WMJ 03 2012

COUNTRY
• White Paper On Ethical Issues Concerning Capital
Punishment
• Violence in the Health Care Sector
• The First Global Climate and Health Summit
• Junior Doctors Network
vol. 58
MedicalWorld
Journal
Official Journal of the World Medical Association, INC
G20438
Nr. 3, July 2012
wmj 3 2012.indd I 7/18/12 9:47 AM
Cover picture from China
Editor in Chief
Dr. Pēteris Apinis
Latvian Medical Association
Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv
editorin-chief@wma.net
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 Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher “Medicīnas
apgāds”, President Dr. Maija Šetlere,
Katrīnas iela 2, Riga, Latvia
Cover painting:
Da Yi Jing Cheng, literally translated as great doctor
is both exquisite skilled and sincere.This is the title
of an article from the classic medical work One
thousand golden prescriptions for emergency
medicine,volume I. The book is written by the
famous doctor SUN Simiao in the Tang Dynasty
(618AD-907AD), it is a must-read medical book for
the doctors in the ancient China.This article states
two issues on medical ethics: one is Jing (exquisite)
which requires the doctor be excellent in their medi-
cal skills as medicine is considered from fine to ex-
quisite; while doctor should also be Cheng (sincere),
with empathy and noble moral.This demonstrates
the early ethics in ancient China that calls on doc-
tors to be outstanding in both hand and mind.
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Members
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Dr. Cecil B. WILSON
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Dr.Torunn JANBU
WMA Chairperson of the Medical
Ethics Committee
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Dr.Frank Ulrich MONTGOMERY
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Dr. Mukesh HAIKERWAL
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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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81
In 1964 the World Medical Association adopted,in Helsinki,a Decla-
ration regarding the Ethical Principles for Medical Research Involving
Human Subjects. As we approach the fiftieth anniversary of the Dec-
laration of Helsinki we should pause to reflect on how the world and
medicine have changed,and examine our current needs and challenges.
As civilizations evolve and mature the epidemiology of disease
changes. New morbidity patterns have evolved, especially in Eu-
rope, North America and Australia in the last 50 years.Whereas in-
fectious diseases and traumatic disorders predominated in the past,
chronic and degenerative processes are more common today.Cancer
is taking its prominent place in the spectrum of chronic diseases.
The numbers of doctors and medical staffs have grown significant-
ly, but significant specialization has also taken place. We still take
medical histories and examine patients, but rely more and more on
modern medical technology to arrive at diagnoses.
To an increasing degree in modern times, medical philosophy fo-
cuses on topics of life and death, such as the management of pa-
tients who have cardiac arrests. In these instances, cardiopulmonary
resuscitation is provided not only by medical personnel, but also by
non-professionals who have obtained training in vocational schools.
In solving the dilemma of whether or not to begin resuscitation in a
life-threatening emergency, the doctor should focus on the expected
outcome – what will be the quality of life for the patient upon dis-
charge from the hospital? Using modern medical expertise it is usu-
ally possible to return patients to fully functional lives and normal
life expectancy following cardiac insult.
Cardiopulmonary resuscitation of cardiac arrest is successful in 70–
98 per cent of attempts. After successful resuscitation, quality of life
is ensured for most survivors, and it is very common for people to
have long life expectancy in spite of serious cardiac disease.
An ethical dilemma arises when one has to allocate limited finan-
cial resources for health care in the 21st
century: how much should
be expended to prolong the life of one person versus spending the
scarce health care dollar on a larger portion of the population? Since
1990 the average lifespan has been extended by one year every four
years. During this same time period health care expenditure has in-
creased three to five per cent a year, a figure much higher than the
growth of the gross national product.
Today, given enough resources, people’s lives can be significantly
prolonged with the aid of modern medicine. Doctors, patients and
their families understand this. These resources are expended espe-
cially on prevention, early diagnosis and rehabilitation.
There is competition for the health care dollar. A certain portion
usually comes from social security funds that have been paid for
by individuals during their lifetimes to which they are entitled. The
remainder is typically paid for by the state, to which people also
believe they are entitled.
Regardless of the economic wealth of any country, resources are not
unlimited. As a result, dissatisfaction with the health care system
develops among medical professionals and the general public. In
reality, the delivery of medical care in the 21st
century has become a
paradox: the more money that is expended on health care,the longer
people live (although suffering from their chronic illnesses), but the
more financial resources are needed.
Leaders of medical associations and other influential health officials
around the world are paying increasing attention to health issues,
such as disease prevention, smoking, alcohol, vaccination, nutritious
food, physical exercise, ecology and a healthy lifestyle. And, a cor-
nucopia of ethical problems has opened – public health issues exist
in Europe and Africa, North and South America, Christian and
Muslim countries. Implementation of public health improvements
has often been met with a hypocritical attitude toward issues such as
the calamity of smoking and the widespread use of narcotics. More
than three million newborns die each year, mostly in developing
countries.Lack of food in poor countries leaves 170 million children
underweight, while at the same time, nearly a billion people in the
world are overweight due to excess food consumption and lack of
exercise.
In studying the social determinants of health, the World Health
Organization has focused on nine broad areas: early child develop-
ment, globalization, health systems, measurement and evidence, ur-
banization, employment conditions, social exclusion, priority public
health conditions and women and gender equity. A dominant figure
in the study of inequalities of health care and their causes is Eng-
land’s Sir Michael Marmot. He maintains that social standing is an
important determinant of health and life expectancy.
Recognizing the far-reaching changes that have occurred in medi-
cine in the 21st
century, it is obvious that a new document that ad-
dresses the ethics and philosophy of our modern time is in order.
There is no organization better suited to produce this Declaration
than the World Medical Association.
Editorial
Dr. Peteris Apinis, Editor in Chief
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82
WMA news
1. Why has the WMA engaged in discuss-
ing the use of capital punishment?
2. Is capital punishment torture?
3. Is the use of capital punishment unethical?
4. Is capital punishment just?
Liberty / Libertarianism
Free market libertarians
Utilitarianism
Virtue
Equality / Egalitarianism
An eye for an eye
Racial disparities
The dilemma of revenge
5. Criminal law and the argument of de-
terrence and retribution
Gregg vs. Georgia 1976
Base vs. Rees 2008
6. Why the use of medication in capital
punishment?
7. Some statistics
Reported executions in 2010
Reported death sentences in 2010
8. References
This paper was drafted by the Danish Medical
Association with the support of WMA Working
Group on capital punishment.
1. Why has the WMA engaged
in discussing the use of
capital punishment?
The WMA has a strong tradition oppos-
ing the involvement of physicians in capital
punishment. Recently, it has been debated
whether it is morally and ethically wrong
that drugs produced to cure people are also
used in prisons with the aim of ending a
person´s life.
A Danish Pharmaceutical company, H.S.
Lundbeck A/S had to take a stance and act
to try to prevent the use of one of its prod-
ucts, Nembutal, for executions after massive
pressure from media and human rights´
groups as well as the medical community.
This makes it relevant to discuss the ethics
of capital punishment and how it is executed
today. Since many executions are performed
by the use of drugs requiring some kind of
guidance from health care personnel, the
question reappears: Does the medical com-
munity have to take a stance against the use
of capital punishment?
In China prisoners are executed by the use
of fire arms. But still a doctor may be in-
volved giving a drug before the execution
and after when pronouncing the death of
the prisoner. Iran and Saudi Arabia have
other methods. Mostly death by hanging
is used here. In the United States capital
punishment is mainly performed by the
use of lethal injection. In a few states other
methods can be used including firing squad.
94 % of all executions happen in these four
countries according to Amnesty Interna-
tional (2005).
2. Is capital punishment
torture?
The definition of torture according to the
United Nations (UN) Convention against
Torture is: “Torture means any act by which
severe pain or suffering, whether physical or
mental, is intentionally inflicted on a person
for such purposes as obtaining from him or
a third person information or a confession,
punishing him for an act he or a third per-
son has committed or is suspected of having
committed, or intimidating or coercing him
or a third person, or for any reason based on
discrimination of any kind, when such pain
or suffering is inflicted by or at the instiga-
tion of or with the consent or acquiescence
of a public official or other person acting in
an official capacity. It does not include pain
or suffering arising only from,inherent in or
incidental to lawful sanctions”.
The crucial point being that capital punish-
ment is not regarded as torture since the
definition in the UN Convention against
Torture does not include pain and suffering
arising only from inherent in or incidental
to lawful actions, which capital punishment
is.
3. Is the use of capital
punishment unethical?
This question is related to the question of
whether capital punishment is just. There-
fore inthe following paragraphs different
schools of ethics will be summarized and for
each paragraph a conclusion will be drawn
as to whether, from the point of view of the
individual way of thinking, capital punish-
ment can be regarded as ethical.
4. Is Capital Punishment just?1
a. Liberty/ Libertarianism
What matters most for justice is liberty. Ar-
ticle 3 in the Universal Declaration of Hu-
1 In an abstract by Matthew Robinson “Govern-
ment and Justice Studies, Journal of Theoretical
and Philosophical Criminology 2011”, different
theories of justice are applied to study whether
capital punishment achieves its purpose of bring-
ing justice to society. The author investigates
whether libertarian, egalitarian or the utilitarian
school of thought will come to the conclusion
that death penalty is just. The abstract is based
on a number of references and statistical material
(see reference). The author states (p. 50) that the
individual opinion on the death penalty is affect-
ed by many factors such as race, gender, age, level
of income, political party and ideology, geography
of residence and religious beliefs.
White Paper On Ethical Issues Concerning
Capital Punishment
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WMA news
man Rights posits: “Everyone has the right
to life, liberty and security of person.”
The issue over which capital punishment
supporters disagree is whether the right to
life espoused in the US and International
Law should be maintained after a person
commits murder. Death penalty supporters
maintain that, by taking a life, murderers
should sacrifice their own life as a form of
retribution; opponents disagree and argue
that these rights cannot be sacrificed1
.
Robinson continues that such philosophical
arguments can be resolved with empirical
evidence:
“Thus we must simply examine whether
capital punishment as actually practiced in
the US helps achieve liberty or diminishes
it. Empirically it is easy to see that capital
punishment is so rarely used that capital
punishment does not help achieve or assure
liberty in society. Stated simply, if an execu-
tion was necessary to help achieve and as-
sure liberty for potential victims, states fail
citizens 98–99% of the time because only
1–2 % of convicted murderers are executed
or sentenced to death respectively2
.
It is also worth noting that innocent people
are wrongly accused of murder, sentenced
to death and occasionally executed which is
an affront to liberty. Sometimes people who
would be regarded as not mentally compe-
tent may be executed in other jurisdictions.
The libertarian argument of capital punish-
ment is thus that the death penalty is un-
just.”
b. Free market libertarians
Most of the arguments put forward by
these libertarians are economic in nature.
Free market libertarians have not written
1 Robinson, p. 43.
2 Robinson p. 44.
about the death penalty but it is interesting
to know that capital punishment is gener-
ally more expensive than other sanctions
including life imprisonment.
As an example a study in North Carolina
showed that the cost of a death penalty
sentence was 216,000 $ and the total cost
per execution was $ 2.16 million more than
lifeimprisonment3
.
c. Equality/Egalitarianism
What matters most for justice is equality
of opportunity in society and taking care of
the least advantaged citizens.
There are significant racial disparities, class
disparities and gender disparities in capital
punishment practice4
.
The underlying causes are both the race and
gender of the prosecutors, the jurors and
characteristics pertaining to both the defen-
dants and the victims.Thus an undeniable
conclusion of capital punishment practice is
that the death penalty is applied in an un-
equal fashion.
d. Utilitarianism
The view of utilitarianism is that whether
something is just depends on whether it
maximizes the utility or greatest happiness
for the greatest number of people.
As a specific deterrent capital punishment
is efficient: the perpetrator cannot kill again
and more innocent lives might be saved.
The relevant question might however be:
to what degree are murderers likely to kill
again?
Is capital punishment likely to prevent fu-
ture killings? A study quoted by Robinson
3 Robinson, p. 44.
4 Robinson p. 45 and 36–42.
says that, out of 238 paroled offenders, less
than 1 % were returned to prison for com-
mitting a subsequent homicide.
Sunstein and Vermeule suggest that studies
show that 18 lives are saved per execution5
.
The very high figure seems to run contrary
to other views cited in this paper.
You can however argue that executions may
be excessive because effective incapacitation
can be achieved through life imprisonment,
although leaving a risk that the offender
might kill again while in prison.
Capital punishment can also bring closure
for the victim’s family but the delay in con-
viction often makes this point of little com-
fort or use to the family.
To determine the relative utility of capital
punishment one must assess the benefits
against the costs of capital punishment.
