational and
regulatory duties, National Medical Associations must do their
utmost to promote and support the concept of professionally-
led regulation amongst their membership and the public.
Any system of professionally-led regulation must ensure6.
a) the quality of the care provided to patients,
b) the competence of the physician providing that care and
c) the professional conduct of physician.
To ensure the patient quality continuing care, physicians must
participate actively in the process of Continuing Professional
Development in order to update and maintain their clinical
knowledge, skills and competence.
The professional conduct of physicians must always be within7.
the bounds of the Code of Ethics governing physicians in each
country. National Medical Associations must promote profes-
sional and ethical conduct among physicians for the benefit of
their patients. Ethical violations must be promptly recognized
and reported. The physicians who have erred must be appropri-
ately disciplined and where possible be rehabilitated.
National Medical Associations are urged to assist each other in8.
coping with new and developing problems, including potential
inappropriate threats to professionally-led regulation.The ongo-
ing exchange of information and experiences between National
Medical Associations is essential for the benefit of patients.
An effective and responsible system of professionally-led regu-9.
lation by the medical profession in each country must not be
self serving or internally protective of the profession, and the
process must be fair, reasonable and sufficiently transparent to
ensure this. National Medical Associations should assist their
members in understanding that self-regulation cannot only be
perceived as being protective of physicians, but must maintain
the safety, support and confidence of the general public as well
as the honour of the profession itself.
Declaration of Ottawa
on Child Health
Adopted by the 50th World Medical Assembly, Ottawa,
Canada, October 1998 and amended by the WMA
General Assembly, New Delhi, India, October 2009
PREAMBLE
Science has now proven that to reach their potential, children need
to grow up in a place where they can thrive – spiritually,emotionally,
mentally, physically and intellectually*
. That place must have four
fundamental elements:
a safe and secure environment;•
the opportunity for optimal growth and development;•
health services when needed; and•
monitoring & research for evidence-based continual improve-•
ment into the future**
.
* Irwin LG, Siddiqi A, Hertzman C. “Early Child Development: A Power-
ful Equalizer. Final Report”. World Health Organization Commission on the
Social Determinants of Health June 2007.
** WHO Commission on Social Determinants of Health (Closing the Gap in a
Generation) 2008
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Physicians know that the future of our world depends on our chil-
dren: their education, their employability, their productivity, their
innovation, and their love and care for one another and for this
planet. Early childhood experiences strongly influence future de-
velopment including basic learning, school success, economic par-
ticipation, social citizenry, and health3
. In most situations, parents
and caregivers alone cannot provide strong nurturing environ-
ments without help from local, regional, national and international
organizations.***
Physicians therefore join with parents, and with
world leaders to advocate for healthy children.
The principles of this Declaration apply to all children in the world
from birth to 18 years of age, regardless of race, age, ethnicity, na-
tionality, political affiliation, creed, language, gender, disease or dis-
ability, physical ability, mental ability, sexual orientation, cultural
history, life experience or the social standing of the child or her/his
parents or legal guardian. In all countries of the world, regardless of
resources, meeting these principles should be a priority for parents,
communities and governments. The United Nations Convention
on the Rights of Children (1989) sets out the wider rights of all
children and young people, but those rights cannot exist without
health.
GENERAL PRINCIPLES
1. A place with a safe and secure environment includes:
Clean water, air and soil;•
Protection from injury, exploitation, discrimination and from tra-•
ditional practices prejudicial to the health of the child, and
Healthy families, homes and communities.•
2. A place where a child can have good health and development
offers:
Prenatal and maternal care for the best possible health at birth;•
Nutrition for proper growth, development and long-term health;•
Early learning opportunities and high quality care at home and•
in the community;
Opportunities and encouragement for physical activity;•
*** Canadian Charter for Child and Youth Health
Affordable & accessible high quality primary & secondary educa-•
tion.
3. A full range of health resources available to all means:
The best interests of the child shall be the primary consideration•
in the provision of health care;
Those caring for children shall have the special training and skills•
necessary to enable them to respond appropriately to the medical,
physical, emotional and developmental needs of children & their
families;
Basic health care including health promotion, recommended im-•
munization, drugs & dental health;
Mental health care and prompt referral to intervention when•
problems identified;
Priority access to drugs for life- or limb-threatening conditions•
for all mothers and children;
Hospitalization only if the care and treatment required cannot be•
provided at home, in the community or on an outpatient basis;
Access to specialty diagnostic and treatment services when need-•
ed;
Rehabilitation services and supports within community;•
Pain management and care and prevention (or minimization) of•
suffering;
Informed consent is necessary before initiating any diagnostic,•
therapeutic, rehabilitative, or research procedure on a child. In
the majority of cases, the consent shall be obtained from the
parent(s) or legal guardian, or in some cases, by extended family,
although the wishes of a competent child should be taken into
account before consent is given.
4. Research****
& monitoring for continual improvement includes:
All infants will be officially registered within one month of birth;•
All children will be treated with dignity and respect;•
Quality care is ensured through on-going monitoring of services,•
including collection of data, and evaluation of outcomes;
Children will share in the benefits from scientific research rel-•
evant to their needs;
The privacy of a child patient will be respected.•
**** Proposed WMA statement on ethical principles for medical research on child
subjects
WMA Resolution on Task
Shifting from the Medical
Profession
Adopted by the WMA General Assembly,
New Delhi, India, October 2009
In health care, the term “Task Shifting” is used to describe a situa-
tion where a task normally performed by a physician is transferred
to a health professional with a different or lower level of education
and training, or to a person specifically trained to perform a limited
task only, without having a formal health education. Task shifting
occurs both in countries facing shortages of physicians and those
not facing shortages.
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A major factor leading to task shifting is the shortage of qualified
workers resulting from migration or other factors. In countries facing
a critical shortage of physicians, task shifting may be used to train al-
ternate health care workers or laypersons to perform tasks generally
considered to be within the purview of the medical profession. The
rationale behind the transferring of these tasks is that the alternative
would be no service to those in need. In such countries, task shifting
is aimed at improving the health of extremely vulnerable populations,
mostly to address current shortages of healthcare professionals or tackle
specific health issues such as HIV. In countries with the most extreme
shortage of physicians, new cadres of health care workers have been
established. However, those persons taking over physicians’ tasks lack
the broad education and training of physicians and must perform their
tasks according to protocols, but without the knowledge, experience
and professional judgement required to make proper decisions when
complications arise or other deviations occur.This may be appropriate
in countries where the alternative to task shifting is no care at all but
should not be extended to countries with different circumstances.
In countries not facing a critical shortage of physicians,task shifting
may occur for various reasons: social, economic, and professional,
sometimes under the guise of efficiency, savings or other unproven
claims. It may be spurred, or, conversely, impeded, by professions
seeking to expand or protect their traditional domain. It may be
initiated by health authorities, by alternate health care workers and
sometimes by physicians themselves. It may be facilitated by the
advancement of medical technology, which standardizes the perfor-
mance and interpretation of certain tasks, therefore allowing them
to be performed by non-physicians or technical assistants instead of
physicians. This has typically been done in close collaboration with
the medical profession. However, it must be recognized that medi-
cine can never be viewed solely as a technical discipline.
Task shifting may occur within an already existing medical team,
resulting in a reshuffling of the roles and functions performed by the
members of such a team. It may also create new types of personnel
whose function is to assist other health professionals, specifically
physicians, as well as personnel trained to independently perform
specific tasks.
Although task shifting may be useful in certain situations, and may
sometimes improve the level of patient care,it carries with it signifi-
cant risks. First and foremost among these is the risk of decreased
quality of patient care,particularly if medical judgment and decision
making is transferred. In addition to the fact that the patient may
be cared for by a lesser trained health care worker, there are specific
quality issues involved, including reduced patient-physician contact,
fragmented and inefficient service, lack of proper follow up, incor-
rect diagnosis and treatment and inability to deal with complica-
tions.
In addition, task shifting which deploys assistive personnel may ac-
tually increase the demand on physicians. Physicians will have in-
creasing responsibilities as trainers and supervisors, diverting scarce
time from their many other tasks such as direct patient care. They
may also have increased professional and/or legal responsibility for
the care given by health care workers under their supervision.
The World Medical Association expresses particular apprehension
over the fact that task shifting is often initiated by health authori-
ties, without consultation with physicians and their professional
representative associations.
RECOMMENDATIONS
Therefore, the World Medical Association recommends the follow-
ing guidelines:
1. Quality and continuity of care and patient safety must never be
compromised and should be the basis for all reforms and legisla-
tion dealing with task shifting.
2. When tasks are shifted away from physicians, physicians and
their professional representative associations should be con-
sulted and closely involved from the beginning in all aspects
concerning the implementation of task shifting,especially in the
reform of legislations and regulations. Physicians might them-
selves consider initiating and training a new cadre of assistants
under their supervision and in accordance with principles of
safety and proper patient care.
3. Quality assurance standards and treatment protocols must be
defined, developed and supervised by physicians. Credential-
ing systems should be devised and implemented alongside the
implementation of task shifting in order to ensure quality of
care.Tasks that should be performed only by physicians must be
clearly defined. Specifically, the role of diagnosis and prescrib-
ing should be carefully studied.
4. In countries with a critical shortage of physicians, task shifting
should be viewed as an interim strategy with a clearly formulat-
ed exit strategy. However, where conditions in a specific country
make it likely that it will be implemented for the longer term, a
strategy of sustainability must be implemented.
5. Task shifting should not replace the development of sustain-
able, fully functioning health care systems. Assistive workers
should not be employed at the expense of unemployed and un-
deremployed health care professionals.Task shifting also should
not replace the education and training of physicians and other
health care professionals. The aspiration should be to train and
employ more skilled workers rather than shifting tasks to less
skilled workers.
6. Task shifting should not be undertaken or viewed solely as a cost
saving measure as the economic benefits of task shifting remain
unsubstantiated and because cost driven measures are unlikely
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to produce quality results in the best interest of patients. Cred-
ible analysis of the economic benefits of task shifting should be
conducted in order to measure health outcomes, cost effective-
ness and productivity.
7. Task shifting should be complemented with incentives for the
retention of health professionals such as an increase of health
professionals’ salaries and improvement of working conditions.
8. The reasons underlying the need for task shifting differ from
country to country and therefore solutions appropriate for one
country cannot be automatically adopted by others.
9. The effect of task shifting on the overall functioning of health
systems remains unclear. Assessments should be made of the
impact of task shifting on patient and health outcomes as well
as on efficiency and effectiveness of health care delivery. In par-
ticular, when task shifting occurs in response to specific health
issues, such as HIV, regular assessment and monitoring should
be conducted of the entire health system. Such work is essential
in order to ensure that these programs are improving the health
of patients.
10. Task shifting must be studied and assessed independently and
not under the auspices of those designated to perform or finance
task shifting measures.
11.Task shifting is only one response to the health workforce short-
age. Other methods, such as collaborative practice or a team/
partner approach, should be developed in parallel and viewed
as the gold standard. Task shifting should not replace the de-
velopment of mutually supportive, interactive health care teams,
coordinated by a physician, where each member can make his or
her unique contribution to the care being provided.
12. In order for collaborative practice to succeed, training in lead-
ership and teamwork must be improved. There must also be
a clear understanding of what each person is trained for and
capable of doing, clear understanding of responsibilities and a
defined, uniformly accepted use of terminology.
13.Task shifting should be preceded by a systematic review, analysis
and discussion of the potential needs, costs and benefits. It
should not be instituted solely as a reaction to other develop-
ments in the health care system.
14.Research must be conducted in order to identify successful train-
ing models. Work will need to be aligned to various models cur-
rently in existence. Research should also focus on the collection
and sharing of information, evidence and outcomes. Research
and analysis must be comprehensive and physicians must be part
of the process.
15. When appropriate, National Medical Associations should col-
laborate with associations of other health care professionals in
setting the framework for task shifting. The WMA shall con-
sider establishing a framework for the sharing of information
on this topic where members can discuss developments in their
countries and their effects on patient care and outcomes.
WMA Emergency Resolution
supporting the Rights of Patients
and Physicians in the Islamic
Republic of Iran
Adopted by the WMA General Assembly,
New Delhi, India, October 2009
WHEREAS,
Physicians in the Islamic Republic of Iran have reported:
Unsettling practices of injured persons being taken to prisons, with-
out adequate medical treatment or the consensus of the attending
physicians;
Physicians being hindered from treating patients;
Concern about the veracity of documentation related to the death of
patients and physicians being forced to clinically inaccurate docu-
mentation; and
Corpses and badly injured political and religious prisoners who
were admitted to hospitals with signs of brutal torture, including
sexual abuse.
THEREFORE, the World Medical Association
1. Reaffirms its Declaration of Lisbon: Declaration on the Rights
of the Patient, which states that whenever legislation, government
action or any other administration or institution denies patients the
right to medical care, physicians should pursue appropriate means
to assure or to restore it.
2. Reaffirms its Declaration of Hamburg: Declaration Concern-
ing Support for Medical Doctors Refusing to Participate in, or to
Condone, the Use of Torture or Other Forms of Cruel, Inhuman
or Degrading Treatment, which encourages doctors to honor their
commitment as physicians to serve humanity and to resist any pres-
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sure to act contrary to the ethical principles governing their dedica-
tion to this task.