Assessing the contribution of capital pun-
ishment to the overall welfare of society is
difficult however. How can you measure
the worth of closure to the families? And
how should we evaluate the racial and so-
cial bias that has been proven statistically
to be true for capital punishment? Robin-
son concludes that “In spite of all this, it is
a safe conclusion that capital punishment
as practiced in the United States has only
modest benefits but enormous costs. Thus
the utilitarian argument of capital punish-
ment is that the death penalty is unjust.”
Sunstein and Vermeule argue to the con-
trary6
.
e. Virtue
Aristotle´s theory suggests that justice de-
mands giving people what they deserve or
what they are due.
5 Cass R. Sunstein and Adrian Vermeule: “Is Capi-
tal punishment morally required? Acts, omissions
and life-life trade offs” 58 STAN.L. Rev. 703.
6 See above reference.
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With regard to virtue based theorists we
must recall that the most important ques-
tion is whether capital punishment respects
and promotes our values, our moral good-
ness and whether it is the right thing to do.
The questions are difficult to answer given
the wide variety of values, morals, and sense
of right1
.
f. An eye for an eye
If a state kills only 1 % of murderers, do we
achieve an eye for an eye? Should the state
execute more?
The biblical argument to uphold capital
punishment is an eye for an eye, a tooth for
a tooth i.e. the argument of retribution. In
opposition to this broad definition which
addresses capital punishment is the text
“Vengeance is mine said the Lord”.
Different philosophers have related to the
subject of the death penalty but have in-
terpreted the great thinkers and schools of
philosophy differently. Some philosophers
might find the utilitarian school in favor of
capital punishment and others might argue
against.
The Norwegian philosopher Lars Fr. H. Sven-
dsen (“The philosophy of cruelty”) says about
Emmanuel Kant:
“The death penalty is a problem with regard
to the fundamental idea of humanity be-
cause humanity is based on the idea of the
absolute value of a person´s life no matter
what and the death penalty represents the
absolute denial of a person´s right to life.
But this idea can collide with the idea of a
just society:
To Kant justice is absolute and he thinks
that the death penalty is the only right way
to punish murder because the punishment
has to be a goal in itself. He believes in
the “ius talionis” where the wrong doing
1 Robinson p, 51.
is punished by a similar punishment. But
in fact you can also find arguments in the
categorical imperative by Kant against the
death penalty which says that a person has
to be considered a goal in itself and never
as a means to achieving a goal. If you use
the perpetrator as a means to achieving
justice you then violate the categorical im-
perative.”
Sunstein and Vermeule say about Kant that
he is a retributivist: For a retributivist the
penalty of death is morally justified or per-
haps even required. Other defenders of cap-
ital punishment are consequentialists and
often also welfarists who believe that ethics
involve the greatest amount of welfare for
the biggest amount of people2
.
As opposed to these schools of philosophy
many deontologists believe that capital
punishment counts as a moral wrong3
.
g. Racial disparities
Amnesty International (AI)4
finds signifi-
cant racial disparities in prosecutors deci-
sion on charging,noting that the death pen-
alty is sought far more frequently in cases
where the victims were white than when
they were black.
A quoted study by William J. Bowers from
1975–1976 shows that the racial combina-
tion of a black killing a white was virtually
“as strong a predictor of a first degree murder
indictment as any of the legal relevant factors
except a felony circumstance.”
William J. Bowers and Glenn L. Pierce
found that in Florida, as in other states,
the large majority of homicides were intra-
racial, i.e. committed within the same racial
2 Sunstein and Vermeule 58 STAN. L. Rev 703 p.
704.
3 Sunstein and Vermeule.
4 Amnesty International, United States of Ameri-
ca,The Death Penalty, p.30–31.
group. Although there was a high homicide
rate among both whites and blacks in all
states examined (Florida, Georgia, Texas,
Ohio), far more killers of whites than killers
of blacks were sentenced to death.They also
found that although most killers of whites
were white, blacks killing whites were pro-
portionately more likely to receive a death
sentence. In Florida and Texas for example
blacks who killed whites were respectively
five to six times more likely to be sentenced
to death than those who had killed blacks.
No white offender in Florida had ever been
sentenced to death for killing a black per-
son during the period studied (late 1970´s).
The first case presented was in 1980 where a
white man was sentenced to death for kill-
ing a black woman.
h. The dilemma of revenge
Kant points out that the necessity of achiev-
ing justice is a deeply rooted in us: Crimes
need to be punished. However, it is unclear
what can be regarded as a suitable punish-
ment from a retribution point of view:
“When it comes to people like Saddam or
Eichmann the question is whether any pun-
ishment can ever counterbalance/make up
for their actions”.
Also the humane person may reach the
conclusion that a death penalty is suitable,
explains Inga Floto:
“You can say that the human life is so valu-
able that we do not have any right to take it
away. But you can also say the opposite: that
it is so valuable that he who wastes his life
has lost his right to live.
This is a dilemma, which I think we cannot
solve. I do not believe that we have the right
to take another person´s life – not even the
life of murderers, but I cannot judge others
who think that murder is such a cruel act
that it should be punished with death. We
do not have any higher authority to decide
this.We only have our own conscience”, she
says.
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Human rights organizations state that
the use of capital punishment is denial of
the ultimate human right, the right to life
i.e. the willful state induced denial of the
person´s right to life. Some may say that a
person can forfeit his right to life by com-
mitting a terrible crime.
Capital punishment is also a dilemma for
the UN. In the dilemma lies the idea of a
just society and at the same time the idea
of humanity.
5. Criminal law and the
argument of deterrence
and retribution
The reason to uphold capital punishment
in modern times is the argument of deter-
rence and to some degree retribution since
certain crimes are so grievous and affront
to humanity “that the only adequate response
may be the penalty of death”1
. Still it is debat-
ed whether capital punishment violates the
8th
amendment’s ban on cruel and unusual
punishment.
a. Gregg vs. Georgia 1976
In a legal challenge to the death penalty as
cruel and unusual punishment under the
Eighth Amendment, the Supreme Court
of the United States upheld a state’s right
to use capital punishment as a tool in the
criminal court. Though the court admitted
that retribution is no longer a dominant ob-
jective in criminal law,it emphasized its role
in capital punishment where it is “the com-
munity’s belief that certain crimes are them-
selves so grievous an affront to humanity that
the only adequate response may be the penalty
of death.”
The Court cited to the British Royal Com-
mission on Capital Punishment which
1 Gregg v. Georgia, 184.
stated that capital punishment in extreme
cases is supportable because “the wrong-doer
deserves it, irrespective of whether it is a deter-
rent or not.”
The issue of deterrence was also explored
by the Court. At the time of the case, the
Court thought statistical studies of capital
punishment’s deterrent effect were incon-
clusive, citing a variety of studies from the
1950’s–1970’s. They assumed that the death
penalty may be a significant deterrent for
some criminals, but not for others. In the
end, the Court emphasized that it is the
state’s role to adjudicate criminal violations,
and permitted capital punishment in accor-
dance with the state’s moral consensus and
the social utility of such a sanction, citing
deterrence and retribution as justifiable ra-
tionales.
States vary in whether they cite retribution
(the more controversial justification) and/
or deterrence as justifications for employ-
ing capital punishment. Some states have
deemed retribution an invalid rationale for
criminal punishment, but there is evidence
that, in practice, this retribution is still used
to justify criminal punishment in these
states.
In the period between 1972 and 1976 the
Supreme Court of the United States pro-
duced an effective moratorium on capital
punishment.
In a discourse on capital punishment, Sun-
stein and Vermeule2
– using state data from
1977–1999 – focused on the murder rate in
each state before and after the death penalty
was suspended and reinstated. The authors
find a substantial deterrent effect.
However, a recent study offers more refined
findings. By disaggregating state data, Jo-
anna Shepherd finds that the nationwide
2 Sunstein and Vermeule: “Is capital punishment
morally required? Acts, omissions, and life trade
offs” 58 STAN. L. Rev. 703.
deterrent effect of capital punishment is en-
tirely driven by 6 states that are executing
more people than the rest3
.
b. Base vs. Rees 2008
In a videotaped debate in the New England
Journal of Medicine three physicians and a
lawyer in 2008 debated the case of Base vs.
Rees.The case was brought before the court
of Kentucky and the object was to establish
whether or not the formula used for capi-
tal punishment was in violation of the 8th
amendment on cruel and inhuman punish-
ment.
The formula dates back to 1977 and was
introduced by a doctor A.J. Chaplin. It con-
sists of thiopental (to sedate), pancuronium
bromide (to avoid twitching and spasms)
and potassium chloride (to stop the heart).
The court found that the petitioners failed
to show that Kentucky´s execution method
amounted to “cruel and unusual punishment”.
One of the judges of the court decided that
although the use of pancuroinium bromide
raised legitimate concerns, the petitioners
failed to show that Kentucky´s execution
method amounted to “cruel and unusual
punishment”. However this judge also re-
marked: “Although the death penalty has
serious risks – e.g. that the wrong person
may be executed, that unwarranted animus
about the victim´s race, for example, may
play a role, and that those convicted will
find themselves on the death row for many
years – the penalty´s lawfulness is not before
the court”.
AI addressed the question of deterrence in a
publication from 19874
.
3 Shepherd: “Deterrence versus Brutilization”, su-
pra note 9.
4 Amnesty International: United States of Amer-
ica, The Death Penalty, Amnesty International
Publications, p. 162–166.
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AI states that detailed research in the USA
and other countries has provided no evi-
dence that the death penalty deters crime
more effectively than other punishments. In
some countries, the number of homicides
actually declined after abolition. In Canada
for example the murder rate fell from 3.09
per 100,000 in 1975 (the year before aboli-
tion) to 2.74 in 1983.
A United Nations study published in 1980
found that: “Despite much more advanced
research efforts mounted to determine the
deterrent value of the death penalty,no con-
clusive evidence has been obtained on its
efficacy.”
According to AI, US studies have shown
that, under past and present death penalty
statutes, the murder rate in death penalty
states has differed little from that in other
states with similar populations and social
and economic conditions. A study by Thor-
sten Sellin who studied murder rates be-
tween 1920 and 1974 is referenced.
In the same publication by AI, crime trends
are referenced. In Florida and Georgia re-
search has shown an increase in homicides
in the period immediately following the re-
sumption of executions. Florida had carried
out no executions for nearly 15 years when
a prisoner was executed in 1979.Three years
following the resumption of executions in
1980, 1981 and 1982 Florida had the high-
est murder rates in the state´s recent history,
with a 28 percent increase in homicides in
1980.
6. Why the use of medication
in capital punishment?
A member of the panel of the New Eng-
land Journal of Medicine, Professor Debo-
rah Denno (lawyer), states why the combi-
nation of drugs was introduced in 1977.
“The law turned to medicine to save the
death penalty”. The drugs were to replace
the electric chair and the object was to
make the death penalty look more hu-
mane.
Soon after this, the AMA took a position
against the involvement of physicians in ex-
ecutions. From Gawande – “When law and
ethics collide” 1
:
“But medicine balked. In 1980, when the first
execution was planned using Dr. Deutsch’s
technique, the AMA passed a resolution
against physician participation as a violation
of core medical ethics. It affirmed that ban in
detail in its 1992 Code of Medical Ethics.
Article 2.06 states, “A physician, as a mem-
ber of a profession dedicated to preserving
life when there is hope of doing so, should not
be a participant in a legally authorized ex-
ecution,” although an individual physician’s
opinion about capital punishment remains
“the personal moral decision of the individ-
ual.” It states that unacceptable participation
includes prescribing or administering medi-
cations as part of the execution procedure,
monitoring vital signs, rendering technical
advice, selecting injection sites, starting or
supervising placement of intravenous lines,
or simply being present as a physician. Pro-
nouncing death is also considered unaccept-
able, because the physician is not permitted to
revive the prisoner if he or she is found to be
alive. Only two actions were acceptable: pro-
vision at the prisoner’s request of a sedative to
calm anxiety beforehand and certification of
death after another person had pronounced it.
The code of ethics of the Society of Correctional
Physicians establishes an even stricter ban:
“The correctional health professional shall . .
. not be involved in any aspect of execution
of the death penalty.” The American Nurses
Association (ANA) has adopted a similar
prohibition. Only the national pharmacists’
society, the American Pharmaceutical Asso-
ciation, permits involvement, accepting the
voluntary provision of execution medications
by pharmacists as ethical conduct”.
1 Gawande A. (2006) “When Law and Ethics
Collide — Why Physicians Participate in Execu-
tions”. NEJM 354:1221-1229
The method of lethal injection has given rise
to problems and concerns in the medical
community worldwide.The WMA adopted
its policy on non involvement of physicians
in capital punishment in 1981. The Reso-
lution on Physician participation in Capi-
tal punishment has since been amended in
2000 and 2008.
Recently in 2010 and 2011 some pharma-
ceutical companies and some European
governments have adopted policies against
exporting drugs that may be used for execu-
tions with or without pressure from human
rights activists.
Turning back to the New England Journal
of Medicine, the panel concludes:
“The involvement of physicians in some part of
the procedure is necessary if it should be per-
formed without complications and pain.”
7. Some statistics on
capital punishment
Source: web.amnesty.org
• In 2005 at least 2,148 people were ex-
ecuted in 22 countries and at least 5,186
people were sentenced to death in 53
countries.
• 94 percent of all executions took place in
China, Iran, Saudi-Arabia and the US.
• AI estimates that at least 1,770 were ex-
ecuted in China in this year but the num-
ber may be higher.
• AI estimates that at least 20,000 people
await their execution.
Reported death sentences and executions
in 2010:
Where “+” is indicated after a country and it
is preceded by a number, it means that the fig-
ure Amnesty International has calculated is a
minimum figure. Where “+” is indicated after
a country and is not preceded by a number, it
indicates that there were executions or death
sentences (at least more than one) in that coun-
try but it was not possible to obtain any figures.
wmj 3 2012.indd 86 7/18/12 9:47 AM
87
Highlights on the WMA’s
activities during the World
Health Assembly
The last World Health Assembly has been a
busy time for the World Medical Associa-
tion.This year, the WMA co-organised two
side-events with other organisations – one
on palliative care and the other on social de-
terminants of health. In parallel, the World
Health Professions Alliance (WHPA) – in
which the WMA is an active member –
presented four public statements respec-
tively on non-communicable diseases, the
Millennium Development Goals (MDGs),
Counterfeit medicines and on the role of
WHO in collecting and disseminating data
on attacks on health in complex humanitar-
ian emergencies.
Reducing the Burden of Pain and
Suffering: Developing Palliative Care
in Low and Middle Income Countries
This side-event took place on May 23rd
at
the initiative of Human Rights Watch, in
cooperation with the Worldwide Palliative
Care Alliance, the WMA and other rel-
evant partners1
.The event was sponsored by
1 Union for International Cancer Control, Inter-
national Association of Hospice and Palliative
Care, Trivandrum Insitute of Palliative Sciences,
Open Society Foundations, Kenya Hospice and
Palliative Care Association. With the support of
the Open Society Foundations.
References
1. Allen, Ronald J. & Shavell, Amy: “Further re-
flections on the Guillotine” (2005).
2. Amnesty International: United States of
America, The Death Penalty. Amnesty Interna-
tional Publications, 1987.
3. Daly R.: “Participation in the death Penalty”
(2006).
4. Floto,Inga: “The Cultural History of the Death
Penalty – rituals and methods 1600–2000”
(“Dødsstraffens kulturhistorie – ritualer og me-
toder 1600–2000”).
5. Gawande A: “When law and ethics collide  –
Why Physicians participate in executions”
NEJM 354 (2006).
6. Gawande A. et al: “Physicians and Execution –
Highlights from a discussion on Lethal Injec-
tion” NEJM 358 (2008).
7. Robinson M.: “Assessing the Death Penalty us-
ing Justice Theory” (2011).
8. Sunstein and Vermeule: “Is Capital Punish-
ment Morally required? – Acts, omissions and
life-life trade offs”.
9. Steiker, Carol S.: “No capital punishment is not
morally required – deterrence, deontology and
the death penalty”.
10. Williams,Daniel R.:“The futile debate over the
morality of the death penalty – a critical com-
mentary on the Steiker and Sunstein-Vermeule
debate”.
11. Svendsen,Lars Fr.H.: “The Philosophy of Cru-
elty” (Ondskabens filosofi) 2005.
Reported executions
in 2010
China 1000s
Iran 252+
North Korea 60+
Yemen 53+
United States of
America 46
Saudi Arabia 27+
Libya 18+
Syria 17+
Bangladesh 9+
Somalia 8+
Sudan 6+
Palestinian Authority 5
Reported death sentences
in 2010
China +
Pakistan 365
Iraq 279+
Egypt 185
WMA page 11
Nigeria 151+
Algeria 130+
Malaysia 114+
United States of
America 110+
India 105+
Afghanistan 100+
Zambia 35
Saudi Arabia 34+
Viet Nam 34+
Bangladesh 32+
United Arab Emirates 28+
Yemen 27+
Tunisia 22+
Ghana 17
Mauritania 16+
Mali 14+
Central African
Republic 14
Japan 14
Gambia 13
Lebanon 12+
Palestinian Authority 11+
Liberia 11
Sudan 10+
Syria 10+
Jordan 9
Taiwan 9
Singapore 8+
Somalia 8+
Zimbabwe 8
Indonesia 7+
Thailand 7+
Ethiopia 5+
Kenya 5+
Tanzania 5+
Uganda 5+
Bahamas 5+
Equatorial Guinea 4
Jamaica 4
Laos 4
Morocco/Western Sahara 4
South Korea 4
Kuwait 3+
Belarus 3
Madagascar 2+
Malawi 2
Myanmar 2
Benin 1+
Burkina Faso 1+
Guyana 1+
Bahrain 1
Barbados 1
WMA page 12
Chad 1
Guatemala 1
Maldives 1
Sierra Leone 1
Brunei Darussalam +
Cameroon +
Democratic Republic of
Congo +
Iran +
Libya +
North Korea +
Sri Lanka +
Trinidad and Tobago +
World Health Assembly Report,
Geneva, Switzerland, 2012
WMA news
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88
the Republic of Kenya, the United States
of America, the Republic of Panama and
Australia.
Following the September 2011 UN Gen-
eral Assembly Political Declaration on
Non-Communicable Diseases, which com-
mitted countries to ensure the availability
of palliative care, the WHA was seen as an
important forum for sharing experiences in
implementing palliative care and providing
guidance to countries as they implement
this commitment.
Dr. Cecil Wilson, the WMA President-
Elect, talked about the critical role of the
medical community in ensuring the avail-
ability of palliative care. Denouncing the
negative economic impact and human suf-
fering of inadequate pain treatment, Dr.
Wilson called for equal access to pain treat-
ment without discrimination and the in-
clusion of end-of-life care issues in under-
graduate and postgraduate medical training.
As well, Dr. Wilson reminded the partici-
pants that the duty of physicians was to heal
where possible, to relieve suffering and to
protect the best interests of their patients.
Other interventions included Hon. Dr. Beth
Mugo, Minister of Public Health and Sani-
tation of the Republic of Kenya; Hon. Dr.
Christine Ondoa, Minister of Health of the
Republic of Uganda; as well as leading ex-
perts on palliative care. Ambassador Jimmy
Kolker, Principal Deputy Director of the
Global Health Office, the United States
Department of Health and Human Ser-
vices, moderated the event.
It is hoped that this event will encourage
sustained attention from the World Health
Assembly to the situation of millions of
people with incurable illnesses who cur-
rently do not have access to palliative care.
WMA Resolution on the Access to Ad-
equate Pain Treatment, Montevideo
October 2011 : https://www.wma.net/
en/30publications/10policies/p2/index.html
Governments Must Do More to
Invest in end-of-life Care
Governments and research institutions must be encouraged by
national medical associations to invest additional resources in
developing treatments to improve end-of-life care, according to
Dr. Cecil Wilson, President elect of the World Medical Associa-
tion.
Speaking in Geneva today (Wednesday), he said that millions of
people around the world with cancer and other diseases suffered
moderate to severe pain without access to adequate treatment.
‘A consequence of inadequate pain treatment is a negative eco-
nomic impact and human suffering, ‘ he said. ‘In most cases pain
can be stopped or relieved with inexpensive and relatively simple
treatment interventions.’
Dr. Wilson, who was speaking at a side meeting of the World
Health Assembly, added ‘All people should have the right to ac-
cess to pain treatment without discrimination….Governments
must ensure the adequate availability of controlled medicines,and
governmental drug control agencies’.
He said that the appropriate use of morphine, new analgesics and
other measures could relieve pain and other distressing symptoms
in the majority of cases. Health authorities must make necessary
medications accessible and available to physicians and their pa-
tients.
Yet in many parts of the world palliative and life-sustaining mea-
sures required technologies and/or financial resources that were
simply not available. He also said that as far as pain and symptom
management were concerned it was essential to identify patients
approaching the end-of-life as early as possible
The increasing number of people who required palliative care and
the increased availability of effective treatment options meant
that end-of-life care issues should be an important part of under-
graduate and postgraduate medical training. The duty of physi-
cians was to heal where possible,to relieve suffering and to protect
the best interests of their patients.
Social Determinants of
Health: Building capacity to
achieve health equity
In October 2011, the World Health Or-
ganization invited the member states and
civil society partners to the World Con-
ference on Social Determinants of Health
(SDH) in Rio de Janeiro. The purpose was
to build support to implement policies and
strategies to reduce health inequities, by
addressing these social determinants. The
Rio Declaration adopted by the Confer-
ence translated this call into a global polit-
ical commitment for the implementation
of a SDH approach to reducing health in-
equities and achieving other global health
priorities. Further reorienting the health
sector towards reducing health inequities
was one of the identified priority action
areas.
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89
As a follow-up, the UK Government, in
partnership with the WMA and the Inter-
national Federation of Medical Students
Associations (IFMSA), with the support
of WHO, held a side-event on May 24th
to explore concrete mechanisms for the
health sector to engage in achieving health
equity.
This side event was moderated by Kathryn
Tyson, Director of International Health
and Public Health Delivery, Department of
Health, United Kingdom. It opened with
a film produced by WHO, Department of
Ethics, Equity, Trade and Human Rights,
following the World Conference on Social
Determinants of Health.
Professor Sir Michael Marmot, Chair of
the Socio-Medical Affairs Committee of
the WMA and former Chair of the WHO
Commission on Social Determinants of
Health, underlined the role of doctors and
national medical associations to advance
health equity through Social Determinants
of Health. Christopher Pleyer, President
of IFMSA, talked about education and
training as a pre-requisite to reduce and
prevent health inequities. Finally, Dr. Rüdi-
ger Krech, Director of the Department of
Ethics, Equity,Trade and Human Rights at
WHO, emphasized the indispensable role
of the UN in promoting a global agenda for
health equity.
In parallel, the Rio Declaration was official-
ly adopted by the World Health Assembly.
The presentations of the side event are
available on WHO website:
http://www.who.int/social_determinants/ad-
vocacy/en/index.html
Outcome of the World Conference
on Social Determinants of Health
The Sixty-fifth World Health Assembly, Having considered
the report on the World Conference on Social Determinants of
Health (Rio de Janeiro, Brazil, 19–21 October 2011);1
Reiterating the determination to take action on social determi-
nants of health as collectively agreed by the World Health As-
sembly and reflected in resolution WHA62.14 on reducing
health inequities through action on the social determinants of
health, which notes the three overarching recommendations of
the Commission on Social Determinants of Health: to improve
daily living conditions; to tackle the inequitable distribution of
power, money and resources; and to measure and understand the
problem and assess the impact of action;
Recognizing the need to do more to accelerate progress in ad-
dressing the unequal distribution of health resources as well as
conditions damaging to health at all levels;
Recognizing also the need to safeguard the health of the popula-
tions regardless of global economic downturns;
Further acknowledging that health equity is a shared goal and
responsibility and requires the engagement of all sectors of gov-
ernment, all segments of society, and all members of the interna-
tional community, in “all-for-equity” and “health-for-all” global
actions;
1 Document A65/16.
Recognizing the benefits of universal health coverage in enhanc-
ing health equity and reducing impoverishment;
Reaffirming the political will to make health equity a national,
regional and global goal and to address current challenges – such
as eradicating hunger and poverty; ensuring food and nutritional
security, access to affordable, safe, efficacious and quality medi-
cines as well as to safe drinking-water and sanitation, employ-
ment and decent work and social protection; protecting envi-
ronments and delivering equitable economic growth through
resolute action on social determinants of health across all sectors
and at all levels;
Welcoming the discussions and results of the World Conference
on Social Determinants of Health (Rio de Janeiro, Brazil, 19–21
October 2011),
1. ENDORSES the Rio Political Declaration on Social Deter-
minants of Health adopted by the World Conference on Social
Determinants of Health,1 including as a key input to the work of
Member States and WHO;
2. URGES Member States:
(1) to implement the pledges made in the Rio Political
Declaration on Social Determinants of Health with
regard to (i) better governance for health and devel-
opment, (ii) promoting participation in policy-mak-
ing and implementation, (iii) further reorienting the
health sector towards reducing health inequities, (iv)
strengthening global governance and collaboration,
and (v) monitoring progress and increasing account-
ability;
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WMA news
WMA Luncheon on Women’s,
Maternal and Girls’ Health
Every year during the World Health As-
sembly, the WMA organises a reception for
Ministers of Health and Heads of Delega-
tions of the Assembly.This year the Honor-
able Kathleen Sebelius, the U.S. Secretary
of Health and Human Services, was the
key note speaker on the topic of Women’s,
Maternal and Girls’ Health – Their Futures in
Our Hands (see p. 95).