3. Reaffirms its Declaration of Tokyo: Guidelines for Physicians
Concerning Torture and other Cruel,Inhuman or Degrading Treat-
ment or Punishment in Relation to Detention and Imprisonment,
which:
prohibits physicians from participating in, or even being present•
during the practice of torture or other forms of cruel or inhuman
or degrading procedures;
requires that physicians maintain utmost respect for human life•
even under threat, and prohibits them from using any medical
knowledge contrary to the laws of humanity.
4. Reaffirms its Resolution on the Responsibility of Physicians in
the Documentation and Denunciation of Acts of Torture or Cruel
or Inhuman or Degrading Treatment; which states that physicians
should attempt to:
ensure that detainees or victims of torture or cruelty or mistreat-•
ment have access to immediate and independent health care;
ensure that physicians include assessment and documentation of•
symptoms of torture or ill-treatment in the medical records us-
ing the necessary procedural safeguards to prevent endangering
detainees.
5. Refers to the WMA International Code of Medical Ethics,
which states that physicians shall be dedicated to providing com-
petent medical service in full professional and moral independence,
with compassion and respect for human dignity.
6. Urges the government of the Islamic Republic of Iran to respect
the International Code of Medical Ethics and the standards in-
cluded in the aforementioned declarations to which physicians are
committed.
7. Urges National Medical Associations to speak out in support of
this resolution.
WMA Resolution on Medical
Workforce
Adopted by the 50th World Medical Assembly, Ottawa,
Canada, October 1998 and amended by the WMA
General Assembly, New Delhi, India, October 2009
PREAMBLE
The health of our countries depends upon keeping the population
healthy. Health care is a key right of individuals.This care is depen-
dent upon access to highly-trained medical and other healthcare
professionals. Well-functioning health care systems depend upon
these sufficient human resources. Comprehensive and extensive
planning on a national level is required in order to ensure that a
country has a medical workforce in all fields of medicine that meets
the present and future health needs of the entire population of that
country.
There are currently significant shortages in the area of health hu-
man resources. These shortages are present in all countries but are
especially pronounced in developing countries where health human
resources are more limited.
The problem is made more severe by the fact that many countries
have not invested adequately in the education, training, recruitment
and retention of their medical workforce. The ageing population in
developed countries has also been reflected by an ageing medical
workforce. Many developed countries address their medical work-
force shortages by employing health care professionals from devel-
oping countries to bolster their own health care systems.
The migration of health care professionals from developing coun-
tries to developed countries has,over the past ten years,impaired the
performance of health systems in developing countries. Economic
realities of insufficient investments in health care and inadequate
facilities and support for health care professionals have continued to
be responsible for this migration.
The World Health Organization has recognized that the crisis of
health workforce shortages is impeding the provision of essential,
life-saving interventions.It has therefore established structures such
as the Global Health Workforce Alliance, a partnership dedicated
to identifying and implementing solutions to the health workforce
problems. The WHO is promoting the development of a cadre of
medical/clinical assistants who propose to join the medical work-
force to partially address these shortages.
RECOMMENDATIONS
Recognizing that health care systems require adequate numbers of
qualified and competent health care professionals, the World Medi-
cal Association asks all National Medical Associations to partici-
pate and be active in addressing these requirements and to:
1. Call on their respective governments to allocate sufficient finan-
cial resources for the education, training, development, recruitment
and retention of physicians to meet the medical needs of the entire
population in their countries.
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2. Call on their respective governments to ensure that the educa-
tion, training and development of healthcare professionals meets
the highest possible standards including:
The training and development of medical/clinical assistants where•
this is applicable and appropriate and
Ensuring clear definitions of scope of practice and conditions for•
adequate support and supervision.
3. Call on governments to ensure that appropriate ratios are main-
tained between population and the medical workforce at all levels,
including mechanisms to address reduced access to care in rural and
remote areas, based on accepted international norms and standards
where these are available.
4. Take measures to attract and support individuals within their
countries to enter the medical profession and also call on their re-
spective governments to take such action.
5. Actively advocate for programs that will ensure the retention of
physicians within their respective countries and ensure governments’
recognition of this need.
6.Call on governments to improve the health care working environ-
ment (including access to appropriate facilities, equipment, treat-
ment modalities and professional support), physician remuneration,
physician living environment and career development of the medi-
cal workforce at all levels.
7. Advocate for the development of transparent memoranda of un-
derstanding between countries where migration of trained health
care professionals is an issue of concern and enlist where possible the
NMA of origin and receiving NMA’s to support these physicians.
WMA Statement on
Inequalities in Health
Adopted by the WMA General Assembly,
New Delhi, India, October 2009
PREAMBLE
For over 150 years, the existence of health inequality has been ac-
knowledged worldwide. The recently published Final Report of the
WHO Commission on Social Determinants of Health has high-
lighted the critical importance of health equity to the health, econ-
omy and social cohesiveness of all countries. It is clear that while
there are major differences between countries,especially between the
developing and developed countries, there are also substantial dis-
parities within countries with respect to various measures of socio-
economic and cultural diversity. Disparities in health can be defined
as either disparities in access to healthcare, disparities in quality of
care received, or both.The differences manifest themselves in a wide
variety of health measures, such as life expectancy, infant mortality,
and childhood mortality. Particularly disturbing is evidence of the
gradual and ongoing widening of specific disparities.
At the core of this issue is the healthcare provided by physicians.
National medical associations should take an active role in combat-
ing social and health inequalities in order to allow their physician
members the ability to provide equal, quality service to all.
The Role of the Health Care System
While the major causes of health disparities lie in the socio-eco-
nomic and cultural diversity of population groups, there is a very
significant role for the health care system in their prevention and
reduction.This role can be summarized as follows:
To prevent the health effects of socio-economic and cultural in-•
equality and inequity – especially by health promotion and dis-
ease prevention activities (Primary Prevention)
To Identify, treat and reduce existing health inequality, e.g. early•
diagnosis of disease,quality management of chronic disease,reha-
bilitation (Secondary and Tertiary Prevention).
RECOMMENDATIONS
The members of the medical profession, faced with treating the re-
sults of this inequity, have a major responsibility and call on their
national medical associations to:
1. Recognize the importance of health inequality and the need to
influence national policy and action for its prevention and re-
duction
2. Identify the social and cultural risk factors to which patients and
families are exposed and to plan clinical activities (diagnostic
and treatment) to counter their consequences.
3. Advocate for the abolishment of financial barriers to obtaining
needed medical care.
4. Advocate for equal access for all to health care services irrespec-
tive of geographic, social, age, gender, religious, ethnic and eco-
nomic differences or sexual orientation.
5. Require the inclusion of health inequality studies (including the
scope, severity, causes, health, economic and social implications)
as well as the provision of cultural competence tools, at all lev-
els of academic medical training, including further training for
those already in clinical practice.
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WMA Resolution on Improved
Investment in Public Health
Adopted by the 50th World Medical Assembly, Ottawa,
Canada, October 1998 and amended by the WMA
General Assembly, New Delhi, India, October 2009
INTRODUCTION
Each country should have a health system with enough resources to
attend to the needs of its population. However today, many coun-
tries across the world are suffering wide inequities and inequalities
in health care and this is causing problems of access to health servic-
es for the poorer segments of society [the weak or underprivileged].
The situation is especially serious in low-income countries.
The international community has attempted to improve the situ-
ation. The 20/20 initiative of 1995, the 1996 Initiative for Heavily
Indebted Poor Countries (HIPC), and Objectives for Millennium
2000 Development (MDGs) are all initiatives aimed at reducing
poverty and dealing with poor health, inequities and inequalities
between the sexes, education, insufficient access to drinking water
and environmental contamination.
The objectives are formed as an agreement with acknowledgement
of the contributions which developed countries can make, in the
shape of trade relations, development assistance, reduction of the
burden of debt, improving access to essential medication and the
transfer of technology. Three of the eight objectives are directly re-
lated to health, which has a considerable influence on various other
objectives that interact to support each of the others within a struc-
tural framework,these are designed to increase human development
globally. The eight Millennium Development Objectives (MDO)
foresee a development vision based on health and education, thus
affirming that development does not only refer (allude) to economic
growth.
Various reports from the World Health Organization have un-
derlined the opportunities and skills [or techniques] which are
currently involved in bringing about significant improvements in
health, as well as helping to reduce poverty and encourage growth.
Additionally, the reports highlight the fact that it is of fundamental
importance to reduce limitations on human resources, in order to
increase the achievements of the public health system, a situation
which requires urgent attention. These limitations are related to
work, training and payment conditions, and play a substantial role
in determining capacity for sustained growth of access to health
services.
RECOMMENDATIONS
The World Medical Association urges National Medical Associa-
tions to:
1. Advocate that their governments should adhere to and promote
the proposals to increase investment in the health sector; and to
adhere to and promote initiatives to reduce the debt burden for the
poorest countries on the planet.
2. Advocate [defend] the inclusion of public health factors in all
fields of policy provision, since health is mostly determined by fac-
tors that are external to the area of healthcare, for example, housing
and education. [Health is not only medicine, it also depends on liv-
ing standards].
3. Encourage and support countries in the planning and implemen-
tation of investment plans,which invest in health for the poor; guar-
antee that more resources be used for health in general, with greater
efficiency and impact; and reduce limitations for the most effective
use of the additional investments.
4. Maintain vigilance to ensure that the investment plans focus
maximum attention on generating capacity, that they promote lead-
ership skills and promote incentives to retain and place qualified
personnel, whilst it is taken into consideration that the limitations
in relation to the previous matter currently constitute the greatest
obstacle for progress.
5. Urge international financial institutions and other important
donors to: i) Adopt the necessary measures to help the countries
that have already organised mechanisms to prepare their investment
plans, and provide assistance to those countries that have begun to
take the necessary steps, with the support and participation of the
international community; ii) Help countries to obtain funds to de-
velop and implement their investment plans; iii) Continue provid-
ing technical assistance to the countries for their plans.
6. Exchange information in order to coordinate efforts to change
policies in these areas.
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WMA news
“Speaking Books” launched at the World
Medical Association AGM in New Delhi
In a joint collaboration, the WMA togeth-
er with Pfizer, and South African NGO
SADAG (The South African Depression
and Anxiety Group) launched the next two
books in their ongoing series of “Speaking
Books” for vulnerable communities.
The “Speaking Books” first launched in
South Africa for rural and least served
communities are to help patients gain a ba-
sic understanding of clinical trials that they
may choose to participate in.The first in this
series was field tested in South Africa at
TB, and HIV and AIDS facilities. Patients
overwhelmingly gained a better under-
standing of their rights and responsibilities,
with results indicating that:
93% of patients understood that they•
would be told how long to take the medi-
cine or vaccination and the duration of
the trial;
91% understood that they would be al-•
lowed to stop the trial at anytime;
91% were aware that they must tell their•
doctor about other medications they were
taking;
100% knew both that they had rights•
when participating and that their infor-
mation would be private.
This hard backed book with 16 pages of
culturally appropriate illustrations, has a re-
corded soundtrack, so that with the push of
a button, each page can be read, heard and
viewed simultaneously. Each book is cus-
tomized to meet the needs of the local com-
munity, recorded in the required language
and read by a well known local personality
The first “Speaking Book” in South Africa
was as a result of the collaboration between
the South African Medical Association,
The Steve Biko Centre for Bioethics, the
World Medical Association and sponsored
by Pfizer in the interests of patient educa-
tion.This “Speaking Book” was produced to
support the principles of the Declaration of
Helsinki in promoting Good Clinical Prac-
tice and protecting the human rights, safety,
and well-being of clinical trial participants.
According to Dr. Soeren Rasmussen, Se-
nior Director for Pfizer Inc and responsible
for implementing Pfizer’s “Speaking Book”
program, “There is a need for informing
people with limited literacy skills on how
clinical trials work,and by using the “Speak-
ing Book” it has made it possible for us to
deliver simple messages that will be seen
read, heard and understood. We first intro-
duced the “Speaking Books” with WMA
for Africa, followed by India in Hindi and
Telugu,and now the next in our series being
an anti-smoking “Speaking Book” recorded
in Mandarin focusing on Chinese youth”
“Speaking Books”enable patients with little or
no literacy skills to understand critical health
care messages and to take them home to share
with their families so that the clinical trial
concept is fully understood by all. The sound
tracks are read by local celebrities and in the
language of choice for that community. By
being battery operated even the most isolated
and remote community can be reached with
this innovative cost effective tool.
In India the first ever dual language “Speak-
ing Book”was distributed using both Hindi
and Telugu for use by clinics, trial centres
and hospitals. One clinical trial sister com-
mented that, “The book is a great idea to
send home with each person. Sometimes
people forget things you have said to them.
With the book they can listen over and over
again until they understand fully”.
Developed by a small South African mental
health NGO, these “Speaking Books” have
now been distributed globally in 14 lan-
guages and on 35 health care topics. www.
booksofhope.com
The “Speaking Book” delivers important
health information to low-literacy commu-
nities.Available free of charge,each book fo-
cuses on a single subject, such as a particular
disease – or a healthcare assistance program.