Secretary Sebelius emphasised the need for
universal access to care in general, and the
benefit in investing in health care. Further-
more, she highlighted that while women
play a key role as health keepers for fami-
lies, many health care systems failed to con-
sider the unique health needs of women.
Dr.  Mukesh Heikerwal accentuated the
vision and engagement of the WMA in
emphasizing the special situation of women
in health care. The reception was very well
attended with more than 200 participants.
WHA’s Results related to the
WMA Advocacy Priorities
Non-communicable diseases
The Political Declaration of the UN High
Level Meeting on NCDs in 2011 urged
WHO and the member states to develop a
global monitoring framework with targets
and indicators on NCD before the end of
2012. At the 65th
WHA a discussion on
(2) to develop and support policies, strategies, programmes
and action plans that address social determinants of
health,with clearly defined goals,activities and account-
ability mechanisms and with resources for their imple-
mentation;
(3) to support the further development of the “health-in-
all-policies” approach as a way to promote health eq-
uity;
(4) to build capacities among policy-makers, managers, and
programme workers in health and other sectors to facili-
tate work on social determinants of health;
(5) to give due consideration to social determinants of
health as part of the deliberations on sustainable de-
velopment, in particular in the Rio+20 United Nations
Conference on Sustainable Development and deliber-
ations in other United Nations forums with relevance
to health;
3. CALLS UPON the international community to support the
implementation of the pledges made in the Rio Political Dec-
laration on Social Determinants of Health for action on social
determinants of health, including through:
(1) supporting the leading role of WHO in global health
governance and promoting alignment of policies, plans
and activities on social determinants of health with
those of its partner organizations in the United Nations
system, development banks and other key international
organizations, including in joint advocacy, and in facili-
tating access to the provision of financial and technical
support to countries and regions, in particular develop-
ing countries;
(2) strengthening international cooperation, with a view to
promoting health equity in all countries, through facili-
tating transfer on mutually agreed terms of expertise,
technologies and scientific data in the field of social de-
terminants of health, as well as exchanging good prac-
tices for managing intersectoral policy development;
(3) facilitating access to financial resources;
4. URGES those developed countries that have pledged to
achieve the target of 0.7% of gross national product for official
development assistance by 2015, and those developed countries
that have not yet done so, to make additional concrete efforts to
fulfil their commitments in this regard, and also urges developing
countries to build on progress achieved in ensuring that official
development assistance is used effectively to help to achieve de-
velopment goals and targets;
5. REQUESTS the Director-General:
(1) to duly consider social determinants of health in the
assessment of global needs for health, including in the
WHO reform process and WHO’s future work;
(2) to provide support to Member States in implementing
the Rio Political Declaration on Social Determinants of
Health through approaches such as “health-in-all poli-
cies” in order to address social determinants of health;
(3) to work closely with other organizations in the United
Nations system on advocacy, research, capacity-building
and direct technical support to Member States for work
on social determinants of health;
(4) to continue to convey and advocate the importance of
integrating social determinants of health perspectives
into forthcoming United Nations and other high-level
meetings related to health and/or social development;
(5) to report to the Sixty-sixth and Sixty-eighth World
Health Assemblies, through the Executive Board, on
progress in implementing this resolution and the Rio
Political Declaration on Social Determinants of Health.
wmj 3 2012.indd 90 7/18/12 9:47 AM
91
WMA news
this framework took place with limited
opportunities for the member states to
reach agreement. Thanks to the initiative
of several countries, finally the 193 mem-
ber states adopted the resolution to reduce
preventable deaths from NCDs by 25% by
the year 2025, with the remaining targets
to be agreed at a formal Member State
consultation before the end of October
2012.
WHO Reform
At the 65th
WHA member states endorsed
reforms to the management and priority
setting processes at WHO.
It was agreed that WHO should become
more transparent, result-focused, account-
able and effective. As the five priorities for
future WHO activity, the member states
defined: communicable diseases; non-
communicable diseases; health through
the life-course; health systems; and pre-
paredness, surveillance and response. Fur-
thermore, the delegates emphasized that
WHO should increase its focus on  the
social, economic and environmental deter-
minants of health.
One critical point of the reform process
was not discussed— how to make WHO’s
future governance more inclusive and par-
ticipatory by involving external stakeholders
such as philanthropic bodies and industry.
This topic is too controversial for many
countries. It  raises many questions, start-
ing with the question of mandate and not
ending with the fact that some foundations
contribute more to global health than many
countries do.
Another core reform issue that wasn’t dis-
cussed was how WHO finances its opera-
tions. The organization is suffering a finan-
cial crisis due to several factors, including
reduced government funding. Last year, it
slashed its annual budget of $US4.5 billion
by nearly a quarter.
A New Role for WHO in Complex
Humanitarian Emergencies 
One of the items on the agenda of the last
World Health Assembly related to the role
of WHO as the health cluster lead in meet-
ing the growing demands of health in hu-
manitarian emergencies. A draft resolution
was submitted to the Assembly for adop-
tion.
With the resolution, the Member States
called on WHO  Director-General: “…to
provide leadership at the global level in de-
veloping methods for systematic collection and
dissemination of data on attacks on health
facilities,  health workers, health transports,
and patients in complex humanitarian emer-
gencies, in coordination with other relevant
United Nations bodies, other relevant actors,
and intergovernmental and nongovernmen-
tal organizations, avoiding duplication of ef-
forts”.
From the start, the initiative had been
actively supported by the Safeguarding
Health Coalition1
, in which the WMA is
an observer. The proposal had been first
submitted to the Executive Board in Janu-
ary. The Coalition and other organisations
concerned had sent an open letter to the
attention of Dr. Margaret Chan and made
an oral statement in support of the initia-
tive.
Similarly, last May at the World Health
Assembly, numerous organizations joined
1 The Safeguarding Health in Conflict coalition
promotes respect for international humanitarian
and human rights laws that relate to the safety
and security of health facilities, workers, am-
bulances and patients during periods of armed
conflict or civil violence. The founding members
include Intra Health International, Center for
Public Health and Human Rights at the Johns
Hopkins Bloomberg School of Public Health,
Doctors for Human Rights, International
Council of Nurses, International Health Pro-
tection Initiative, Karen Human Rights Group,
Medact, Merlin – UK and Physicians for Hu-
man Rights.
the coalition in a statement encourag-
ing the WHO member states to adopt
the resolution so that the work of devel-
oping methods to collect data and report
on attacks can commence. The statement
was made on behalf of the World Health
Professional Alliance, and was supported
by the American Public Health Associa-
tion, CARE, the Center for Public Health
and Human Rights at the John Hopkins
Bloomberg School of Public Health, Doc-
tors for Human Rights, International
Health Protection Initiative, Interna-
tional Federation of Health and Human
Rights Organisations, International Medi-
cal Corps, International Rehabilitation
Council for Torture Victims, International
Rescue Committee, Intra Health Interna-
tional, Management Sciences for Health,
Medact, Merlin, Physicians for Human
Rights, Women’s Refugee Commission
and World Federation of Public Health
Associations.
Going forward, the coalition will advocate
for effective implementation of the World
Health Assembly resolution.
The resolutions adopted by the World
Health Assembly can be downloaded from
WHO’s following website:
http://apps.who.int/gb/e/e_wha65.html
Ms Clarisse Delorme,
WMA Advocacy Advisor
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WMA news
On behalf of the World Health Professional
Alliance, which includes:
World Medical Association
International Council of Nurses
International Pharmaceutical Federation
World Confederation for Physical Therapy
World Dental Federation.
These organizations speak on behalf of mil-
lions of health workers worldwide. This
statement is also supported by the following
organizations:
American Public Health Association
CARE
Center for Public Health and Human
Rights of the John Hopkins Bloomberg
School of Public Health
Doctors for Human Rights
Human Rights Watch
International Health Protection Initiative
International Federation of Health and
Human Rights Organisations
International Medical Corps
International Rehabilitation Council for
Torture Victims
International Rescue Committee
IntraHealth International
Management Sciences for Health
Medact
Merlin
Physicians for Human Rights
Women’s Refugee Commission
World Federation of Public Health Asso-
ciations
Health care workers are on the frontline
during complex humanitarian emergen-
cies. Health providers and those they serve
deserve protection. Indeed, the strength
and performance of the health system re-
quire it. Yet, in crises where health needs
are most urgent, health care workers are at
greatest risk of assault, arrest, obstruction of
their duties, kidnapping and death. Health
facilities and ambulances are also at risk of
attack. The health community must mobi-
lize to assure adherence to the principle of
impartiality of health care in humanitarian
emergencies.
At the 64th
Assembly, and again at the Ex-
ecutive Board, WHO’s Director General,
Dr. Margaret Chan, spoke eloquently of the
need for WHO to respond.
The foundation of protection and preven-
tion is information. WHO has a unique
role to play in collecting and disseminating
data on attacks. For that reason, we support
resolution EB130.R14 (see below), in par-
ticular, paragraph 8, calling on the Director
General:
“…to provide leadership at the global level in
developing methods for systematic collection
and dissemination of data on attacks on health
facilities, health workers, health transports,
and patients in complex humanitarian emer-
gencies…”
We call on the WHO Member States to
adopt the resolution. This will be a strong
affirmation of the Member States commit-
ment to protect health workers, services and
patients.
Statement of World Health Professional
Alliance adressed to World Health Assembly
WHO’s response, and role as the health
cluster lead, in meeting the growing demands
of health in humanitarian emergencies
The Executive Board,
Having considered the report on WHO’s response, and role as
the health cluster lead,in meeting the growing demands of health
in humanitarian emergencies,1
RECOMMENDS to the Sixty-fifth World Health Assembly
the adoption of the following resolution:
The Sixty-fifth World Health Assembly,
1 Document EB130/24.
Having considered the report on WHO’s response, and role as
the health cluster lead,in meeting the growing demands of health
in humanitarian emergencies;
Recognizing that humanitarian emergencies result in avoidable
loss of life and human suffering, weaken the ability of health sys-
tems to deliver essential life-saving health services, produce set-
backs for health development and hinder the achievement of the
Millennium Development Goals;
Reaffirming the principles of neutrality, humanity, impartiality and
independence in the provision of humanitarian assistance, and reaf-
firming the need for all actors engaged in the provision of humani-
tarian assistance in situations of complex humanitarian emergencies
and natural disasters to promote and fully respect these principles;
Recalling Article 2(d) of the Constitution of the World Health
Organization on the mandate of WHO in emergencies,and reso-
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lutions WHA58.1 on health action in relation to crises and disas-
ters and WHA59.22 on emergency preparedness and response;1
Recalling United Nations General Assembly resolution 46/182
on the strengthening of the coordination of humanitarian emer-
gency assistance of the United Nations and the guiding principles
thereof, confirming the central and unique role for the United
Nations in providing leadership and coordinating the efforts of
the international community to support countries affected by hu-
manitarian emergencies, establishing, inter alia, the Inter-Agency
Standing Committee, chaired by the Emergency Relief Coordi-
nator, supported by the United Nations Office for the Coordina-
tion of Humanitarian Affairs;
Takin note of the humanitarian response review in 2005, led by
the Emergency Relief Coordinator and by the Principals of the
Inter-Agency Standing Committee aiming at improving urgency,
timeliness, accountability, leadership and surge capacity, and rec-
ommending the strengthening of humanitarian leadership, the
improvement of humanitarian financing mechanisms and the
introduction of the clusters as a means of sectoral coordination;
Taking note of the Inter-Agency Standing Committee Princi-
pals’ Reform Agenda 2011–2012 to improve the international
humanitarian response by strengthening leadership, coordination,
accountability, building global capacity for preparedness and in-
creasing advocacy and communications;
Recognizing United Nations General Assembly Resolution
60/124, and taking note of WHO’s subsequent commitment to
supporting the Inter-Agency Standing Committee transforma-
tive humanitarian agenda and contributing to the implementa-
tion of the Principals’ priority actions designed to strengthen in-
ternational humanitarian response to affected populations;
Reaffirming that it is the national authority that has the primary
responsibility to take care of victims of natural disasters and other
emergencies occurring on its territory, and that the affected State
has the primary role in the initiation, organization, coordination,
and implementation of humanitarian assistance within its territory;
Taking note of the 2011 Inter-Agency Standing Committee
guidance note on working with national authorities, that clusters
should support and/or complement existing nationalcoordina-
tion mechanisms for response and preparedness and where ap-
1 Resolutions WHA34.26, WHA46.6, WHA48.2, WHA58.1, WHA59.22
and WHA64.10 reiterate WHO’s role in emergencies.