This book explains clinical trials to potential
participants including goals, possible risks,
and patient rights and responsibilities.
Healthcare practitioners request the free
“Speaking Books”and give them to their pa-
tients. Patients considering participation can
take the books home and share them with
friends, family, and community members.
After spending a week with the book in
their homes, community members who had
never taken part in a clinical trial shared
their experiences:
“I like the explanation about clinical tri-•
als. It is clear and understandable”
“I liked the voice… and all the informa-•
tion given. It was really great”
“I liked how the talking book encourages•
reading”
Dr. Brian M. Julius (bj@booksofhope.com)
Hindi – English bilingual “Speaking Book”
Ms. Yoonsun Park
Ms. Anne-Marie Delage
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148
Medical Ethics, Human Rights and Socio-medical affairs
Dong-Chun Shin
Introduction
The world’s greatest health concern in the
21st
century is global warming. Warnings
against the dangers of future climate change
are heralded by every newspaper. Average
global temperature has increased by 0.74 °C
with a span of 0.56-0.92 °C over the past
century, which has resulted in numerous
problems such as increasing rainfall, melt-
ing glaciers and flooding of low-lying areas
around the equator. Decrease in crop yield
and higher frequency of nature disasters
and communicable diseases also threaten
mankind. Many countries have tried to re-
duce greenhouse gas emission. Even the US
House of Representatives drafted a clean
energy legislation called the American
Clean Energy and Security Act, also known
as the “Waxman-Markey Bill” on 26, June
2009.
Climate change threatens to stall economic
development in Asia and Oceania and en-
dangers the health and safety of its vast
population. Climate change causes temper-
ature, wind and precipitation to vary, with
profound effects on natural systems. This,
in turn, has effects on the health, safety and
livelihoods of people – especially the dis-
advantaged. Nowhere in the world are as
many people affected by climate change as
in Asia and Oceania.
Climate change will intensify typhoons,
droughts, heat waves, landslides and other
natural hazards in a region which already
suffers from more natural disasters than any
other part of the world. During the last de-
cade,Bangladesh,India,the Philippines and
Viet Nam have topped the list of countries
facing serious climate risks. The cumulative
losses due to natural disasters have averaged
nearly $20 billion over the same period.
Future warming will cause an increase of
sea-levels, warmer ocean temperatures and
higher sea water acidity, leading to greater
coastal erosion and threatening the health
of marine ecosystems.
Climate Change in Asia and Oceania
Asia is the most populous continent in the
world. Marine and coastal ecosystems in
Asia are likely to be affected by sea-level ris-
es and temperature increases.Future climate
change is likely to affect agriculture and ag-
gravate the risk of food and water short-
ages by amplifying climate variability and
accelerating glaciers melting [1]. From the
Himalayas, which provide water to a billion
people, to the coastal areas of Bangladesh,
South Asian countries must prepare against
the impact of global warming. A moder-
ate rise in temperatures could cause seri-
ous changes to the environment in South
Asia [2]. A large number of deaths from
heat waves have been reported in India [3]
and Siberia [4]. An endemic morbidity and
mortality of diarrheal disease, closely asso-
ciated with poverty and hygiene, also have
been reported in South Asia [5].
Figure 1.
Himalaya Glacier and Asian rivers
Most Asian countries have already realised
their own risk related with climate change,
but not all of them are prepared against
it. Some leading countries have developed
efforts for reducing greenhouse gas emis-
sions and have even started to support other
countries in Asia. For example, CarboEast-
Asia (China, Japan and Korea) copes with
climate change by developing measure-
ments, theory and modelling that helps
quantify and understand the global warm-
ing mechanism [6].
In December 1993, Korea joined the
UNFCCC.It is currently classified as a non-
Annex I (industrialized countries) and II
(developed countries) country and therefore,
has no obligation to reduce emissions during
the first commitment period (2008-2012).
However, after the first commitment period,
the international demand for Korean’s par-
ticipation in the international efforts to tack-
le global warming will be even stronger [7].
China is also a developing country and
does not have an international obligation to
cut emissions. But, in the 2007 G8 meet-
ing in Germany, the Chinese government
unveiled its first national plan for climate
change. This plan contained China’s aim to
reduce energy use by a fifth before 2010 and
to increase the amount of renewable energy
production [8].
Impact of climate change in Asia and Oceania
region and challenges ahead
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Medical Ethics, Human Rights and Socio-medical affairs
Japan has provided training in developing
countries and has promoted monitoring,
analysing and interpreting of observational
data, as well as sharing climate change data
in the Asia-Pacific region with other gov-
ernments [9].
The Oceania region ranges from the lush
tropical rainforests of Indonesia to the inte-
rior deserts of Australia. Climate is strongly
influenced by the ocean and El Niño. Small
island states and the coastal regions – where
most of the population is concentrated – are
highlyvulnerabletoincreasingcoastalflood-
ing and erosion due to a rising sea level.The
recent increase in ocean temperatures has
damaged many of the region’s spectacular
coral reefs, one of the world’s most diverse
ecosystems.
Extreme temperatures have contributed to
the deaths of some 1100 people aged over 65
each year in 10 Australian and 2 New Zea-
land cities.The projected rise in temperature
for the next 50 years is predicted to result in
a substantial increase in heat-related deaths
in all the cities studied, in the absence of
adaptive measures. Temperate cities show
higher rates of deaths due to heat than trop-
ical cities. Global warming is projected to
reduce the number of cold winter days and
a few cities may actually experience fewer
annual deaths in the short-term due to this.
In the medium to long-term,however,these
health gains would be greatly outweighed
by additional heat-related deaths.
Extreme rainfall events are expected to in-
crease in almost all Australian states and
territories by 2020. Annual flood-related
deaths and injuries may also increase by
up to 240 %, depending on the region. The
situation by 2050 is mixed. As the climate
changes, parts of Australia are projected to
have substantially less rainfall, and in these
places the risk of flooding is predicted to
lessen. Most parts of the country, however,
are still predicted to be at far greater risk
of flood-related deaths and injuries than at
present.
The “malaria receptive zone” may expand
southwards, to include regional towns like
Rockhampton, Gladstone and Bundaberg.
However, in the foreseeable future malaria
itself is not a direct threat to Australia under
climate change, as long as a high priority is
placed on prevention via the maintenance
and extension of public health and local
government infrastructure.
Warmer temperatures and stronger rainfall
variability are predicted to increase the in-
tensity and frequency of food-borne and
water-borne diseases. Successful adaptation
to the projected climate changes will require
the upgrading of sewerage systems and safer
food production and storage processes. Due
to their poor living conditions and limited
access to public services, Aboriginal people
living in remote arid communities will be
exposed to increased risk. The annual num-
ber of diarrheal admissions among Aborigi-
nal children living in the central Australian
region is predicted to increase by 10 % by
2050.
The number of people exposed to flood-
ing due to sea-level rise in Australia and
New Zealand is predicted to approximately
double in the next 50 years, although abso-
lute numbers would still be low. For the rest
of the Pacific region, however, the number
of people who experience flooding by the
2050s could increase by a factor of more
than 50 to between 60,000 and 90,000 in an
average year. As well as the impact of flood-
ing on settlements, the impact of sea-level
rise on freshwater quality and quantity is
likely to be a critical threat to Pacific Island
health and welfare.
The first detectable changes in human
health may well be alterations in the geo-
graphic range and seasonality of certain
vector-borne infectious diseases. Summer-
time food-borne infections (e.g. salmo-
nellosis) may show longer-lasting annual
peaks. The public health consequences of
the disturbance of natural and managed
food-producing systems, of rising sea-levels
and of population displacement for reasons
of physical hazard, land loss, economic dis-
ruption and civil strife may not become evi-
dent for several decades.
Reducing the total level of greenhouse gas
emissions is a primary preventive health
strategy.Because the current levels of green-
house gases will continue to influence the
climate over the next several hundred years,
Table 1. General statistics in Asia by year 2005
* Sources
Area/Population: UN Statistics Division /• “www.nationmaster.com”
Average temperature/Annual precipitation: World Meteorological Organization•
CO• 2
emission: UN Statistics Division / IPCC AR4 report
Gross National Income: The World Bank•
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Medical Ethics, Human Rights and Socio-medical affairs
greater research effort must be devoted to
how humans can adapt to these changes.
The health impacts of climate change will
be strongly influenced by the extent and rate
of warming, as well as local environmental
conditions and social behaviours and the
range of social, technological, institutional,
and behavioural adaptations taken to reduce
the threats.
Some individuals and communities will
lack the resources required for adequate
response. Remote Aboriginal communi-
ties, low income households, the elderly and
many Pacific Island countries will be most
vulnerable [14].
Climate Change and Human Health
We can see some of the health effects that
may lie ahead if extreme weather events
continue to increase. Heat waves like the
one that hit Chicago in 1995, killing some
750 people and hospitalising thousands,
have become more common. Hot, humid
nights, which have become more frequent
with global warming, magnify the effects.
The 2003 European heat wave – involving
temperatures that were 18°F (10°C) above
the 30-year average,with no relief at night –
killed 21,000 to 35,000 people in five coun-
tries.
But even more subtle, gradual climatic
change can quietly damage human health.
During the past two decades,the prevalence
of asthma in the United States has qua-
drupled, in part because of climate-related
factors. For Caribbean islanders, respiratory
irritants are carried by dust clouds from
Africa’s expanding deserts and then swept
across the Atlantic by trade winds accelerat-
ed by the widening pressure gradients over
warming oceans. Increased levels of plant
pollen and soil fungi may also be involved.
When ragweed grows in conditions with
twice the ambient level of carbon dioxide,
the stalks sprout 10 percent taller and pro-
duce 60 percent more pollen. Elevated car-
bon dioxide levels also promote the growth
and sporulation of some soil fungi. Diesel
particles deliver these aeroallergens deeper
into our alveoli and present them to im-
mune cells along the way.
Mosquitoes, which can carry many diseases,
are very sensitive to temperature changes.
Warming of their environment – within
their viable range – boosts their rates of re-
production and the number of blood meals
they take, prolongs their breeding season,
and shortens the maturation period for the
microbes they disperse. In highland regions,
as permafrost thaws and glaciers retreat,
mosquitoes and plant communities are mi-
grating to higher ground.
Extremely wet weather may bring its own
share of ills. Floods are frequently followed
by disease clusters: downpours can drive
rodents from burrows, deposit mosquito-
breeding sites, foster fungus growth in
houses, and flush pathogens, nutrients, and
chemicals into waterways. Milwaukee’s
cryptosporidium outbreak, for instance, ac-
companied the 1993 floods of the Missis-
sippi River and norovirus and toxins spread
in Katrina’s wake. Major coastal storms
can also trigger harmful algal blooms (“red
tides”), which can be toxic, help to create
hypoxic “dead zones” in gulfs and bays and
harbour pathogens.
Prolonged droughts, for their part, can
weaken trees’ defences against infestations
and promote wildfires, which can cause in-
juries, burns, respiratory illness, and deaths.
Shifting weather patterns are jeopardising
water quality and quantity in many coun-
tries, where groundwater systems are al-
ready being overdrawn and underfed. Most
montane ice fields are predicted to disap-
pear during this century – removing a pri-
mary source of water for humans, livestock,
and agriculture in some parts of the world.
And many habitats are not faring well.
Coastal zones, for example, are in trouble:
coral reefs are suffering from warming-
induced “bleaching,” excess waste, physical
damage, overfishing, and fungal and bacte-
rial diseases. Reefs provide a buffer against
storms and groundwater salinisation and
offer protection for fish,the primary protein
source for many inhabitants of island na-
tions. One reef resident, the cone snail, pro-
duces a peptide that is 1000 times as potent
as morphine and that is not addictive. We
may never know what other potential treat-
ments will be lost as reefs deteriorate.
Climate Change and Influenza
Climate change would almost certainly al-
ter bird migration, influence the AI virus
transmission cycle and directly affect virus
survival outside the host [12].Some say that
Table 2. General statistics in Oceania by year 2005
* Sources
Area/Population: UN Statistics Division /• “www.nationmaster.com”
Average temperature/Annual precipitation: World Meteorological Organization•
CO• 2
emission: UN Statistics Division / IPCC AR4 report
Gross National Income: The World Bank•
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Medical Ethics, Human Rights and Socio-medical affairs
swine flu (H1N1) and climate change are
inextricably related [13]. Tropical Africa
is not the only area where deadly viruses
have recently emerged. In South-East Asia,
severe epidemics of dengue hemorrhagic
fever started in 1954 and flu pandemics
have originated from China such as the
Asian flu (H2N2) in 1957, the Hong-Kong
flu (H3N2) in 1968, and the Russian flu
(H1N1) in 1977. However, it is especially
during the last ten years that very danger-
ous viruses for mankind have repeatedly de-
veloped in Asia.The evolution of these viral
diseases was probably not directly affected
by climate change, but we cannot simply
pass over this pattern.
Mitigation: Black Carbon
The Annex I & II Parties and other coun-
tries that have more developed technology
and research circumstances must co-operate
with developing countries to reduce the
damage from climate change. We all need
to focus on the newly emerging issues, such
as new greenhouse gas pollutants other than
classic sources and pandemic health effects
amplified by climate change.