propriate,government,or other appropriate national counterparts
should be actively encouraged to co-chair cluster meetings with
the Cluster Lead Agency;
Recalling resolution WHA64.10 on strengthening national
health emergency and disaster management capacities and resil-
ience of health systems, which urges Member States, inter alia, to
strengthen all-hazards health emergency and disaster risk-man-
agement programmes;
Reaffirming also that countries are responsible for ensuring the
protection of the health, safety and welfare of their people and
for ensuring the resilience and self-reliance of the health system,
which is critical for minimizing health hazards and vulnerabilities
and delivering effective response and recovery in emergencies and
disasters;
Recognizing the comparative advantage of WHO through its
presence in,and its relationship with Member States,and through
its capacity to provide independent expertise from a wide range of
health-related disciplines, its history of providing the evidence-
based advice necessary for prioritizing effective health interven-
tions,and that the Organization is in a unique position to support
health ministries and partners as the global health cluster lead
agency in the coordination of preparing for, responding to and
recovering from humanitarian emergencies;
Recalling WHO’s reform agenda and taking note of the report in
2011 by the Director-General on Reforms for a healthy future,1
which led to the creation of a new WHO cluster, Polio, Emer-
gencies and Country Collaboration, aimed at supporting regional
and country offices to improve outcomes and increase WHO’s
effectiveness at the country level, by redefining its commitment
to emergency work and placing the cluster on a more sustainable
budgetary footing;
Welcoming the reform in 2011 transforming the WHO cluster
Health Action in Crisis into the Emergency Risk Management
and Humanitarian Response department as a means of imple-
menting these reforms, ensuring that the Organization becomes
faster, more effective and more predictable in delivering higher
quality response in health, and that the Organization holds itself
accountable for its performance;
Recalling resolutions WHA46.39 on health and medical services
in times of armed conflict; WHA55.13 on protection of medical
missions during armed conflict; and the United Nations General
Assembly resolution 65/132 on safety and security of humanitar-
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ian personnel and protection of United Nations personnel, con-
siders that there is a need of systematic data collection on attacks
or lack of respect for patients and/or health workers, facilities and
transports in complex humanitarian emergencies,
1. CALLS ON Member States and donors:
(1) to allocate resources for the health sector activities dur-
ing humanitarian emergencies through United Nations
Consolidated Appeal Process and Flash Appeals, and
for strengthening WHO’s institutional capacity to exer-
cise its role as the Global Health Cluster Lead Agency
and to assume health cluster lead in the field;
(2) to ensure that humanitarian activities are carried out in
consultation with the country concerned for an efficient
response to the humanitarian needs, and to encourage
all humanitarian partners, including nongovernmental
organizations, to participate actively in the health clus-
ter coordination;
(3) to strengthen the national level risk management,health
emergency preparedness and contingency planning pro-
cesses and disaster management units in the health min-
istry, as outlined in resolution WHA64.10, and, in this
context, as part of the national preparedness planning,
with the Office for the Coordination of Humanitarian
Affairs where appropriate, identify in advance the best
way to ensure that the coordination between the inter-
national humanitarian partners and existing national
coordination mechanisms will take place in a comple-
mentary manner in order to guarantee an effective and
well-coordinated humanitarian response;
(4) to build the capacity of national authorities at all levels
in managing the recovery process in synergy with the
longer-term health system strengthening and reform
strategies, as appropriate, in collaboration with WHO
and the health cluster;
2. CALLS ON the Director-General:
(1) to have in place the necessary WHO policies,guidelines,
adequate management structures and processes required
for effective and successful humanitarian action at the
country level, as well as the organizational capacity and
resources to enable itself to discharge its function as the
Global Health Cluster Lead Agency,in accordance with
agreements made by the Inter-Agency Standing Com-
mittee Principals; and assume a role as Health Cluster
Lead Agency in the field;
(2) to strengthen WHO’s surge capacity, including develop-
ing standby arrangements with Global Health Cluster
partners,to ensure that WHO has qualified humanitarian
personnel to be mobilized at short notice when required;
(3) to ensure that in humanitarian crises WHO provides
Member States and humanitarian partners with pre-
dictable support by coordinating rapid assessment and
analysis of humanitarian needs, including as a part of
the coordinated Inter-Agency Standing Committee
response, building an evidence-based strategy and ac-
tion plan, monitoring the health situation and health
sector response, identifying gaps, mobilizing resources
and performing the necessary advocacy for humanitar-
ian health action;
(4) to define the core commitments,core functions and per-
formance standards of the Organization in humanitar-
ian emergencies, including its role as the Global Health
Cluster Lead Agency and as Health Cluster Lead
Agency in the field, and to ensure full engagement of
country, regional and global levels of the Organiza-
tion to their implementation according to established
benchmarks, keeping in mind the ongoing work on the
Inter-Agency Standing Committee transformative hu-
manitarian agenda;
(5) to provide a faster, more effective and more predictable
humanitarian response by operationalizing the Emer-
gency Response Framework, with the performance
benchmarks in line with the humanitarian reform, and
to ensure the accountability of its performance against
those standards;
(6) to establish necessary mechanisms to mobilize WHO’s
technical expertise across all disciplines and levels, for
the provision of necessary guidance and support to
Member States, as well as partners of the health cluster
in humanitarian crises;
(7) to support Member States and partners in the transition
to recovery, aligning the recovery planning, including
emergency risk management as well as disaster riskre-
duction and preparedness, with the national develop-
ment policies and ongoing health sector reforms, and/
or using the opportunities of post-disaster and/or post-
conflict recovery planning;
(8) to provide leadership at the global level in developing
methods for systematic collection and dissemination
of data on attacks on health facilities, health workers,
health transports, and patients in complex humanitarian
emergencies, in coordination with other relevant United
Nations bodies,the International Committee of the Red
Cross, and intergovernmental and nongovernmental or-
ganizations, avoiding duplication of efforts;
(9) to provide a report to the Sixty-seventh World Health
Assembly, through the Executive Board, and thereafter
every two years, on progress made in the implementa-
tion of this resolution.
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Every country in the world recognizes the
huge benefits of investing in health. Healthy
children are better students. Healthy adults
are more productive workers. Healthy fami-
lies can make greater contributions to their
communities. And when we live longer,
healthier lives, we have more time to do our
jobs, play with our children, and watch our
grandchildren grow up.
And yet, in too many countries, including
my own, we fall short when it comes to the
health of women.
One reason for this is that women are more
likely to depend on a male partner to access
health care.And they’re often less likely to have
the resources they need to get care on their own.
Another obstacle is health systems that too
often fail to consider the unique health needs
of women.
In the United States, it wasn’t until the 1980s
thatwomenwereevenincludedinclinicaltrials.
As a result, we had no idea what treatments or
medicines were particularly effective for wom-
en. We didn’t know what might happen when
a drug that had been tested on a 180-pound
man, was given to a 110-pound woman.
Despite the progress we’ve made since then,
disparities persist to this day. Women in
America often pay more for health insur-
ance,just because they’re women.And to add
insult to injury, these plans often don’t even
cover the basic care they need. In my coun-
try, just one out of 8 plans for those who buy
their own insurance cover maternity care – as
if getting pregnant were some very rare con-
dition.
The result is that far too many women, who
often serve as the health care gatekeepers for
their families, go without care themselves.
Of course, we see the same thing around the
world. Every two minutes, a woman dies
from complications related to pregnancy or
childbirth. The risks are even greater if you
live in the developing world – where three
out of every four women needing care for
complications from pregnancy do not re-
ceive it.
Even in places where care is available, the
demand is so great that it often stretches re-
sources to their limits.
Last year I visited the maternity ward of the
MnaziMmoja Hospital in Zanzibar, Tanza-
nia. There were so few beds and nurses that
some women had to share beds in the post-
natal room. And others were discharged just
hours after giving birth.The hospital was do-
ing heroic work. And the women who were
able to deliver there, were among the lucky
ones. Yet, so much need still went unmet.
We know that when we under-invest in
women’s health, whole families pay the price.
When a mother dies the chance of her child
dying within 12 months, increases seven fold.
So under President Obama, we’re putting
a new focus on women’s health – at home
and abroad. In the United States, the key to
those efforts is the Affordable Care Act, our
most important women’s health legislation in
years.
The health care law starts by ending dis-
crimination against pre-existing conditions.
Insurers are already prohibited from denying
coverage to children because they have asth-
ma or diabetes. And beginning in 2014, all
women will be protected from being locked
out of the market because they’re a breast
cancer survivor,or gave birth by c-section,or
were a victim of domestic violence.
In the past  – because they were worried
about losing their health coverage  – too
many women didn’t have the freedom to
make important decisions like changing jobs,
starting a new company, even leaving a bad
marriage. Now that women know they can’t
be turned away because of their health sta-
tus, we’re taking those choices back from the
insurance companies and returning them to
the women where they belong.
Next, the law prohibits insurers from charg-
ing women more just because they’re women.
To put it another way: this means that being a
woman is no longer a pre-existing condition.
And the law helps women get the preventive
care they need to stay healthy,from mammo-
grams to contraception to an annual check-up
where you get to sit down and talk with your
doctor, as a basic part of any insurance plan.
These improvements are happening across
the lifespan. Young girls now have access to
the vaccinations they need stay healthy with-
out their parents worrying about additional
costs. And seniors are getting better care to
help manage their chronic conditions.
Speech given by the US Secretary of Health and
Human Services Kathleen Sebelius at the WMA
Luncheon in Geneva, Switzerland, May 22, 2012
Kathleen Sebelius
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Put all these changes together and they rep-
resent the most important and comprehen-
sive American law affecting women’s health
in decades.
Now,we’ve also made women and girls a pri-
ority for our Global Health Initiative – a new
approach to coordinating the US govern-
ment’s global health work around the world.
With a focus on collaboration, and innova-
tion, this initiative – launched by President
Obama – allows us to maximize America’s
own strengths and support other nations as
they work to improve their people’s health.
We are integrating our programs across the
U.S. Government so they can work together
more effectively. And we are looking for new
and better ways to work with international
partners, multilateral organizations, NGOs
and foundations to meet our common goals.
Through it all, we’ve made women’s health a
key priority – and that includes family plan-
ning. We know that access to contraception
allows women to space their pregnancies and
have children during their healthiest years.
And delaying pregnancy beyond adolescence
can reduce infant mortality and dramatically
improve a child’s long-term health. Provid-
ing a woman the tools to plan how many
children she has, and when she has them, is
essential to her health and her family’s health.
Now, just as important is making sure that,
when women are pregnant, they get the care
and support they need to have a safe and
healthy pregnancy and delivery.
The Global Health Initiative’s ‘Saving Moth-
ers Giving Life’ campaign is a great example
of these efforts. We know that for mothers
and children at risk, the first 24 hours post-
partum are the most dangerous.That’s when
two out of every three maternal deaths, and
almost half of newborn deaths occur.
So we’re working together with groups like
Merck for Mothers, the American College of
Obstetricians and Gynecologists,Every Moth-
er Counts,and the Government of Norway,to
make sure mothers get the essential care they
need during labor, delivery, and those crucial
first 24 hours, so they can survive and thrive.
We’re focusing on countries with the po-
litical will to bring about change. And with
more than $90 million in generous support
from our non-governmental partners, we
have begun selecting pilot sites in the regions
of Uganda and Zambia where women are
facing some of the highest maternal mortal-
ity ratios in the world.
‘Saving Mothers Giving Life’ is just one ex-
ample.But it illustrates an approach that runs
throughout the Global Health Initiative. It
starts by identifying the most urgent health
challenges affecting some of the world’s
poorest nations. Next, we identify the best
people in the world with the specific exper-
tise to solve these problems. Then we bring
them together, and make sure they have the
tools, resources and flexibility to take action.
For too long,too many women and girls have
had their lives marred by illness or disability,
just because they didn’t have access to health
services. When we deprive women of the
care and support they need to stay healthy
or get well, we’re also robbing them of hope
for the future.
That’s the moral argument for making wom-
en’s health a priority. But there’s a strategic
argument too.
Women are gateways to their communities.
Around the world, women are primarily re-
sponsible for managing water, nutrition, and
household resources. They’re responsible for
accessing health services for their families.
Many of them are closely involved in actually
providing health care for those around them.
So by improving the health of women, we
can improve the health of communities too.
Consider the story of Jemima, a woman liv-
ing with HIV in rural western Kenya. At
one point, the effects of her HIV got so bad
she had wasted to 77 pounds. That’s when a
volunteer brought Jemima, her husband, and
her sick grandchild to a U.S. government-
supported health clinic.
They went home with what is called a “Basic
Care Package” – a bundle of low-cost health
interventions, developed by public health
researchers from our CDC Global AIDS
Program to prevent the most debilitating,
opportunistic infections among people living
with HIV.
Jemima bounced back.She regained a healthy
weight. And today she is a health leader in
her community. She founded a group that
offers emotional support and small loans to
families touched by HIV. She sells health
products to help support the eight sick and
orphaned children she has adopted. And she
has referred more than 100 HIV-infected
men, women, and children to receive care at
the same facility where she got help.
In Jemima, our investment saved not only a
life,but a mother,a community leader,an en-
trepreneur and a health advocate.
What we know from our work with part-
ners around the world is that improving the
health of women and girls, unleashes pow-
erful new opportunities – not just for them
or their families – but for their communities
and countries.