Greenhouse causing gases in the Earth’s
atmosphere are SO2
, water vapour, (about
80%) and carbon dioxide. But nowadays,
greater interest is being directed towards
black carbon and aerosol. It is reported that
a strong radiative heating effect was caused
when black carbon (BC) was mixed in at-
mospheric aerosols [11]. And black carbon
is estimated to be the second largest con-
tributor to global warming following car-
bon dioxide. Today, the majority of black
carbon emissions from developing coun-
tries in South Asia are from biofuel cook-
ing, whereas in East Asia, coal combustion
for residential and industrial uses plays a
larger role. Regulating black carbon emis-
sions from diesel engines or local emission
sources presents a significant opportunity to
reduce black carbon’s global warming im-
pact.
Future Adaptation
Considering the magnitude of potential
impacts, greater efforts need to be devoted
to building climate resilience in sectors and
climate-proofing infrastructure of at-risk
areas. The impact of climate change may
undermine the long-term development of
many countries. The poorest people in the
poorest countries are likely to suffer most.
Climate change is not the only issue on the
global agenda, but it requires our greatest
personal and regional attention and com-
mitment.
References
Climate Change 2007: impacts, adaptation and vulner-1.
ability : working group II to the 4th assessment report of
the intergovernmental panel on climate change. [Docu-
ment on the Internet] [cited 2009 October 7].Available
from: http://www.ipcc.ch/publications_and_data/publi-
cations_ipcc_fourth_assessment_report_wg2_report_im-
pacts_adaptation_and_vulnerability.htm.
Understanding and responding to climate change in de-2.
veloping Asia. Asian Development Bank, 2009. [Docu-
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from: http://www.adb.org/Documents/Books/Climate-
Change-Dev-Asia/default.asp.
Lal M. Global climate change: India’s monsoon and its3.
variability: final report under “Country Studies Vulner-
ability and Adaptation”. 2002 September. 58 p.
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Checkley W, Epstein LD, Gilman RH, Figueroa D, Cama5.
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Peruvian children. Lancet. 2000 Feb 5; 355 (9202): 442-
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policymakers: IPCC Plenary XXVII; 2007 Nov 12-
17;Valencia, Spain [document on the Internet] [cited
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assessment-report/ar4/syr/ar4_syr_spm.pdf.
Jacobson MZ. Strong radiative heating due to the mixing11.
state of black carbon in atmospheric aerosols. Nature. 2001
Feb 8; 409 (6821): 695-7.
Gilbert M, Slingenbergh J, Xiao X. Climate change and12.
avian influenza. Rev Sci Tech. 2008 Aug;27(2):459-66.
Mawle A. Swine flu and climate change are inextricably13.
related. Voice of the public health movement [document
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aspx.
McMichael A, Woodruff R, Whetton P, Hennessy K,14.
Nicholls N, Hales S, Woodward A, Kjellstrom T. Human
health and climate change in Oceania : a risk assessment:
2002. [Document on the Internet] [cited 2009 October
7]. Available from http://nceph.anu.edu.au/Staff_Stu-
dents/Staff_pdf_papers/Rosalie_Woodruff/Health_Cli-
mate_Change_Impact_Assessment_2002.pdf.
Epstein PR. Climate change and human health. N Engl15.
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http://content.nejm.org/cgi/content/full/353/14/1433.
Dong-Chun Shin, MD, PhD
Chair, Executive Committee
of International Affairs,
Korean Medical Association
Professor, Dept. of Preventive Medicine,
Yonsei University College of Medicine
Climate
change
Environ-
mental
conditions
Social conditions
(„upstream”determinants
of health)
Direct Exposure
(temperature
precipitation,
sea level rise,
extreme events)
Indirect Exposure
(change in water, air
and food quality, vector
ecology, ecosystems,
agriculture, industry
and settlements)
Social &
economic
disruption
Health
System
conditions
Health
impacts
Source: IPCC 2007
*
Modifying influence*
Figure 2. Climate Change and Health Impact Pathways
wma 8.indd 151wma 8.indd 151 12/4/09 4:23:36 PM12/4/09 4:23:36 PM
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Medical Ethics, Human Rights and Socio-medical affairs
As the rates of lifestyle and stress-related
illness increase worldwide, the Anthropedia
Foundation (APF) advances the Science of
Well-Being and offers solutions to foster
health and happiness that are adapted to
the 21st century. APF is a non-profit orga-
nization that promotes well-being through
health and education initiatives, and is ded-
icated to empowering individuals of all ages
to reach their fullest potential for physical,
mental, and social well-being. Anthrope-
dia is led by an institute of professionals
from the fields of medicine, psychology, art,
education, and public health. Members of
the Anthropedia Institute examine effec-
tive and scientifically based practices from
their fields and design comprehensive strat-
egies to improve physical,mental,and social
well-being. Based on the findings of the
Institute, the foundation creates resources
that teach people ways to cultivate healthy
lifestyles, psychological resilience, character
development, and self-awareness. Resources
are simple, practical, and powerful, and can
be used by individuals, professionals, and
organizations seeking an effective approach
to achieving and sustaining well-being.
Existing biomedical approaches to illness
prevention and treatment often fail to ad-
dress the complex relationships between a
person’s body, mind, and social context [1, 2,
3]. Furthermore, healthcare systems world-
wide are limited in their ability to provide
opportunities for people to receive the at-
tention, personalized care, health education
resources, lifestyle counseling, and support
necessary to foster long-term health and
happiness. APF aims to prevent disease
and promote health by providing healthcare
professionals with tools to apply a compre-
hensive approach that encourages consider-
ation and care for the whole person (body,
thoughts, and psyche) within their social
context.
APF develops and provides multi-media
courses in well-being that individuals can
use on their own and professionals can offer
as a complement to therapy. Anthropedia’s
Know Yourself series is a step-by-step course
in well-being designed to help people aug-
ment health and happiness, face stressful
challenges, and find greater satisfaction in
their lives. Know Yourself offers an approach
to mental and physical well-being that is
based on the latest research in psychiatry,
psychology, neuroscience, and mind-body
health, including studies on self-aware-
ness, personality, positive thought, and life
satisfaction. Specifically, the series builds on
the research and clinical work of C. Robert
Cloninger, MD [4]. Supplemental materi-
als for each part of Know Yourself, including
summaries and exercises are also available
on Anthropedia’s website (www.anthrope-
dia.org).The Know Yourself series is received
well by individuals and is successfully used
in schools, criminal rehabilitation, medical
treatments, and therapy settings.
APF also develops and provides evalua-
tion tools for professionals and individu-
als to gain insight into a person’s sense of
well-being, emotional outlook, and higher
cognitive processes via temperament and
character measurements, as well as through
positive and negative emotion inventories,
and life satisfaction scales. The presence of
positive emotions,as well as a persons’ability
to be resourceful, purposeful, goal directed,
controlled, and aware of one’s psychological
attachments and dependences, are strong
positive predictors of health [4]. The Tem-
perament and Character Inventory (TCI) is
the most advanced and comprehensive test
of personality available to date. Designed by
C. Robert Cloninger MD, the TCI identi-
fies the intensity of and the relationships
between the seven basic personality dimen-
sions of temperament and character, which
interact to create the unique personality of
an individual [5]. The TCI provides a pro-
file that can help people understand them-
selves or another person, such as their child,
spouse, friend, or anyone else they know
well. Low Self-Directedness is a strong in-
dicator of vulnerability to major depressive
disorders [6]. High Self-Directedness is
also a predictor of rapid and stable response
to both antidepressants and CBT [7].
When a patient or health care professional
has a more complete understanding of a
person’s unique character and temperament
traits, and how they help or hinder a per-
Anthropedia’s initiatives to
promote person centered care
Sita Kedia Lauren E. Munsch
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Medical Ethics, Human Rights and Socio-medical affairs
son’s experience of well-being, they can take
a more personalized and targeted approach
to treatment. APF has worked to make this
test available through our website for both
individual and professional use,as well as for
clinicians interested in using the test for re-
search.The TCI is a validated assessment in
both adolescents and adults offered in sev-
eral languages [8, 9]. Quantitative scoring
of the profiles allows comparison to other
people. It also allows for predictions about
situations that are difficult or stressful, and
ways of dealing with those difficulties.
Anthropedia’s initiatives promote person-
centered care by providing professionals
with tools to learn more about their pa-
tients, and by increasing the availability
of educational resources that teach ways
to develop and sustain physical and men-
tal health. For more information about
the Anthropedia Foundation please visit
www.anthropedia.org.
References:
1. Mezzich, J.E. and I.M. Salloum, Clinical complexity and
person-centered integrative diagnosis. World Psychiatry,
2008. 7(1): 1-2.
2. Mezzich, J.E., Positive health: conceptual place, dimen-
sions and implications. Psychopathology, 2005. 38(4):
177-9.
3. Mezzich, J.E., Psychiatry for the Person: articulating
medicine’s science and humanism.World Psychiatry,2007.
6(2): 65-7.
4. Herrman, H., R. Moodie, and S. SR, Mental Health Pro-
motion, in International Encyclopedia of Public Health,
K. Heggenhougen and S. Quah, Editors. 2008, Anademic
Press: San Diego.
5. Cloninger,C.R.,Feeling Good:The Science of Well Being.
2004, New York: Oxford University Press.
6. Farmer,A.,et al.,A sib-pair study of the Temperament and
Character Inventory scales in major depression. Arch Gen
Psychiatry, 2003. 60(5): 490-6.
7. Cloninger, C.R., A practical way to diagnosis personality
disorder: a proposal. J Pers Disord, 2000. 14(2): 99-108.
8. Cloninger, C.R., D.M. Svrakic, and T.R. Przybeck, A psy-
chobiological model of temperament and character. Arch
Gen Psychiatry, 1993. 50(12): 975-90.
9. Lyoo, I.K., et al., The reliability and validity of the junior
temperament and character inventory. Compr Psychiatry,
2004. 45(2): 121-8.
Sita Kedia, MD, Lauren E. Munsch, MD
Neil Pakenham-Walsh
Every day, tens of thousands of children,
women and men die needlessly for want of
simple, low-cost interventions – interven-
tions that are often already locally available.
A major contributing factor is that the mother,
family caregiver or health worker does not have
access to the information and knowledge they
need, when they need it, to make appropriate
decisions and save lives. For example:
8 in 10 caregivers• in developing coun-
tries do not know the two key symptoms of
childhood pneumonia – fast and difficult
breathing – which indicate the need for
urgent treatment[1] (only 20% of chil-
dren with pneumonia receive antibiotics
despite wide availability,and 2 million die
each year);
4 in 10 mothers• in India believed that
they should withhold fluids if their baby
develops diarrhoea (worldwide, 1.8 mil-
lion children die every year from dehy-
dration due to diarrhoea)[2];
3 in 4 hospital doctors• responsible for
sick children in district hospitals in Ban-
gladesh, Dominican Republic, Ethiopia,
Indonesia, Philippines, Tanzania, and
Uganda had poor basic knowledge of com-
mon killers such as childhood pneumonia,
severe malnutrition, and sepsis[3];
4 in 10 general practitioners• in Pakistan
used tranquilisers as their standard treat-
ment for hypertension[4].
HIFA2015 is a rapidly growing campaign
and knowledge network with more than
2900 professionals from 150 countries
worldwide – healthcare providers, librarians,
publishers, researchers, policymakers and
others committed to improve health care.
Every day, members exchange ideas, expe-
rience and expertise on ways to enhance
the availability of relevant, reliable health-
care information in low-income countries.
Lack of access to healthcare information
is a hidden killer
Healthcare Information For All by 2015
By 2015, people will no longer be dying for lack of knowledge
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Medical Ethics, Human Rights and Socio-medical affairs
Our common goal: By 2015, every person
worldwide will have access to an informed
healthcare provider – people will no longer be
dying for lack of knowledge.
Together, we are building a specialised web-
based tool,the HIFA2015 Knowledge Base.
This harnesses the collective experience and
expertise of HIFA2015 members as a basis
for a better understanding of the informa-
tion needs of different groups of healthcare
provider in different contexts, and ways of
meeting those needs. A prototype is avail-
able at www.hifa2015.org/knowledge-base.
“HIFA2015 is needed as a global forum
which provides space for professionals
from all parts of the world to exchange
views and share knowledge.” Dr Najeeb
Al-Shorbaji, Director of Knowledge
Management and Sharing, World Health
Organization, HIFA2015 Foundation
Document 2008
The HIFA2015 Knowledge Base will pro-
vide the evidence we need to persuade gov-
ernments and funding agencies to commit
political and financial support for diverse
efforts to improve availability and use of
healthcare information, especially where it
is most needed. For too long, the informa-
tion needs of healthcare providers in low-
income settings have been neglected.
Each year the campaign includes a focus
on a particular cadre of healthcare provider.
In 2008 the focus was on health students
(medical, nursing, midwifery and allied
health). The HIFA 2009 Challenge is ad-
dressing the information needs of nurses
and midwives, in collaboration with the
British Medical Association, Global Al-
liance for Nursing and Midwifery, Inter-
national Council of Nurses, International
Confederation of Midwives, Royal Col-
lege of Midwives, Royal College of Nurses,
WHO and others. In 2010 the HIFA2015
membership will turn its attention to Com-
munity Health Workers.
The HIFA2015 members have evolved the
campaign strategy (see Figure).The strategy
focuses on improving interdisciplinary com-
munication (HIFA2015 and CHILD2015
forums),understanding (HIFA2015 knowl-
edge base) and advocacy (see figure, above
dotted line). These are the three pillars of
the campaign, providing an enabling envi-
ronment to support and inform independent
health information activities by HIFA2015
members and others.
HIFA2015 Forums
Understanding AdvocacyCommunication
HIFA2015 Knowledge Base
Healthcare Information for All
Promote evidence-
based solutions
Strengthened, independent action by
HIFA 2015 members and others
Better health information production and delivery world
wide, based on:
• better und understanding of information needs
and barriers, and how to address them
• more sharing of experience and expertise,
and lessons learned
• increased investment in evidence-based,
cost-effective solution
Figure: The HIFA2015 Campaign strategy and how it assists HIFA2015 members and others to
achieve our common goal.
Upper section: HIFA2015. All stakeholders are invited to use and contribute to the HIFA2015
Forums and HIFA2015 Knowledge Base. HIFA2015 members share experience and build an
understanding of information needs and barriers, and how to meet them.This in turn provides the
evidence base needed to identify and promote cost-effective solutions.
Lower section: Independent action by HIFA2015 members and others. HIFA2015 members rep-
resent thousands of organisations that produce, exchange and deliver health information. These
organisations benefit from their participation in the HIFA2015 Forums and Knowledge-Base.
Their collective impact is increased, leading progressively to Healthcare Information For All by
2015, a future where people are no longer dying for lack of knowledge.
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Medical Ethics, Human Rights and Socio-medical affairs
HIFA2015 is administered by the Global
Healthcare Information Network (www.
ghi-net.org), assisted by the HIFA2015
Steering Group, three Working Groups
(HIFA Challenge; Knowledge Base; Fund-
raising & Marketing), an International
Expert Advisory Panel, and dozens of HI-
FA2015 volunteers.
Over 70 leading health and development
organisations have officially committed to
work together towards the HIFA2015 goal.
Examples are shown below.
HIFA2015 Supporting Organisations•
(2009 funders in bold)
Association for Health Information and•
Libraries in Africa
BioMed Central•
Book Aid International•
British Medical Association•
eIFL•
European Association of Senior Hospital•
Physicians
European Federation of Salaried Doctors•
Faculty of Public Health (UK)•
Hesperian Foundation•
INCLEN•
Institution of Engineering and Technol-•
ogy
International Council of Nurses•
International Federation of Medical Stu-•
dents’ Associations
International Medical Corps•
London School of Hygiene and Tropical•
Medicine
Medical Library Association•
Medsin•
Partnerships in Health Information•
Royal College of Midwives•
Royal College of Nursing•
Royal College of Obstetricians and Gy-•
naecologists
Standing Committee of European Doc-•
tors
Teaching-Aids at Low Cost•
Tropical Health and Education Trust•
WHO African Regional Office Library•
On 19th November 2009, in Maputo, Mo-
zambique, we are launching HIFA2015-
Portuguese in collaboration with the ePOR-
TUGUÊSe network, hosted at WHO
headquarters. In 2010 we hope to launch
HIF2015 in French, with other languages
to follow.
The HIFA2015 campaign strategy is cur-
rently only 20% funded, with thanks to the
British Medical Association, Royal College
of Midwives and Royal College of Nursing.
This means that we are far from reaching
our full potential. We welcome additional
offers of funding and in-kind support to
enable us to achieve our goal.
We also invite all readers to join the cam-
paign as individuals. To find out more, and
to contribute your expertise to our efforts,
please visit our website: www.hifa2015.org.
References
1. Wardlaw T et al. Pneumonia: the leading killer of
children. Lancet 2006;368:1048-50
2. Wadhwani N. An integrated approach to reduce
childhood mortality and morbidity due to diarrhoea
and dehydration. http://hetv.org/india/mh/plan/
hetvplan.pdf
3. Nolan T et al. Quality of hospital care for seri-
ously ill children in less-developed countries. Lancet
2001;357(9250):106-10
4. Jafar TH et al. General practitioners’ approach to
hypertension in urban Pakistan: disturbing trends in
practice. Circulation 2005;111(10):1278-83.
Dr. Neil Pakenham-Walsh,
HIFA2015 Coordinator
The Medical Women’s International As-
sociation has been in existence since 1919,
when it was founded in New York city by a
group of medical women from around the
world. Dr. Esther Pohl Lovejoy was its first
president.
As a non-political, non-sectarian and non-
profit association of medical women repre-
senting women physicians from all five con-
tinents, the Medical Women’s International
Association’s objectives are:
To offer women in medicine the oppor-•
tunity to meet, network and discuss issues
concerning the health and well-being of
humanity.
To promote the general interest of women•
in medicine by developing cooperation,
friendship and understanding without
regard to race, religion or political views.
To overcome gender-related differences•
in health and healthcare between women
and men, girls and boys throughout the
world.
The Medical Women’s International
Association (MWIA)
Shelley Ross
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To overcome gender-related inequalities•
within the medical profession.
To promote health for all throughout the•
world with particular interest in women,
health and development.
The Association is composed of eight geo-
graphical regions:Northern Europe,Central
Europe, Southern Europe, North America,
Latin America, Near East and Africa, Cen-
tral Asia and Western Pacific. Each region
is represented on the Executive Committee
by its regional Vice-President. The Presi-
dent, President-Elect, Treasurer, Secretary-
General and the Vice-Presidents are elected
by the members for a term of three years.
The MWIA Secretariat in Burnaby, Cana-
da,coordinates the interests and activities of
the Organization.
Dr. Atsuko Heshiki is the current President
and Dr. Shelley Ross is the Secretary-Gen-
eral.
Every three years, the MWIA holds an in-
ternational meeting. The last meeting was in
Accra,Ghana,in 2007 and the next meeting
will be in Munster, Germany, in July, 2010.
The theme of the 2010 conference will be
“Globalisation in Medicine – Challenges and
Opportunities,” with a focus on four sub-
topics: Gender Strategies, Addiction, Epi-
demic Plagues and Nutrition. Please visit
the website at www.mwia2010.net and
plan to join us.
MWIA has advocated on numerous for
gender and health issues for many years.
MWIA wrote a Training Manual on Gen-
der Mainstreaming in Health for physicians
and helped the World Health Organiza-
tion Department of Gender Women and
Health develop their gender training mod-
ules. MWIA’s manual can be accessed on
the webpage at www.mwia.net. Numer-
ous workshops on gender and health have
been held at regional and national meetings.
MWIA has also written a Training Manual
on Adolescent Sexuality, which can be ac-
cessed on the website.
MWIA has been on the forefront of work
on female genital mutilation,with one of our
members from Sierra Leone having written
a book back in the 1980’s on the topic and
appearing in the Danish film entitled The
Silent Pain. MWIA participated recently in
a large meeting organized by the WHO on
this subject in Kenya.
In many countries, women physicians have
been instrumental in developing govern-
ment-funded programs for prevention
of cervical cancer by the use of the HPV
vaccines, early detection and treatment.
MWIA was represented in October in Lu-
saka, Zambia, at a meeting of cervical can-
cer prevention and treatment strategies.
MWIA has recently partnered with the
International Osteoporosis Foundation
to make women aware that osteoporosis
is a silent killer. MWIA participated in a
survey conducted in Europe, Mexico and
Canada to assess the public’s perception
of the osteoporotic woman. Much to the
surprise of physicians, this is no longer as-
sumed to be a disease of the old and frail,
but one that affects women who are active
and who want to be in charge of their lives.
A second survey was done to see if mothers
and daughters were aware of the dangers of
osteoporosis.
With an increasingly large proportion of
women in medical schools, MWIA has
sought to ensure the training of women
in leadership roles to ensure that medicine
continues to have significant influence on
policy decisions in the health field. MWIA
feels that medicine must not be allowed to
become a Pink Collar Profession.
MWIA is active in primary health care de-
livery, with several of its members on the
front lines of delivering health care in vari-
ous areas around the world.
In Calcutta, the West Bengal Branch of
MWIA runs a Mission Hospital. Dona-
tions are always welcome, as the physicians
volunteer their time at the hospital.
MWIA is pleased to attend the annual
meetings of the World Medical Association
as an observer. MWIA would be pleased
to partner with the World Medical Associa-
tion in projects of mutual interest.
Shelley Ross, MD, Secretary-General, MWIA
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Introduction
The declaration of a national health emer-
gency in any country in the world is a de-
cision that is adopted by the authorities in
the face of unexpected or unusual events
that produce a situation that is considered
a public health emergency [1] of national or
international concern. These diverse events
go from natural disasters,armed conflicts,to
disease outbreaks or potentially pathogenic
events that constitute a threat to the public
health of a country and of other States.
This type of declaration is usually accom-
panied by decisions of a legal and admin-
istrative nature, that allow the authorities
to adopt dispositions that, amongst other
things, temporarily restrict liberties, as in
the case of quarantines, and/or temporar-
ily eliminate certain requisites demanded of
the national public administrations for the
acquisition of the goods and services neces-
sary to protect the health of the population
affected by the events that produced the
emergency.
The case we are concerned with, the decla-
ration of emergency recently announced by
the President of the Bolivarian Republic of
Venezuela, Hugo Chavez [2], is sui generis.
On one hand, it is not the result of an un-
expected or unusual event of a kind that is
frequently invoked to adopt such a decision;
on the other hand, it is not supported by
any administrative act. Other kinds of facts
are clearly at play here, and revealing their
meaning is the purpose of this article,which
draws heavily on an open letter addressed to
President Chavez by Venezuelan ex-Minis-
ters of Health Blas Bruni Celli, Jose Felix
Oletta, Rafael Orihuela, Pablo Pulido and
Carlos Walter.
The announcement of the emergency dec-
laration and a question that warrants a
different response
“In the social area, we have an emergency at
this time: health. Let us state that we are all in
a state of emergency (…) Two thousand Barrio
Adentro*
primary health care units have been
closed. What happened there? We have all been
negligent” [3]. In this wars was this declara-
tion of emergency announced to the Ven-
ezuelans in an extended Cabinet Meeting
held on 19 September.
Venezuelans were surprised that President
Chavez asked himself “What happened
there?” The president seems to have forgot-
ten that both he and the Cuban Govern-
ment decided to start a progressive transfer
of 4500 Cuban doctors from Venezuela to
Bolivia by 2006?
Since 2007, various studies as well as state-
ments [4, 5] by the users of the parallel sys-
tem of Barrio Adentro, have shown serious
problems in access and quality of services.
This dissatisfaction worsened when the per-
sonnel were reduced upon being transferred
(without explanation to the Venezuelan
people) to other countries.
Of the 8000 buildings scheduled to be built
as popular clinics for the Barrio Adentro I
network only 2000 have been built, and in
the clinics and attention sites that are op-
erative,the tasks of primary health attention
* Barrio Adentro (BA) I is the name that the Ven-
ezuelan government uses to designate a network of
primary attention in a health system that is parallel
to the conventional one, that began operating in
2003.This system is managed by the Cuban Medi-
cal Mission in Venezuela outside the rectory of the
Ministry of Health.
had to be limited. In addition, many of the
“cooperantes” or Cuban health profession-
als or technicians were moved to work at
the “Comprehensive Diagnostic Centres”**
.
Very soon the provision of services was
discontinuous and irregular, the hours of
operation were reduced and many modules
closed their doors. This resulted in discom-
fort and frustration among the users and
among those that in good faith accepted to
get involved in health activities. Finally, the
infrastructure has deteriorated due to lack
of maintenance and use.
It seems that President Chavez has not
found out that on January 2008, the Presi-
dent of The Metropolitan College of Phy-
sicians and representative of the National
Bolivarian Physicians Front stated: “Unfor-
tunately, I have to admit that the wonderful
plan of Barrio Adentro has collapsed. The cen-
tres have been transformed into simple points
of reception. The constitutional goal has not
been met” [6].
The abandonment of the 2000 Barrio Aden-
tro centres to which the President referred
is not the only problem this system faces.
Barrio Adentro generated a new network
within the public subsystem, which deep-
ened and broadened the segmentation and
fragmentation of the Venezuelan health sys-
tem. These characteristics were some of the
flaws that the Ministry of Health and Social
Development (today the Ministry of Popu-
lar Power for Health) pointed out about the
health system existing in the country before
1999, and that needed to be corrected [7].
From a technical, administrative, and man-
agerial perspective, Barrio Adentro was
never integrated into the Public Health
System; on the contrary, it was a critical fac-
tor in debilitating the existing system. At
the same time, this system did not achieve
** The Comprehensive Diagnostic Centers are part
of the medical assistance establishments that con-
stitute the network for secondary attention in the
parallel health system managed by the Cuban
Medical Mission in Venezuela.