If we want to improve education, we should
be giving our young women the healthy start
they need to succeed in school. If we want to
boost productivity, we can make sure women
have access to health care, including family
planning and other reproductive health ser-
vices.If we want to build stronger communi-
ties, let’s enable women to teach their neigh-
bors how to prevent disease and stay healthy.
Around the globe, our nations face many
challenges. And investing in women’s health
is one of the best ways we can address them
together.
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Thank you for this profound honour.As you
know, the summer Olympics start soon in
London.
I mention this because my journey to this
stage has been – for me – something of an
Olympic race itself.
I love watching athletes compete. And at
the Olympic level, they inspire a pride of
accomplishment in each of us, and each of
us feels part of their success.
When an American athlete wins, we cheer.
When they stand on the podium with a
medal on their chest,as the national anthem
plays, we share their tears of joy.
Now some of you may know that I’ve run
a race or two in my time, but I can tell you,
running 13 marathons or completing 13
triathlons is something completely differ-
ent than becoming the 167th
president of
the AMA.
This was much harder.
The truth is, I’ve learned we all need each
other’s support to make great things hap-
pen.
Tonight, there are many people to thank –
those who supported me and encouraged
me to keep on going. You are the ones who
didn’t think I was completely crazy to keep
on going race after race…well, most of you.
I’m reminded of what Olympic marathoner
Don Kardong said: “No doubt a brain and
some shoes are essential for success, al-
though if it comes down to a choice, pick
the shoes. More people finish marathons
with no brains than with no shoes.”
Rest assured I’ve laced up my sneakers for
the start of my run as AMA president.
And I look forward to making great strides
together with you, who represent the best of
our profession.
Just like the Olympic athletes, when one of
us wins, we all win. It’s all of us on that po-
dium, wearing the medal.
Now, my path into this profession may have
been different than that chosen by many of
you.
It turns out that my high school, here in
Chicago, was named for Nicholas Senn,
who happened to be the AMA’s 49th
presi-
dent.
Say what you will about foreshadowing or
fate, but given my skill set at the time, it was
probably for the best that I didn’t go some-
place named for another prominent Chica-
goan – say, Michael Jordan Prep, or Mike
Ditka Magnet School.
Could’ve been a disaster.
For me, medicine and then psychiatry be-
came a calling. When I was in college, my
brother died in an accident.
That tragedy fueled my desire to do some-
thing that made a difference to help people.
To become a physician.
I wanted to help repair shattered minds –
to guide people through the minefields of
depression, or personality disorders  – or
crushing changes in circumstance.
I wanted to help someone who was trou-
bled – lead a fulfilling, normal and healthy
life.
I wanted to pull a profoundly depressed
person back from the ledge of a potential
suicide, and watch him grow from a trou-
bled adolescent – to a productive adult.
In 40 years as a psychiatrist, I’ve been for-
tunate to help many people. For me, that’s
what it’s all about.
For our specialty, taking a person whose
mental health is in jeopardy – and helping
them toward recovery  – is like watching
someone walk again, or curing cancer.
When something is wrong in the brain or
the mind, it affects the whole person. The
challenge is in how we determine what’s re-
ally going on – whether it’s psychological or
neurochemical or both.
It’s no coincidence the words, psychiatrist,
and psychic, are in some way connected.We
are trained to listen both to what is said out
loud – and what isn’t said at all.
“To Run and Not Grow Weary”
Jeremy A. Lazarus, MD, President,
American Medical Association
Inaugural Address, American Medical Association,
2012 Annual Meeting,
June 19, 2012, Chicago, Illinois
Jeremy A. Lazarus
UNITED STATES OF AMERICA Regional and NMA news
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Listen to all sides – and then help people
find their own path.
By listening – and working to find common
ground, I want to bring greater unity to our
AMA.
And while we can be thoughtful and delib-
erative and not act in haste, we recognize
also that we stand at a healthcare crossroad.
Our patients cannot afford the luxury of
indefinite time for us to simply talk about
the issues.
In the 21st
century,we can advance and grow
only by incorporating the insights of physi-
cians from all specialties, cultures, practice
settings, states and regions, and ideologies.
There’s a real opportunity, regardless of the
political paralysis in Washington, for us to
unify to promote the practice of medicine –
to AMA members and non-member physi-
cians alike – around the country.
But any success will materialize only if we
are unified on the issues that matter most to
us, and our patients.
Ask a random physician about what the
AMA does and how it represent physicians
. . . chances are you would get a variety of
responses.
So we’re working to harness the legacy of
the AMA – what was – in a way that helps
us all define what the future of the AMA
can be.
You’ve heard a lot about the “AMA equa-
tion” this week.
But it bears repeating: The AMA is the sum
of many parts: Our House of Delegates,
with more than 185 physician groups rep-
resented.
Membership – in which physicians engage
each other – and learn from each other.
The tools and expertise we provide to help
physicians manage practices.
Our pacesetting work in ethics – our efforts
to end disparities  – and our crown jewel
publication JAMA and others – that make
us a leader in research and education.
And advocacy – giving voice to physicians
in courthouses, statehouses, the media and
in Washington, DC.
We are proof that those with opposing views
can see the bigger picture and do what’s best
for physicians and patients. That’s how we
all win.
One recent example is the 200 million dol-
lars returned to physicians because of AMA
leadership in the United Health settlement.
Or the needed delays the AMA won in
implementing costly and confusing ICD-
10 measures.
In these ways, the AMA touches the vast
majority of physicians in this country  –
members and non-members  – in tangible
ways.
And the AMA is well-positioned to influ-
ence an uncertain future.
Nonetheless, to improve health outcomes,
accelerate change in medical education and
shape health care delivery and payment sys-
tems so they work better for physicians – are
not modest ambitions.
To meet these challenges we sometimes go
over them. Or go under them, or around
them. Sometimes we ask for help – ask for
a hand up to clear the obstacle. That’s what
achievers do.
I’ve been with the AMA and in the medical
profession long enough to understand and
respect the differences we have.
But I’ve been witness to our mutual inter-
ests. And how powerful we are when we
work together to fulfil them. I ask you to
help me explore that aspect – and expand
it.
This year, the AMA celebrates its 165th
birthday. Since our founding, we’ve been a
player on the national stage.
But great organizations with a long history
do not need to live in the past. Respecting
tradition does not mean we can’t create  –
and pursue – our future.
The years ahead are a new race to be run –
and to finish we’ll need more than just tal-
ented physicians.
The AMA has shown both courage and a
willingness to face what’s ahead – to shape
it – confront it – and when sensible, to con-
form to it.
To succeed is to evolve. It reminds me of
when Woody Allen compared a relationship
to a shark – that it has to move forward or
it dies.
It’s not enough for the AMA merely to act,
but to keep at it. To refuse to quit. To face
challenges and rise above them.
One of the most important lessons I have
learned in medicine, in my pursuits – in my
life – is the value of persistence.
As I mentioned, competing in marathons
and triathlons has been a passion for me.
I enjoy the challenge and pushing myself
beyond what some may find reasonable.
And running 26.2 miles or finishing a
140.6-mile triathlon is no cakewalk.
Mary Wittenberg of the New York Road
Runners Club described it this way. She
said: “Virtually everyone who tries the mar-
athon has trained for months. That com-
mitment, physical and mental, gives it its
meaning, be the day’s effort fast or slow. It’s
all in conquering the challenge.”
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This persistence  – this effort  – helps give
meaning to what the AMA accomplishes
on behalf of physicians and patients, every
day.
This is what we have in common.Each of us
has already run a marathon.
You completed medical school. Or you
run a medical practice  – a small business.
Or make split-second treatment decisions
where life and death are in the balance.
Sometimes all of these.
You, like me, want a positive outcome even
when the unexpected happens.
An example. In one triathlon, I was on the
bicycle leg of the race going over Vail Pass
in Colorado.
I rounded a curve and came upon a wom-
an who had wrecked her bike. She was
sprawled on the ground, injured, exhausted,
dazed from a concussion.
With her was a fellow competitor – also a
physician (and fortunately an ER doc) – ad-
ministering first aid. I stopped as well – and
when I could not be of further help, went
on my way.
But the doctor who stopped first ulti-
mately suspended his race. He stayed
with his new patient for two hours – and
sacrificed his chance to complete an event
for which he’d trained for months. Why?
Because he’d trained for years to be a phy-
sician.
The well-being of the patient always comes
first – even when it isn’t our own patient.
This selfless service has been a hallmark of
who we are, as physicians, since the dawn
of time.
And it’s one of the valuable lessons I’ve
learned from my own encounters with the
hard ground. Not to give up.
In this most contentious time in our coun-
try, the AMA will do more than step up to
a podium.
We will run – we will win the race to pro-
vide medical and mental health care services
to all, and we will hear the cheers of those
too often silent.
The AMA rejects the idea of media ‘spin
doctors’ – who hold no medical degree –
attempting to dictate our future. We’ll
stand with physicians and take back our
message.
The AMA rejects the idea that bowing to
the policies of government and insurance
industry bureaucracies are simply inevitable
costs of doing business.
The AMA rejects the notion that legislators
can impose themselves into the patient-
physician relationship and legislate how we
practice –
Whether it concerns what we can ask or say
to our patients – or what tests and proce-
dures are appropriate.
We fight for the interests of physicians.
Sometimes we have prevailed, sometimes
we haven’t, but we’ve been on the course,
pushing our limits, testing our endurance.
Not always winning  – but always being
heard and always finishing.
The documentary filmmaker Bud Greens-
pan, who chronicled the Olympic Games
for almost 60 years, once described a mo-
ment he believed best captured the Olym-
pic ideal of perseverance and commitment.
In Mexico City in 1968,the Tanzanian run-
ner John Ahkwari finished last in the mara-
thon.
Midway through the race, he had fallen
and torn a deep gash in his leg. In agony,
he limped into the stadium 90 minutes af-
ter the winner, his leg bruised, bandaged
and bleeding. For everyone else, the race
was over.The stadium was nearly empty, the
lights dimmed.
Bud Greenspan was still there, his cameras
still rolling. He asked John Ahkwari why on
earth he kept going with such a serious in-
jury, with no hope of winning.
He replied, “My country did not send me
5,000 miles to start a race – they sent me
to finish it.”
That thought will guide me as AMA presi-
dent.
Training for medicine was much like train-
ing for a marathon or triathlon. You learn
your strengths, focus on what you do best,
do it – and don’t quit.
If you get off course on the swim, adjust
your stroke.(Unless you’re fortunate enough
to see Dr. Cecil Wilson’s sailboat in the dis-
tance)
If you get tired on the bike, shift to a lower
gear.
If you can’t run, walk. If you can’t walk, take
a break and try again.
That is an approach we can take to address
the newest challenge we face – health sys-
tem reform.
It means changes for those previously with-
out coverage, changes in payment methods,
changes in how care is delivered.
The Affordable Care Act will soon cover
32 million people without health insurance,
provided neither the Supreme Court nor a
new president overturns the law.
It requires insurance market reforms.
It invests in quality, prevention and well-
ness.
UNITED STATES OF AMERICA Regional and NMA news
wmj 3 2012.indd 99 7/18/12 9:47 AM
100
And it does something else  – it starts us
down the road to a very different system of
payment and delivery.
We’re hearing jargon like “Accountable
Care Organization,” and “medical home,”
and “integration.”
We’ve come far since the days of a family
doctor with a black bag holding the tools
of his trade.
Today, a physician may text a patient on an
iPad while viewing their medical history
and coordinate care among a team of phy-
sicians and other health care professionals.
Such physician-led teams are crucial com-
ponents of medicine’s future.
As more patients live longer and accumu-
late more complex medical conditions, their
care will require more coordination, more
use of clinical data, and professionals work-
ing together.
To be part of a team – and following guide-
lines and best practices  – doesn’t mean
you’ve lost your ability to think, to create, to
act on behalf of your patients.
In the mental health field, a good example
is the DIAMOND Initiative in Minnesota.
Psychiatrists are paid to consult with pri-
mary care practices on the best way to man-
age patients with depression. It’s resulted
in dramatic improvements in patient out-
comes.
The current system discourages this, since
specialists are paid for face-to-face visits
with patients, but not when they advise the
primary care physician.
In 2008, this House of Delegates adopted
principles that support this approach.
The AMA has also backed the medical
home model for mental illness and the prin-
ciple of parity for mental health coverage –
and is part of the Coalition for Fairness in
Mental Illness. We’ve made tremendous
progress, but we can do more.
As AMA president, I will note the need
to better integrate mental health care into
other aspects of medical care – to provide
more resources to treat more people.
Because you can no more separate the heart
from the mind of a person any more than
you can separate the heart from the lungs
and expect them still to function.