A strange form of declaring a health
emergency:
the case of Venezuela
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the expected coverage. Even though Bar-
rio Adentro increased the coverage of the
primary care level, in practice it duplicated
the existing coverage. The question is, how
efficient, effective and sustainable has this
policy been? How much has it contributed
to reduce the regional inequities in terms of
coverage? In addition, there has never been
enough information to evaluate the results,
nor transparency in the management and
rendering of accounts by those who have led
and managed this parallel health system.
For all these reasons, the dismantling of
Barrio Adentro is not a “health emergency”.
It is a fact known for over three years by the
President, the health authorities and most
Venezuelans, a fact that adds to other ills of
the national health system. We regret that
the President accepts it as true only when
the Cuban Government corroborates this
information. It would have been enough
for him to listen to the Venezuelan people,
those who support him, those who support-
ed him, and those who do not agree with
his administration, but particularly, to those
people with scant resources that benefited
from Barrio Adentro and who now feel de-
ceived and cheated.
Responsibilities of the announced
abandonment
The responsibility of the President in this
matter is not transferable. He cannot trans-
fer blame to the rest of his Cabinet, his
governors and his mayors. He and he alone
is responsible for having delegated to a for-
eign government, the Cuban Government,
through the Cuban Medical Mission, the
management, supervision and evaluation of
this Parallel Health System.
How can the President explain to the coun-
try that in January 2008 in his Annual Mes-
sage to the Nation [8], he stated that 6531
primary health centres were in operation and
seven months later, he said 2000 had been
abandoned? How can he explain that on 25
January 2006, at the height of Barrio Aden-
tro, 21 745 Cuban health “cooperantes” were
working, and now with 24 000 “cooperantes”,
2000 health centres have been closed?
It is the duty of the President and of the
State Controller Agencies to promptly or-
der investigations to establish responsibili-
ties in the neglect and abandonment of Bar-
rio Adentro Mission that gave rise to the
aforementioned declaration of emergency,
and what share of the responsibility belongs
to the Cuban Government.
A wrong answer
The solution is not to bring more Cuban
doctors and students to join those already
here, and who are not showing results in
improving the health care in our Nation.
This will only compound the errors and will
delay the actions to start a systematic ap-
proach to improve the Venezuelan health
care system.
After 10 years in power, President Chavez
does not seem to realise that the severe
problems of the Venezuelan health care
system are not limited to the appalling
neglect of Barrio Adentro. During this
decade of President Chavez’s government,
many critical health system functions were
abandoned, deteriorated or improvised. De-
bilitating policies, such as reorienting the
objectives of health campaigns, fragment-
ing,segmenting and centralising health care
services have produced inequity and exclu-
sion, in addition to reducing the coverage
and the quality of health care. Never before
has so much money been spent in health,
in a disorganised, uncontrollable, and non-
transparent way. And never before have the
results, as measured by health indicators,
been so poor.
Fundamental health programs do not show
results, epidemiological surveillance is weak
and the capacity to respond to endemic dis-
eases,epidemics,emerging and re-emerging
diseases is poor and inefficient.There are no
integrated plans against new social health
threats such as violence, drug addiction and
problems arising from population explosion.
Environmental sanitation and the quality
of housing is poor. Public hospitals are in
ruins, Venezuelan mothers are giving birth
on the street, health information has been
arbitrarily restricted, all of which weaken
the response capacity of the system. In ad-
dition, there is a deliberate policy to destroy
the national health manpower, which has
morally damaged the health workers and
their families.
To make matters worse, in these past 10
years of President Chavez and his ruling
party in government, despite having an am-
ple majority in the National Assembly, he
has been unable to foster a broad debate to
approve health legislation that would con-
tribute to make the right to health an effec-
tive right for all Venezuelans.
The critical social reality
The problems related to the health sector af-
fect other social policy areas, which in turn
decisively affect the health of the popula-
tion and their quality of life.
We are deeply concerned that the political
environment, the democratic shift towards
an authoritarian regime, the fragile social
peace, the loss of civil liberties and the re-
Unsanitary conditions near an aban-
doned popular clinic in the “El Hediondito”
(The Stinky) neighborhood
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cently approved unconstitutional laws that
impose a national model stamped with the
personal ideology of President Chavez,have
all advanced simultaneously with repres-
sion and threats to the freedom of speech.
The increasingly unsatisfied social demands
stimulate conflict and have contributed to a
disrupted social dialog, particularly with the
public authorities. These conditions fertil-
ise the way towards greater poverty, deeper
conflicts, greater insecurity, more exclusion,
less health, fewer opportunities for produc-
tive work and less development.
Thus, it is critical to enable a space for so-
cial dialogue in order to reach fundamental
agreements. Amongst these, health is a crit-
ical condition for equitable development,
and this value is the best drive in combating
exclusion and poverty.
The necessary correction
The Venezuelan health system has serious
deficiencies. Improving them requires mak-
ing political decisions sustained by sound
technical and scientific criteria. This is a
hard reality for all Venezuelans, a reality
from which we cannot escape. A shared
destiny forces us to humbly offer wise and
timely responses.
The construction of Venezuela requires
tolerance, respect for personal dignity, will-
ingness to a civilised understanding within
our society that cannot continue oscillating
between extremes of endless and fruitless
confrontation, and indifference or social
autism, driven by hatred, resentment and
thoughtlessness.There is still time to rectify,
to invoke more freedom and more democ-
racy, and in this way call on all Venezuelans
to share the dream of a more just and better
country.
References
1. Organización Mundial de la Salud (2006). Regla-
mento Sanitario Internacional 2005, Ediciones de la
OMS, Ginebra, Suiza.
2. Chávez declara en emergencia sistema de salud.
Avalaible from: http://www.eud.com/2009/09/19/
pol_ava_chavez-declara-en-em_19A2760687.
shtml
3. Chávez declaró en emergencia la salud en Ven-
ezuela. Avalaible from: http://www.eluniversal.
com.ve/2009/09/20/pol_art_chavez-declaro-en-
em_1574464.shtml
4. Rachel Jones, Hugo Chavez’s health-care programme
misses its goals. Lancet. 2008 Jun; 371( 9629):
1988.
5. Aceptación de Barrio Adentro descendió pero
sigue alta. Avalaible from: http://www.guia.com.
ve/noti/50545/aceptacion-de-barrio-adentro-de-
scendio-pero-sigue-alta
6. Fernando Bianco: “La misión Barrio Adentro se
vino abajo”. Avalaible from: http://www.aporrea.
org/misiones/n108067.html
7. Organización Panamericana de la Salud -OPS
(2006). Barrio Adentro: derecho a la salud e inclusión
social en Venezuela, Caracas, Venezuela
8. Mensaje Anual a la Nación del Presidente de la
República. Avalaible from: www.abn.info.ve/
mensaje_anual_2009.doc
Carlos Walter V.
Ex-Minister of Health of the
Bolivarian Republic of Venezuela
Ex- Institutional Development Advisor of
the Pan American Health Organization
Director of the Centre for Development
Studies (CENDES) of the Central
University of Venezuela.
Caracas. Venezuela
Poster on the wall of a fully operating popu-
lar clinic with a list of materials requested of
the community:broom; syringes 5cc, 3cc; white
sheets of paper; staplers; magic markers; toilet
paper; soap powdered and bathroom; Clorox
and masking tape.
Inside an abandoned popular clinic
IMA’s Dedication to TB Care
IMA started perhaps India’s first Public Pri-
vate Mix (PPM) project by joining hands
with the Central TB Division (CTD) to
aid their Revised National Tuberculosis
Control Program (RNTCP) using DOTS
funded by GFATM through our IMA-
GFATM-RNTCP-PPM Project and with
M/s. Eli Lilly in a separate project.We have
sensitised 25 080 private practitioners (PPs)
and trained 3334 of them in providing ser-
vices through 1585 DOT centres in various
States of the country. It is planned to be ex-
tended to whole of the country soon.
IEC material prepared by us has been cir-
culated to all the members for awareness of
the disease and its control and cure among
the masses.Spreading awareness among our
own members is a regular feature through
the mouthpiece of the Association – The
Journal of IMA. A regular news bulletin
highlighting the activities of the project is
being mailed to all the members to incul-
cate a feeling of belonging in them for con-
trol of the disease.
Also, an Indian Medical Professional Asso-
ciations’ Coalition Against TB (IMPACT)
has been formed consisting of 10 specialist
Associations other than IMA to promote
Indian Medical Association:
brief report of all projects
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treatment of TB by PPs on the guidelines
of International Standards for TB Care
(ISTC). Endorsements are being received
from these Associations.
Stop Sex Selection
Taking serious note of the falling sex ratio
in the country, IMA has taken sex selection
prohibition as one of its most important
activities. Therefore, IMA started a project
on sex selection “Cadre of IMA Volunteers
strengthened and capacities built for medi-
cal community to prevent sex selection”with
UNFPA with a goal to prevent sex selection
procedures by stopping the unethical prac-
tice of intra-uterine gender determination
by members of the medical profession and
thereby help to restore the natural child sex
ratio.
A National Mentoring Group to Stop
Sex Selection consisting of 7 permanent
members meets quarterly to plan and de-
vise strategies for proper implementation
of the project. Federation of Obstetric and
Gynaecological Societies of India (FOGSI)
and Indian Radiological and Imaging As-
sociation (IRIA) are being involved in this
activity.
50 eminent members of the Association
known for their dedication against sex se-
lective procedures have been nominated as
IMA Ambassadors Against Sex Selection
(IAASS).They have been sensitised through
workshops and are working for achieving
the aims of the project. Guidelines have
been formulated and issued to them for for-
mation and working of the Doctors Against
Sex Selection (DASS) forums at district
levels.
These Ambassadors share their experiences
on a regular basis through an IMA e-Group.
This helps all of them to plan their strategy
and gear up beforehand in their endeavour.
Contraceptive Updates and
Safe Abortion Techniques
Being of the view that India’s current con-
traceptive prevalence rate is just 48.2 %
and unprotected sex and contraceptive ac-
cidents account for nearly 13% of unwanted
and unplanned pregnancies, the IMA, in
partnership with the Ministry of Health &
Family Welfare, planned and successfully
organised many programmes for sensitisa-
tion of the society and also its own members
about the various methods of contraception.
More than 2000 IMA members have been
trained and sensitised to organise sessions in
their area on the use of contraception. IMA
Family Welfare programme has included
emergency contraception and unsafe abor-
tions as an integral part of the programme.
Many sessions have been organised in vari-
ous IMA Family Welfare activities.
IMA also partnered with UNFPA and has
organised a Resource Persons’Workshop on
“Contraceptive Updates and Safe Abortion
Techniques” which was attended by doctors
from some States of India. These trained
doctors will be conducting total 150 district
workshops in these five States and will fur-
ther train more doctors. We expect to train
nearly 5000 private practitioners in these
States in Family Welfare activities.
One more project by the Ministry of
Health and Family Welfare wherein we will
be organising sensitisation and awareness
Workshop on IMA-GFATM-RNTCP-PPM
Project (a project on TB)
Master Trainers Workshop on Avian Flu
Regional Workshop on “Stop Sex Selection –
Doctors can make a difference”
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programme on the various modes of avail-
able contraceptives and their use in most of
the States is on the anvil. Further we will
identify members who will be interested in
taking up training in No Scalpel Vasectomy
(N.S.V) and Laparoscopic Sterilization in
near future.
Pharmaco Vigilance and Drug Safety
The efficacy and safety of a new drug are
generally studied on a few thousand care-
fully selected and followed up trial subjects.
Therefore, only very frequent adverse reac-
tions are observed during its clinical devel-
opment. Once, the medicine is placed on
the market and the population is exposed,
its actual safety profile is known. To iden-
tify and tackle these risks, the new adverse
reactions should be reported immediately
as a contribution to an incomplete safety
profile.
An IMA Pharmaco Vigilance cell was
formed at IMA HQs, IMA House, New
Delhi with an Advisory committee to mon-
itor and report such adverse reactions ob-
served by the members of the Association
to the competent authorities and related
organisations. Nearly 1200 members from
all States have been trained and sensitised
in the need and procedure of Adverse Drug
Reporting (ADR) / Adverse Event (AE)
reporting through various sessions during
events of IMA at National, State and Dis-
trict levels.
An ADR / AE reporting form has been
circulated amongst members of IMA on
which reports of ADR/AE are being sent
to us by them.
Aao Gaon Chalen Project
“India lives in villages”. However, due to
various socio-economic and other reasons,
the basic healthcare needs of these citizens
of the country cannot be looked after due to
the poor facilities available to them.
Therefore, IMA considered its first duty to
cater to the healthcare needs of the masses
living in these villages. Hence, it was decid-
ed that every State and local branch of IMA
will adopt villages in their area of jurisdic-
tion to provide medical facilities to them at
their doorstep.
Under the project implementation plan,cre-
ation of health awareness (general health &
hygiene, adolescent health, FP, MCH care
especially ANC & anaemia, gender sensiti-
zation, quackery, sex determination, female
infanticide etc.) plays a pivotal role. This is
done through Puppet shows; Nukkad nat-
aks, School health talks; essay & painting
competitions, debates in schools and col-
leges, social meetings involving pradhans,
gram sabha members, community leaders
and religious leaders.
We have been quite successful in achieving
our expected outcomes from this project.
Swine Flu
Despite of the efforts of the Government to
control the spread of Swine Flu,it has taken
the form of an epidemic in our country.