I’ll also want to highlight the impact of
violence on both the mental and physical
health of those abused…
Just like we’ll need you to make a concerted
effort through our Joining Forces Initiative
to help our returning troops, veterans and
their families who suffer with traumatic
brain injury, post-traumatic stress disorder
or post-combat depression.
The wounds of those who have borne the
battle are not always visible.
We’re not just playing defence. Just like in
football, you need a good offense, too.We’re
being proactive, not just reactive.
Education on exercise, preventive health
and nutrition starting in early childhood
that continues through a lifetime will help
create a healthier society.
One with less obesity, cancer and the other
illnesses that debilitate the very people we
care about – and which exact a staggering
societal and financial cost.
For them, physicians must be the role mod-
els for our patient’s health – and for each
other’s.
We have a duty to care not only for our pa-
tient’s health,but for our own,both physical
and psychological.
That’s hard for many physicians to admit –
that they, too, may sometimes need help or
guidance.
When we treat our patients – especially our
youngest ones – remember that you might
be treating or inspiring a future physician.
Our family internist, Dr. Lerner, who suf-
fered from poor circulation in his legs,
nonetheless would climb four flights of
stairs to make a house call.
The doctor I saw was the doctor I knew, and
to me, he represented the profession and as
Dr. Carmel would say, he was my hero.
To me, his actions said: Treat people the
way you want to be cared for, because too
often, this is an uncaring world.
As physicians, as AMA members, we are
the face of this profession,this organization.
We are also its voice.
Let’s be willing to sing from the same page.
Those of you who have sung in choirs know
how a collection of varied but trained voic-
es can lift a crowd to their feet. When the
AMA combines our many voices in harmo-
ny – we can do just that.
For me, it’s not just a metaphor. I paid my
way through college and medical school by
directing synagogue choirs.
There, you have to combine many disparate
voices – and help them sing in harmony.
As director, you work with sopranos and
tenors, altos and baritones, contraltos and
basses. And in some choirs you have to des-
ignate a section called the “lip synchers”.
But even if a voice is out of tune, or the
pipes rusty – I learned that even a mono-
tone can learn a second note.
So we need to rise up – raise our voices – and
sing out for medical liability reform, to end
UNITED STATES OF AMERICARegional and NMA news
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101
Health Care
Squeezing Out the Doctor
The role of physicians at the centre of health care is under pressure
In a windowless room on a quiet street in
Framingham, outside Boston, Rob Goud-
swaard and his colleagues are trying to un-
pick the knottiest problem in health care:
how to look after an ageing and thus sicken-
ing population efficiently.The walls are plas-
tered with photographs of typical patient-
shere a man who exercises occasionally,there
a woman with many chronic ailments. Big
sheets of paper chart each patients course
from the hospital back to a comfortable
life at home, with divergent lines showing
all the problems that might arise and ways
to handle them. To map the many paths to
health in this way Mr Goudswaards team
interviewed a lot of patients and nurses.
But this war room does not belong to a hos-
pital. It belongs to Philips, a Dutch elec-
tronics company. Mr Goudswaard, the head
of innovation for Philipss home-monitor-
ing business, has no medical training. His
speciality is the consumer.
In this section
The past 150 years have been a golden age
for doctors. In some ways, their job is much
as it has been for millennia: they examine
patients, diagnose their ailments and try
to make them better. Since the mid-19th
century, however, they have enjoyed new
eminence. The rise of doctors associations
and medical schools helped separate doc-
tors from quacks. Licensing and prescrib-
ing laws enshrined their status. And as
understanding, technology and technique
evolved, doctors became more effective,
able to diagnose consistently, treat effec-
tively and advise on public-health interven-
tionssuch as hygiene and vaccinationthat
actually worked.
This has brought rewards. In developed
countries, excluding America, doctors with
no speciality earn about twice the income of
frivolous lawsuits, to end the fear of being
dragged into court for no good reason, and
to slow spending on defensive medicine.
Sing out, and demand the Sustainable
Growth Rate be scrapped – and be replaced
with a system that recognizes reality – and
reflects the actual costs of medical care – in
all its effective forms.
Sing out for private contracting legislation,
and physician-led delivery and payment re-
forms.
Sing out our commitment that Americans
need health insurance coverage and that we
finally end health care disparities.
Sing out – for an equitable health care sys-
tem. Where all its elements exist in har-
mony.
We trained all of our adult lives to be the
best physicians we can be. Now is the time
to combine our voices and make a joyful
noise. Rise to this occasion. Be persistent.
And keep going no matter how rough the
terrain, or how tiring the course.
I’ll be alongside AMA staff,every physician,
and this House of Delegates. Together, we
can finish this – and we can win.
Among the most inspirational words I’ve
ever seen were at the 130-mile marker of
a triathlon course, in the 100-degree lava
field in Kona, Hawaii. They were from
Isaiah, and it read: “They that hope in the
Lord will renew their strength. They will
soar like wings on eagles. They will run
and not grow weary – walk and not grow
faint.”
And to that I will add: we will rise up and
be heard.We will run this race,together.We
will persist. And together, we will cross the
finish line.
Thank you.
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102
Health Care
the average worker, according to McKinsey,
a consultancy. Americas specialist doctors
earn ten times Americas average wage. A
medical degree is a universal badge of re-
spectability. Others make a living. Doctors
save lives, too.
With the 21st
century certain to see soar-
ing demand for health care, the doctors
star might seem in the ascendant still. By
2030, 22% of people in the OECD club
of rich countries will be 65 or older, nearly
double the share in 1990. China will catch
up just six years later. About half of Ameri-
can adults already have a chronic condi-
tion, such as diabetes or hypertension, and
as the world becomes richer the diseases of
the rich spread farther. In the slums of Cal-
cutta, infectious diseases claim the young;
for middle-aged adults, heart disease and
cancer are the most common killers. Last
year the United Nations held a summit on
health (only the second in its history) that
gave warning about the rising toll of chronic
disease worldwide.
But this demand for health care looks un-
likely to be met by doctors in the way the
past centurys was.For one thing,to treat the
21st
centurys problems with a 20th
-century
approach to health care would require an
impossible number of doctors. For another,
caring for chronic conditions is not what
doctors are best at. For both these reasons
doctors look set to become much less cen-
tral to health carea process which, in some
places, has already started.
Make do and mend
Most countries suffer from a simple mis-
match: the demand for health care is rising
faster than the supply of doctors. The prob-
lem is most acute in the developing world,
though rich countries are not immune (see
article). It does not help that health care is
notoriously inefficient. Whereas Americas
overall labour productivity has increased by
1.8% annually for the past two decades, the
figure for health care has declined by 0.6%
each year, according to Robert Kocher of
the Brookings Institution and Nikhil Sahni,
until recently of Harvard University. But it
is in poor countries that interest in alterna-
tive ways of training doctors and in alter-
natives to doctors themselves has produced
the most innovation.
One approach to making doctors more effi-
cient is to focus what they do. India is home
to some of the worlds most exciting models
along this line, argues Nicolaus Henke of
McKinsey, who leads the consultancys work
with health systems. Britain has 27.4 doc-
tors for every 10,000 patients. India has just
six. With so few doctors, it is changing the
way it uses them.
Your correspondent recently watched Devi
Shetty, chief executive of Narayana Hru-
dayalaya hospital in Bangalore, making
careful incisions in a yellowed heart, pulling
out clots that resembled tiny octopuses. It
looked difficult. Some of the other tasks at
Narayana Hrudayalaya hospital do not, and
are not. Dr. Shettys goal is to offer as many
surgeries as possible,without compromising
on quality. To do that, he ensures that his
surgeons do only the most complex proce-
dures; an army of other workers do every-
thing else. The result is surgeries that cost
less than $2,000 each, about one-fifteenth
as much as a similar procedure in America.
The trick is repeated in other areas of health
care. Indias LifeSpring hospitals slash the
price of childbirth by augmenting doctors
with less expensive midwives. The costs are
about one-sixth of those in a private clinic.
The Aravind Eye Care System offers surgery
to about 350,000 patients a year. Operating
rooms have at least two beds, so surgeons
can swivel from one patient to the next.
Most important, for every surgeon there are
six eye-care techniciansyoung women re-
cruited and trained by Aravindwho perform
the myriad tasks in the operating room that
do not require a surgeons training.
Other problems have inspired other solu-
tions, with technology filling gaps in the
labour force. The Bill and Melinda Gates
Foundation supports a programme that
uses mobile phones to deliver advice and re-
minders to pregnant women in Ghana. In
December the foundation and Grand Chal-
lenges Canada, a non-profit organisation,
announced $32m in grants for new mobile
tools that will help health-care workers di-
wmj 3 2012.indd 102 7/18/12 9:47 AM
103
Health Care
agnose various ailments. In Mexico, wor-
ried patients can phone Medicall Home, a
telehealth service. If a patient needs care,
Medicall Home can help to arrange a doc-
tors visit. But about two-thirds of patients
concerns can be addressed over the phone by
a doctor (often one only recently qualified).
These programmes are expanding. Medicall
Home is rolling out its service in Colombia
and plans to be operating in Peru by the end
of the year. Aravind has exported its train-
ing model to about 30 developing countries.
Dr. Shetty already has 14 hospitals in India.
He plans to add 30,000 hospital beds in big
health complexes and small hospitals there
over the next seven years, as well as build a
hospital in the Cayman Islands.
Technology does not just allow diagnosis
at a distanceit allows surgery at a distance,
too. In 2001 doctors in New York used ro-
botic instruments under remote control to
remove the gall bladder of a brave woman
in Strasbourg. Robots allow doctors to be
more precise, as well as more omnipresent,
making incisions more neatly than human
hands can. As yet they are enhancements
for surgeons more than they are replace-
ments, but that may change in time. Mili-
tary drones started off being flown by of-
ficers who had gone through the expensive
rigours of flight school; these days other
ranks with far less exhaustive training can
take the controls.
Team effort
Less flashy technology, though, could make
the biggest difference by reducing the
number of crises which require a doctors
intervention. Marta Pettit works on a pro-
gramme to manage chronic conditions that
is run from Montefiore Medical Centre,
the largest hospital system in the Bronx, a
New York borough. Ms Pettit and a squad-
ron of other care co-ordinators examine a
stream of data gathered from health records
and devices in patients homes, such as the
Health Buddy. Made by Bosch, a German
engineering company, the Health Buddy
asks patients questions about their symp-
toms each day. If a diabetics blood sugar
jumps, or a patient with congestive heart
failure shows a sudden weight gain,Ms Pet-
tit calls the patient and, if necessary, alerts
her superior, a nurse.
Other tasks are simpler, but no less im-
portant. Montefiore noticed that one old
woman was not seeing her doctor because
she was scared of crossing the Grand Con-
course, a busy road in the Bronx. So Mon-
tefiore found a new doctor on her side of
the Concourse. Together, such measures
make a difference. Diabetics trips to hospi-
tal plunged by 30% between 2006 and 2010;
their costs dropped by 12%.
Similar programmes will become even more
sophisticated as monitors evolve. Patients
are much happier to monitor themselves
at home with gadgets bought online than
they used to be, and gadget-makers think
there is a huge potential for growth in tak-
ing the trend further. Philips, General Elec-
tric (GE) and others are all upping their
investments in home health, and widening
the markets in which they sell their existing
products (Philips is trying to crack Japan
with emergency-alert devices for the elder-
ly). GEs design gurus predict that a patients
overall condition will soon be measured as
easily as a thermometer measures his tem-
perature.
Such technologies have long seemed prom-
ising; recently the promise has begun to be
borne out.Britain has completed the worlds
biggest randomised trial of telehealth tech-
nology, including gizmos from Philips. The
study examined 6,000 patients with chronic
diseases. According to preliminary results
of a study by Britains health department in
December 2011, admissions to the emer-
gency room dropped by 20% and mortality
plummeted by 45%.
Nursed back to health
Changing health systems is tortuous. Re-
formers are stymied by medical lobbies,ner-
vous patients and heaps of regulations about
who may do what and where. But there is
movement, particularly in the lower ranks
of the labour market. Indias health ministry
has proposed a new three-and-a-half-year
degree that would let graduates deliver ba-
sic primary care in rural areas. Dr. Shetty
thinks his hospitals could benefit from a
broader range of training programmes, to
create workers with a wider array of skills.
Workers with a lot less training than doc-
tors can still be highly effective. Physician
assistants in America can do about 85% of
the work of a general practitioner, accord-
ing to James Cawley of George Washing-
ton University. A pilot programme of rural
health-care workers in Indiathe type that
the health ministry wants to expandfound
that the workers were perfectly able to di-
agnose basic ailments and prescribe ap-
propriate drugs. In some areas non-doctors
actually look preferable. A review of stud-
ies of nurse practitioners in Britain, South
Africa, America, Japan, Israel and Austra-
lia, published in the British Medical Journal,
determined that patients treated by nurses
were more satisfied and no less healthy than
those treated by doctors.
wmj 3 2012.indd 103 7/18/12 9:47 AM
104
History
As early as the 4th
and 5th
century BCE,
the heart, lungs, veins, and arteries were
known to be critically important organs in
the human body – although it would be a
few more centuries before dissection al-
lowed scientists of the time to better un-
derstand how these parts worked to pump
blood and give life.When modern medicine
emerged in the 19th
century, a new under-
standing of microbiology and bacteriology
greatly reduced infection rates and the use
of anesthetics such as ether and chloroform
also became more common. These two ad-
vancements set the stage for the astound-
ing medical innovations of the next century.