IMA has already sensitised all its members
about the Swine Flu epidemic and issued
guidelines through its News Letter. General
public has been informed and sensitised about
the methods to prevent the Swine Flu. An
Information Cell at IMA HQs. is working
round the clock to respond to various queries
of general public and our members.
Tobacco De-addiction and Control
Identifying tobacco as a giant killer with 5.4
million global and around 10 lakhs Indian
tobacco related deaths, IMA undertook a
nationwide campaign against tobacco. To
sensitise health providers about the dangers
of tobacco products and generate awareness
on tobacco related health issues, IMA or-
ganised Public rallies, workshops and lec-
tures on Tobacco Control & De-addiction
on 31 May 2009 all over the country on
“World No Tobacco Day”.
Blood Donation
Voluntary blood donation is one of IMA’s
regular activities with IMA running its own
state-of-art blood banks all over the country
to cater to the needs of patients.
Dr. Dharam Prakash, Hon. Secretary General
Indian Medical Association
Blood Donation camps are being organized
from time to time by IMA Branches
Laparascopic sterilization campNo Tobacco Day Rally organized by various
IMA Branches all over the country
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Taking into consideration a recent official pub-
lication, we provide a brief overview of the
Uruguayan health system in the mid-2000s
and the main measures adopted within the
framework of this change, organising it around
seven issue.
Julio Trostchansky
According to the classic indicators of mor-
tality, the health situation in Uruguay has
been comparable to that in various devel-
oped countries. However, upon observation
of its historical evolution, we maintain that
there has been a severe stagnation in regard
to health indicators, particularly those that
are more specific and closely related to the
transitional model. Up until a few decades
ago, Uruguay was among the top coun-
tries in the Americas for the good results
obtained in the health of its population, al-
though the fact that it failed to follow the
dynamics created by several countries in the
region resulted in slowdown of progress in
the field.
It is said that the health system failed to re-
spond to the needs of the Uruguayan popu-
lation. Demographical, epidemiological and
social transformations that took place ulti-
mately define a new needs profile. Increase
in life expectancy and decrease in fertility
are reflected in an aged population, where
chronic degenerative conditions prevail. In
addition to this, a strong process of eco-
nomic and social inequality experienced in
the past decades caused a large sector of
society to fall below the poverty line. As a
matter of fact, it is in these sectors, deprived
of protection, where the highest child mor-
tality rates are found.
1. From the point of view of the organisa-
tion of the health care services,it is said that
the main problems are grounded on the ex-
istence of two service providers’sub-systems
that were fragmented and had no connec-
tion with one another, unequal in terms of
citizen access to them and showing no signs
of being complementary. In particular, the
State’s main provider remained as an entity
that had no relation with the Ministry of
Health, and thus acted stiffly, evidencing
confusion with other tasks carried out by
the Ministry.
According to official publications, sec-
toral measures were geared towards creat-
ing a national integrated health system, by
strengthening the connection between sub-
sectors, favouring greater equality based on
the strong contribution of resources and
strengthening the main public health care
centre, thus aiming to improve access of
more vulnerable sectors of population and
to encourage complementary bonds be-
tween sub-sectors. The State’s main health
care services provider is decentralised, and
through the reinforcement of financial re-
sources, priority was given to the salaries of
physicians, which increased substantially.
The latter is probably the most relevant
change in terms of human resources, an
aspect that has not been prioritised in the
agenda for change.
2. Likewise, only employees from the for-
mal private sector – without including their
relatives – were covered by a social health
insurance they paid for together with their
employers via their payroll, it being only
possible for them to choose their health
care services provider from among private
medical institutions and later on losing
their right to choose and the said health in-
surance coverage upon retirement.
The new system is said to have a combined
nature in terms of the service providers,
including private and public institutions
acting within the framework of a comple-
mentary and competitive regime, giving a
chance to those insured to choose between
public and private institutions.
At the same time, the rest of the population
had access to health care services under dif-
ferent modalities, ranging from individuals
paying for services out of their own pockets
to free services being funded by taxes col-
lected by the State for indigents or people
lacking enough resources, or else provided
by means of a combination of financing
modalities for specific sectors of the popula-
tion, as for instance, the military and police.
As to relatives, they are specifically included
in the social insurance health coverage,chil-
dren are immediately covered, and as from
2010 spouses will be included according to
the regulations in force.The system consists
in making social insurance into a universal
coverage plan that provides for a graded
admission of citizens to the system that is
funded by the national insurance, turning it
into a life insurance, since insurance rights
survive upon the beneficiaries retirement.
3. The price reimbursed to providers of
health care centres who ensured and ren-
dered health care services was regulated by
a single monthly payment by the State. In
this way, the social sickness insurance and
a large portion of the remaining population
paid their insurance via this system,ignoring
the risk associated with the covered popula-
tion and the expected cost differential, thus
weakening the sustainability of the health
care service system itself. Simultaneously,
Changes in the Uruguayan health system
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the price of important supplies was under
no regulation whatsoever.
From the point of view of payment to health
care centres, the national health insurance
pays according to risk – even partially, as a
stage in the transition process – as distinct
from single payment reimbursement.
Prior to the process of change, a distortion
in the price of co-payments grew stronger
(care-order payments, medicine tickets
and multiple diagnose and treatment tech-
niques), evolving from a way to regulate de-
mand – under State provisions – into a way
to fund the private health care system, and
thus creating great barriers for the access of
users.
Thanks to modifications introduced into the
system, the prices of a number of medicine
tickets controlled by the State were mainly
brought down, although they still hinder
access to consumption by a large portion of
users.
High-cost non-frequent techniques, gen-
erally associated to high-technology, are
covered by the so-called National Resource
Fund, a combined fund (public and private)
and reimbursement system – according to
different modalities – for highly specialised
medical institutions.
4. It is believed that the system portrays a
health care model that fails to emphasise
strategies for primary health care services,
and is instead eminently a therapeutic, hos-
pital-cantered model.
The official document suggests the transfor-
mation of the advanced health care model
based on the implementation of strategies
for primary health care services, according
to regulations that encourage these strate-
gies and additional payments associated
with achieving health care goals that need
to be carried out by the first level of assis-
tance.
5. The document further explains that the
administration and control system is weak-
ened in the different tasks required, there
being no management contracts or incen-
tive programs based on goal accomplish-
ment (health/economic-financial goals).
At the official level, the change process is
to provide the system with a real adminis-
trative and control policy, mainly by means
of the execution of management contracts
and their enforcement and sanctions frame-
work, whereby institutions providing health
care services commit to fulfil the health
programs defined as priority programs.
6. The quality and quantity of services that
the whole structure commits to render was
not clearly defined.
Ministerial authorities reassure that the sys-
tem has managed to level the quality and
quantity of benefits by means of the specific
definition of the national integrated health
system that becomes an explicit guarantee
whose enforcement can be demanded from
the health authorities.
7. Finally, reference is made to the fact that
historically there has been no social partici-
pation in the running of systems or institu-
tional management.
Changes suggest the incorporation of social
participation as a system and institutional
guideline. In this way, the participation of
users and workers of the National Integrated
Health System is strongly encouraged at the
macro level of the National Health Council,
and at the micro level of institutions provid-
ing health care services. Private institutions
will do it by means of Counselling Consult-
ing Councils, and public institutions will
rely on the participation of the board of the
main health care services centre.
Ec. Luis Lazarov, Executive
Committee Consultant;
Dr. Julio Trostchansky, MD, President
SINDICATO MÉDICO del URUGUAY;
Alarico Rodríguez, MD, Head
of Foreign Relations
Health Care Without Harm (HCWH)
and the Health and Environment Alli-
ance (HEAL) are working with the World
Health Organisation (WHO) to launch
a new platform, the Prescription for a
Healthy Planet.
Why you should care
Climate change affects health, the environ-
ment and economy – but the health com-
munity will be picking up the tab as the
health impacts of climate change begin
making themselves felt.
Yet health is largely missing in climate
change discussions.
The health community holds an influential
position in society and in policy-making. If
its voice were heard then climate initiatives
would be significantly stronger and more
health-friendly.
Please join our efforts to bring health to cli-
mate change negotiations
Endorse the Prescription•
Promote the Prescription in National•
Medical Association publications and
elsewhere
Join us in Barcelona for the global launch•
of the Prescription and Network
Prescription for a Healthy Planet
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The problem
There is increasingly powerful scientific evi-
dence that climate change is not only a real-
ity now but is threatening to become a far
more destructive phenomenon much more
quickly than even recently predicted.
One of the most disturbing implications of
climate change is its potentially dramatic
impact on human health around the world.
As the Lancet Commission report says:“the
effects of climate change on health will af-
fect most populations in the next decades
and put the lives and well-being of billions
of people at increased risk.”
Overall, the health impacts of climate
change will be disproportionately felt by the
most vulnerable populations – the poor, the
very young, the elderly and the medically
infirm.
The World Health Organization predicts that
climate change will lead to a series of signifi-
cant health impacts, including: higher levels of
some air pollutants and concomitant increased
respiratory disease; the spread of diseases such
as cholera, malaria, dengue and other infec-
tious diseases; the compromising of agricul-
tural production and food security in some of
the least developed countries leading to greater
malnutrition; an increase in extreme weather
events like floods and droughts with dramatic
impacts especially on the health of people liv-
ing in coastal communities.
The health sector on the front lines
Healthcare providers and public health
practitioners will be on the front lines,
confronting and adapting to this changing
landscape and shifting burden of disease.
Such adaptation will come at a cost: the
more severe the health-related symptoms
of climate change, the greater the outlay of
financial and human resources that will be
required to treat them.
The health sector itself also makes a signifi-
cant contribution to the problem of climate
change. Healthcare is a major consumer of
energy, water, computers, chemicals, phar-
maceuticals, food and other resources. This
consumption leaves a significant climate
footprint.
A leadership role
Precisely because the healthcare sector’s cli-
mate impact is so far-reaching, it must play
a leadership role in developing and model-
ling solutions for the rest of society.
Many healthcare institutions are already
employing a diversity of cost-effective cli-
mate-mitigation measures including energy
efficiency,on-site alternative energy genera-
tion, green building design and construc-
tion, along with more climate-friendly pro-
curement, transportation, food, waste and
water-use policies.
Done correctly, these efforts to reduce our
climate footprint and to move healthcare
toward carbon neutrality will also create
major benefits for public health. The extent
of these benefits is only gradually becoming
known.
Reducing our reliance on fossil fuels and
moving toward clean, renewable energy can
have the added benefit of reducing local
pollution generated by the combustion of
coal, oil and gas. This in turn would reduce
the number of respiratory illnesses related
to such energy consumption, thereby im-
proving public health. Visionary action to
mitigate climate change now will go a long
way toward avoiding major health challeng-
es in the future.
The Prescription for a Healthy Planet, if
implemented, would both help mitigate
climate change’s most severe impacts while
ensuring major benefits to society by pro-
tecting public health.
A prescription for a healthy planet
ProtectPublicHealth:• Take into account
the significant human health dimensions
of the climate crisis along with the health
benefits of climate change mitigation
policies. In conjunction with this, a por-
tion of climate mitigation and adaptation
funds should be targeted for the health
sector.This is needed to ensure evidence
of the health impacts of climate change
is continuously updated and brought to
policy makers, so that the health sector
can adapt to the health impacts of cli-
mate change while reducing its own cli-
mate footprint.To assure a strong voice in
the debate, the health sector should also
be adequately represented on all national
delegations to Copenhagen.
Transition to Clean Energy:• A viable
accord must promote solutions to the cli-
mate crisis that move away from coal, oil,
gas,nuclear power,waste incineration and
fossil-fuel-intensive agriculture. The Co-
penhagen treaty should foster energy ef-
ficiency as well as clean, renewable energy
that improves public health by reducing
both local and global pollution.
Reduce Emissions:• In order to protect
human and environmental health, the
world’s governments must take urgent
action to drastically reduce world-wide
emissions by 2050. Over the next decade,
developed countries must significantly
reduce their greenhouse gas emissions
below 1990 levels. Developing countries
must also commit to stabilizing and re-
ducing their emissions.
Finance Global Action:• A fair and eq-
uitable agreement in Copenhagen should
also provide new and additional resources
for developing countries to reduce their
climate footprint and adapt to the im-
pacts of climate change.
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Reducing the health sector’s
climate footprint
As health professionals and representa-
tives of major healthcare and public health
institutions and associations, we pledge to
aggressively address climate change in our
sector and to promote health-friendly cli-
mate policy in all sectors.
We will work together as part of a global
network to conduct research, share infor-
mation and strategies to reduce our climate
footprint,adapt our health systems and pro-
mote policies for mitigating climate change
that also achieve significant benefits for
public health.
Ultimately it is up to the leaders of the world
to establish a forward thinking framework
that transcends immediate political pre-
rogatives to adequately confront this loom-
ing threat. Therefore we are calling on all
world leaders to take a strong and vision-
ary stand in the Copenhagen negotiations
in December, as well as in the national and
international policy debates that ensue, by
following this simple and clear Prescription
for a Healthy Planet.
The clock is ticking. The time for action is
now.
For more information about signing up
Please contact Dr. Pendo Maro, Senior Cli-
mate Policy Advisor to HCWH Europe
and HEAL: pendo@env-health.org
Website: www.climateandhealthcare.org
Dr. Regina M. Benjamin, former board
member of the American Medical Associa-
tion (AMA) and Chair of the AMA Council
of Ethical and Judicial affairs was appointed
to the position of United States Surgeon
General on October 29, 2009. U.S. Dept. of
Health and Human Services Secretary Kath-
leen Sebelius announced the confirmation,
noting that Dr. Benjamin’s “deep knowledge
and strong medical skills, her commitment
to her patients, and her ability to inspire the
people she interacts with every day will serve
her well as Surgeon General.”
Dr. Benjamin is founder and CEO of the
Bayou La Batre Rural Health Clinic in Bay-
ou La Batre, Alabama, whose mission is to
provide “Health Care with Dignity” to the
impoverished residents of Bayou La Batre.
Born in 1956, Dr. Benjamin attended Xavier
University in New Orleans, and was a mem-
ber of the second class of Morehouse School
of Medicine. She received her MD degree
from the University of Alabama Birmingham,
and completed her residency in family prac-
tice at the Medical Center of Central Georgia.
She returned to her home region of Bayou La
Batre (a small shrimping village along the gulf
coast of Alabama) to establish a solo medical
practice. After several years moonlighting in
emergency rooms and nursing homes to sus-
tain her practice open, mean while obtaining
an MBA fromTulane, Dr.Benjamin convert-
ed her medical office into a small rural health
clinic dedicated to serving the large indigent
population in her community.
Dr. Benjamin is a member of the National
Academy of Science’s Institute of Medicine,
a Diplomat of the American Board of Fam-
ily Practice, and a Fellow of the American
Academy of Family Physicians. She is the
immediate past-chair of the Federation of
State Medical Boards of the United States,
and was a Kellogg National Fellow and a
Rockefeller Next Generation Leader. Con-
sistent with her strong social conscience,
Dr. Benjamin spent time doing missionary
work in Honduras.
In 1995 she was elected to the AMA Board
of Trustees, the first physician under age 40
and the first African-American woman to
be elected. She also served as President of
the AMA Education and Research Foun-
dation (AMA-ERF). In 2002 she became
President of the Medical Association State
of Alabama, the first African American fe-
male president of a State Medical Society in
the United States.
Dr. Benjamin’s extraordinary accomplish-
ments and commitment to her medical
profession have won international recogni-
tion. Dr. Benjamin was previously named
by Time Magazine as one of the “Nation’s
50 Future Leaders Age 40 and Under.” She
was also featured in a New York Times article,
Regina M. Benjamin, MD, MBA,
United States Surgeon General
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The CPME celebrated its 50th
Anniversary
in Winchester (United-Kingdom,the home
town of Dr. Wilks the CPME President)
on October 23rd
and 24th
2009. 4 past Presi-
dents and the current President thanked all
those people that played a role in the past
50 years.
Dr. Alan Rowe is currently retracing the
history of CPME in the context of EU- and
international health policy. In the introduc-
tion he gave of this upcoming description of
50 years CPME he concluded that CPME
can be proud of its accomplishments.
This CPME anniversary meeting was also
directed towards the future. The Gen-
eral Assembly envisaged, and adopted, a
change in its functioning.: From 2010, the 4
CPME subcommittees will be replaced by
working groups, dedicated to specific policy
topics. Along with an increased use of elec-
tronic communication instead of face-to-
face meetings, this shift will allow a more
flexible and cost-effective decision-making
process.
At the Winchester meeting the following
policies were adopted:
“Use of Health Related Genetic In-
formation outside the Health Service”
(http://cpme.dyndns.org:591/adopted/2009/
CPME_AD_Brd_241009_170_f inal_
EN.pdfCP)
ME calls national governments to enact
legislation which should prohibit the use of
health related genetic information outside
the area of direct patient care and health
service, such as for insurance or pension
funds purposes.
“Vitamin D nutritional policy in Europe”
(http://cpme.dyndns.org:591/adopted/2009/
CPME_AD_Brd_241009_179_f inal_
EN.pdf)
CPME believes Vitamin D supplementa-
tion (600-800 IU D3) and a good calcium
intake (about or above 1 g/d) should be
considered (especially) for elderly people.
CPME calls on the EU Institutions to in-
clude vitamin D deficiency in the health
agenda.
Prescription for a Healthy Planet
CPME co-signed the Prescription for a
Healthy Planet, calling for better represen-
tation of the health sector into the negotia-
tions, which must lead to a strong, binding
Copenhagen Treaty that promotes a healthy
climate.
CPME Response to the Commission
proposal for Council Recommendation
on Patient Safety (http://cpme.dyndns.
org:591/adopted/2009/CPME_AD_
EC_160909_075_final_EN.pdf)
CPME welcomes the European Commis-
sion’s proposal,which recognizes the urgency
of joint actions with regard to patient safety.
CPME welcomes the recommendation that
Member States establish reporting systems
that are fair, open and non punitive. In ad-
dition, CPME urges the Council to give due
consideration to the future organization of
EU patient safety work and to the creation
of a European Center for Patient Safety.
Lisette Tiddens-Engwirda, Secretary General
Standing Commitee of European Doctors – 50
“Angel in a White Coat,” as “Person of the
Week” on ABC’s World News Tonight with
Peter Jennings, as “Woman of the Year” by
CBS This Morning, and in People Magazine.
She was featured on the December 1999
cover of Clarity Magazine, and on the Janu-
ary 2003 cover of Reader’s Digest. Dr. Ben-
jamin received the Nelson Mandela Award
for Health and Human Rights in 1998. She
received the 2000 National Caring Award
which was inspired by Mother Teresa,as well
as the papal honor Pro Ecclesia et Pontifice
from Pope Benedict XVI.She is also a recent
recipient of the MacArthur Genius Award.
President Barack Obama praised Dr. Ben-
jamin’s dedication to providing health care
for her rural community in the face of ad-
versity, naming her a “relentless promoter
of prevention and wellness programs” who
“represents what’s best about health care
in America — doctors and nurses who give
and care and sacrifice for the sake of their
patients”. Dr. Benjamin explained that as
Surgeon General she hopes “to be Ameri-
ca’s doctor, America’s family physician” and
she promised to “communicate directly with
the American people to help guide them
through whatever changes may come with
health care reform”.
Dr. Benjamin is worthy of recognition
among the World Medical Association’s
Caring Physicians of the World. She too, ex-
emplifies the three enduring traditions of
the medical profession, caring, ethics and
science, which inspire hope and trust.
Yank D. Coble, MD. Director and
Distinguished Professor Center for Global
Health and Medical Diplomacy
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167
International, Regional and NMA news
A delegation of doctors from Malawi vis-
ited Berlin at the beginning of September.
In just under a week, three Malawian doc-
tors were given an insight into the German
health sector and the system of medical self-
administration. They had accepted an invi-
tation from the German Medical Associa-
tion (Bundesärztekammer – BÄK) and the
German Agency for Technical Cooperation
(Gesellschaft für Technische Zusammenar-
beit – GTZ).
Dr. Douglas Lungu is 43 years old, a surgeon
and Director of the Presbyterian Hospital in
Lilongwe, the capital of Malawi. Dr. Bridget
Msolomba (26) and Dr. Andrew Likaka (29)
both work in hospitals as general practitio-
ners. The three doctors represent Malawi’s
“Society for Medical Doctors”(SMD),which
was only founded in 2008.
The visit focused on various players in the
German health system, such as the German
Medical Association and the German As-
sociation of Hospital Doctors (“Marburger
Bund”).
The guests from Malawi gathered numerous
ideas and suggestions that they said would
help them promote the development of their
medical organisation. They explained that
they had set up their organisation only re-
cently because there were very few doctors
working in Malawi. In statistical terms, an
estimated 64 000 inhabitants are served by
one doctor. Accordingly, there are roughly
200 practising doctors in Malawi with its
population of 13 million,and a single univer-
sity has to cover the demand for junior medi-
cal staff. To guarantee at least a minimum of
healthcare, graduates in medicine have to
agree to work in their home country for two
years after completing their studies.
Medical care is free of charge for patients
in Malawi. At the same time, the country is
facing massive financial challenges, particu-
larly in the health sector: infant mortality is
in the region of eight percent of all births,
the high AIDS rate of 11.9 percent of the
total population causes serious problems,and
the average life expectancy is just 46 years.
Although the doctors and medical assistants
make a major effort to effectively counter-
act the numerous problems in the healthcare
sector, the available budget needs to be util-
ised more efficiently in practice. In the view
of the doctors from Malawi, however, the
distributed structure of the healthcare sys-
tem is in principle sensible and will continue
to be viable in the future.
General practitioners like Dr. Likaka and
Dr. Msolomba are most in demand, because
broad-based knowledge is needed in a hos-
pital. “If you’re not familiar with a disease,
you look up the treatment in a textbook,”
said Dr. Lungu, describing the pragmatic
approach of his hospital doctors. What the
three are very knowledgeable about, is tropi-
cal medicine. Given the wealth of tropical
diseases that are the daily bread of Malawian
doctors, colleagues from abroad were always
amazed, they said with a grin. Consequently,
it would be interesting and instructive for
international doctors to spend some time
working at a tropical hospital in Malawi.
“As far as the equipment of the hospitals is
concerned, the main thing missing is beds,”
said Dr. Lungu. In addition to which, how-
ever, the quality of the products they could
afford often left a lot to be desired. For that
reason, they would very much like to equip
their hospitals with sturdy, second-hand
beds from Europe, for example – if the funds
for the transport were available.
The three Malawian doctors subsequently
experienced what the equipment of a Ger-
man hospital can look like during a tour
of the eye clinic of the Charité hospital in
Berlin. The one-and-a-half-hour visit intro-
duced them to the procedures for dealing
with eye patients. Senior physician Dr. Mir-
iam Doblhofer not only explained the ex-
amination and treatment methods, but also
demonstrated the workflows in patient ad-
ministration, from admission and the course
of the operation, all the way to collaboration
with other specialist clinics.
The exchange between the representatives
of the Malawian and German medical com-
munities was a first step towards closer co-
operation. Although the conditions under
which doctors work around the globe appear
to be very different on the surface, it can be
seen time and again that all doctors have to
contend with many very similar problems.
Unfortunately, their wish to engage in their
curative activity often has to take a back seat
to political, bureaucratic or financial targets.
In this respect, closer contacts help to fur-
ther strengthen the self-image of the medical
community worldwide.
Therefore, the World Medical Association
received the SMD from Malawi as a new
member at this year’s General Assembly in
Delhi/India. Although the new association
joining the WMA is only small, its dedicat-
ed members will no doubt help to strengthen
the medical community, especially in Africa.
More information on the “Society for Medi-
cal Doctors” in Malawi can be found on the
website at www.smdmalawi.org.
Johanna Janotta, Marburger Bund;
Domen Podnar, German Medical Association
Average of one doctor per 64 000 inhabitants
Medical delegation from Malawi as guests of the German medical community
From left to right: Armin Ehl (Secretary
General of Marburger Bund), Johanna
Janotta (Marburger Bund), Domen Podnar
(GMA), Dr. Andrew Likaka (SMD),
Elisabeth Jibikilayi (GMA), Dr. Douglas
Lungu (President of SMD), Dr. Bidget
Msolomba (SMD)
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WMA news
WMA General Assembly, New Delhi 2009 . . . . . . . . . . . . . . 128
Declaration of Delhi on Health and Climate Change. . . . . . . 137
Declaration of Madrid on Professionally-led Regulation . . . . 140
Declaration of Ottawa on Child Health . . . . . . . . . . . . . . . . . 140
WMA Resolution on Task Shifting
from the Medical Profession . . . . . . . . . . . . . . . . . . . . . . . . . . 141
WMA Emergency Resolution supporting the Rights
of Patients and Physicians in the Islamic Republic of Iran . . . 143
WMA Resolution on Medical Workforce. . . . . . . . . . . . . . . . 144
WMA Statement on Inequalities in Health . . . . . . . . . . . . . . 145
WMA Resolution on Improved Investment in Public Health 146
Hindi – English bilingual “Speaking Book”. . . . . . . . . . . . . . . 147
Impact of climate change in Asia and
Oceania region and challenges ahead . . . . . . . . . . . . . . . . . . . 148
Anthropedia’s initiatives to promote person centered care. . . . 152
Lack of access to healthcare information is a hidden killer . . . 153
The Medical Women’s International Association (MWIA) . . 155
A strange form of declaring a health emergency:
the case of Venezuela. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Indian Medical Association:brief report of all projects . . . . . . 159
Changes in the Uruguayan health system . . . . . . . . . . . . . . . . 162
Prescription for a Healthy Planet . . . . . . . . . . . . . . . . . . . . . . 163
Regina M. Benjamin, MD, MBA,
United States Surgeon General. . . . . . . . . . . . . . . . . . . . . . . . 165
Standing Commitee of European Doctors – 50 . . . . . . . . . . . 166
Average of one doctor per 64 000 inhabitants. . . . . . . . . . . . . 167
Contents
WMA General Assembly, New Delhi 2009
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