And yet, surgery of the heart and lungs pre-
sented special problems because the heart
performed the important task of carrying
blood to the brain. A beating heart would
lead to excessive blood loss, and a heart that
wasn’t beating resulted in a brain-dead pa-
tient after only four minutes.
The devastation of World War II led to
more progress in the field of surgical medi-
cine. Doctors on the battlefield, desperate
to help save the lives of injured soldiers,
pioneered new advancements in antibi-
otics, anesthesia, and blood transfusions.
Army surgeon Dr. Dwight Harken suc-
cessfully removed shrapnel from the hearts
of wounded soldiers during the war, prov-
ing that the heart could in fact be operated
upon. Soon after the end of the war, Har-
ken and Dr. Charles Bailey of Philadelphia
used the same technique to repair defective
heart valves, a condition known as mitral
stenosis. However, this type of closed-heart
surgery had its limitations, and patients
with more serious heart conditions had few
options.
Solving this problem became a defining is-
sue in the mid 20th
century. Doctors from
all over the world worked furiously to re-
solve the conundrum. One solution came
when Dr. Wilfred Bigelow discovered that
cooling the body’s core temperature slows
50 Years of Cardiothoracic Surgery
But expanding the supply of non-doctors is
not, in itself, enough. America has led the
world in developing the roles of nurse prac-
titioners and physician assistants. Other,
less trained workers are proliferating there
too. The number of diagnostic medical so-
nographers, who have two years of training,
is expected to jump by 44% between 2010
and 2020, according to the Bureau of La-
bour Statistics. Yet productivity still falls.
This seems to be because new ways of doing
things, and of managing health teams, have
not kept paceand are still under the control
of doctors.
The doctors power rests on their profes-
sional prestige rather than managerial acu-
men, for which they are neither selected nor
trained. But it is a power that they wish to
keep. The Confederation of Medical As-
sociations in Asia and Oceania, a regional
group of doctors lobbies, wants task-shift-
ing limited to emergencies. Japans medical
lobby has vehemently opposed the creation
of nurse practitioners. Indias proposal for
a rural cadre outraged the countrys medi-
cal establishment, and legislation to create
the three-and-a-half-year degree has gone
nowhere.
In 2010 Americas respected Institute of
Medicine (IOM) called for nurses to play
a greater role in primary care. Among other
barriers, nurses face wildly different con-
straints from one state to another. But any
change will first require swaying the doc-
tors. The American Medical Association,
the main doctors lobby, greeted the IOMs
report with a veiled snarl. Nurses are critical
to the health-care team, but there is no sub-
stitute for education and training, the group
said in a statement.
As doctors become scarcer and health costs
continue to rise, more and more systems
will seek to innovate, and the successes they
have will become ever more widely known.
Already, programmes such as Montefiores
are becoming the paradigm for keeping
patients healthy. In December Americas
health department chose Montefiore for a
pilot to improve care and lower costs for the
old.
All this should be cause for excitement. Re-
sources are slowly being reallocated. Nurses
and other health workers will put their
training to better use. Devices will bolster
care in ways previously unthinkable. Doc-
tors,meanwhile,will devote their skill to the
complex tasks worthy of their highly trained
abilities. Doctors may thus lose some of
their old standing. But patients will clearly
win.
Printed from The Economist, June 2, 2012
wmj 3 2012.indd 104 7/18/12 9:47 AM
105
History
the heart rate and allows a longer time in
which to operate-ten minutes as opposed
to four. Drs. John Lewis and Walton Lille-
hei of the University of Minnesota used
the hypothermia method to close an atrial
septal defect in 1952, and Dr. Henry Swan
perfected the procedure, eventually per-
forming hundreds of open-heart surgeries
with relatively low mortality. This rather
cumbersome method was ultimately short-
lived, however, when it became clear that
more complex heart conditions would re-
quire more time than the cooling of the
body allowed. It was evident that a better
approach was needed.
Heart surgeons of the time understood that
a successful heart-lung machine – that is, a
machine that would bypass the heart and
lungs and take over circulation of the blood
during the surgery–had to not only pump
blood, but also resupply oxygen to the red
blood cells and pump blood at sufficient
pressure to supply all the organs in the body,
all without damaging blood platelets in the
process. Anticoagulation was also necessary
to prevent bleeding out during surgery. The
latter problem had been earlier solved by the
discovery of heparin in the early 1900s.The
heart-lung machine had several prototypes,
but it wasn’t until the 1950s that surgeons
were able to use such a device to repair the
hearts of patients.
From 1950–2000, the following timeline
describes some of the important milestones
in cardiothoracic surgery that followed the
development of cardiopulmonary bypass, a
revolutionary advancement that has since
saved thousands of lives.
1951 – Dr. Clarence Dennis of the Univer-
sity of Minnesota performed the first open-
heart surgery using a heart-lung machine.
The patient is a six-year-old girl suffering
from an atrial septal defect. She does not
survive.
1952 – Dr. Forest Dodrill and colleagues
use a mechanical pump (developed with
General Motors) to perform the first suc-
cessful total left-sided heart bypass on a
41-year-old man in Detroit. The patient’s
own lungs were used for oxygenation.
1952 – Dr. Paul Zoll applies electrical
charges to the outside of a patient’s chest to
successfully restart his heart.
1953 – Dr. John Gibbon performs the first
successful intercardiac surgery of its kind
using a heart-lung machine he developed
with IBM. The patient is an 18-year-old
girl with congestive heart failure due to an
atrial septal defect. Unfortunately, the next
two patients to receive surgery with the ma-
chine do not survive. Gibbon declares a one
year moratorium on further surgeries using
his machine.
1955–1956 – A team led by Dr. John Kirk-
lin of the Mayo Clinic uses a heart-lung
machine based on Gibbon’s model to per-
form intercardiac surgery on eight patients,
four of whom survive.
1958 – Swedish surgeon Dr. Ake Senning
places the first implantable pacemaker in a
patient with Stokes-Adams syndrome.
1960 – The first aortic valve replacements
are placed by Dr. Dwight Harken and
Dr.  Lowell Edwards, both of whom use
a caged ball valve. In the next seven years,
2000 of these valves are implanted.
1960 – Dr. Robert Goetz performs what
appears to be the first coronary artery by-
pass operation on a human. He receives
criticism for attempting the experimental
surgery, and never performs another.
1963 – An artificial left ventricle assist
device is successfully used to help wean a
patient from cardiopulmonary bypass after
heart valve surgery.
1964 – Dr. Charles Dotter performs the
world’s first percutaneous transluminal an-
gioplasty in Oregon.
1967 – A South African surgeon,Dr. Chris-
tiaan Barnard, transplants the heart of a
23-year-old woman into a middle-aged
man. He survives for 18-days before dying
of pneumonia brought on by powerful anti-
rejection drugs.
1968 – Dr. Norman Shumway of Stanford
University performs the first heart trans-
plant in the United States.The patient sur-
vives for 14 days. Following the sensation
of this first operation, several more trans-
plant surgeries take place, but with high
mortality.
1974 – Dr.Andreas Gruentzig performs the
first peripheral human balloon angioplasty
1981 – Shumway performs the first suc-
cessful heart-lung transplant with colleague
Dr. Bruce Reitz.
1982 – American surgeon Dr. William
DeVries implants a permanent artificial
heart into a patient at the University of
Utah
1998 – Dr. Friedrich Wilhelm Mohr and
Dr. Alain Carpentier perform the first
robot-assisted mitral valve repair and coro-
nary bypass surgery in France.
Sources:
1. http://cirugiadetorax.org/2011/04/29/history-of-
thoracic-surgery/
2. http://cardiacsurgery.ctsnetbooks.org/cgi/content/
full/2/2003/3?ck=nck
3. http://profiles.nlm.nih.gov/BX/
4. http://www.pbs.org/wgbh/nova/body/pioneers-
heart-surgery.html
5. http://www.med.yale.edu/library/heartbk/
25.pdf
6. http://www.nytimes.com/1999/01/08/us/paul-m-
zoll-is-dead-at-87-pioneered-use-of-pacemakers.
html
7. http://www.ohsu.edu/dotter/40th_anniv.htm
8. http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC101071/
Provided by
Adie Harrington
http://www.surgicaltechnologist.net
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106
Violence in the Health Care Sector
Summary
In the recent report ‘Doctoring the Evi-
dence, Abandoning the Victim’ the Israeli
Public Committee against Torture accuses
several Israeli medical doctors of medical
complicity in torture. When analyzing the
report’s outcomes, the author pleas for a
strong condemnation by the Israeli medical
association of these illicit practices. What’s
more, in line with the report, urging Israel
to restructure its medical system of checks
and balances and recommending the rati-
fication the Optional Protocol of the Con-
vention against Torture aimed at preventing
torture and thus strengthening the rights of
the detained.
Introduction
The alarming report ‘Doctoring the Evi-
dence,Abandoning the Victim’of the Israeli
Public Committee against Torture accuses
Israeli medical doctors of medical complic-
ity in torture.1
These allegations are not new
and have been mentioned before.2
What’s
new is the figures and systematic approach
of these human rights violations. Based on
a series of testimonies and other evidence,
such as medical files of over 100 victims of
torture since 2007, the report demonstrates
that several doctors are (in)directly involved
in torture or cruel and degrading treatment
1 Public Committee against Torture in Israel en
Physicians for Human Rights, ‘Doctoring the
Evidence, Abandoning the Victim. The Involve-
ment of medical professionals in torture and ill-
treatment in Israel’, in collaboration with Physi-
cians for Human Rights, October 2011, .
2 Eg,J.S.Yudkin,“The responsibilities of the World
Medical Association President”, Comment, the
Lancet, 373 (2009) 1115-6.
of Palestinian detained persons in Israeli
detention centres.
Report Outcomes
According to the report, physicians will-
ingly take part in, facilitate or allow torture
by failing to report clinical evidence of it to
the relevant authorities. Evidence of active
involvement includes falsification of medi-
cal records and disclosure of medical infor-
mation to the interrogators of the security
services. Information that is relevant to the
interrogation techniques to be used by the
intelligence services.3
As such Israeli medi-
cal doctors failed to protect detainee’s hu-
man rights, violated the basic principles of
medical ethics and ignored the basic tenets
of medical professionalism.
More common is passive engagement in-
cluding: the failure to oppose, accurately
document,report (suspicion of) torture,and
return the detainees they examined or treat
to their interrogators.4
As such, these doc-
tors remain silent of what they see and hear,
offering moral license for torturers.
International Law and Ethics
International law and international medi-
cal ethics are very clear about the prohibi-
tion of torture.5
Torture violates the essen-
3 See note 1, pp. 28–40.
4 Ibid, pp. 43–45.
5 According to the United Nations Convention
against Torture (UNCAT 1984, Art. 1 section
1), torture is defined as ‘any act by which severe
pain or suffering, whether physical or mental, is
intentionally inflicted on a person for such pur-
poses as obtaining from him or a third person
tial ethical obligation on all physicians to
“first do no harm” and human dignity.6
The
same international standards condemn all
forms of torture and inhuman or degrad-
ing treatment at any time and in any place
whatsoever and can thus never be justified.7
All States are obliged to ensure fully the
implementation of the absolute prohibition
of torture, for instance by means of crimi-
nalizing all acts of torture, never request-
ing medical personnel to commit any act
of torture and respecting the professional
independence and duties of health person-
nel, as well as respecting the doctor’s duty
to report or denounce acts of torture with-
out fear of retribution or harassment, and
not punishing or intimidating medical per-
sonnel not obeying orders or instructions to
information for a confession, punishing him for
an act he or a third person has committed or is
suspected of having committed, or intimidating
or coercing him or a third person or for any rea-
son based on discrimination of any kind, when
such pain or suffering is inflicted by or at the in-
stigation of or with consent or acquiescence of a
public official or other person acting in an official
capacity’.
Apart from UNCAT, the international com-
munity has developed various instruments con-
demning torture and other forms of ill-treatment,
such as the Art. 7 of the International Covenant
on Civil and Political Rights of December 19,
1966 and Art. 3 of the European Convention for
the Protection of Human Rights and Fundamen-
tal Freedoms of November 4, 1950; UN Human
Rights Council. Resolution on torture and other
cruel,inhuman or degrading treatment or punish-
ment: The role and responsibility of medical and
other health personnel, 2009, A/HRC/10/L.32.
6 WMA International Code of Medical Ethics.
Adopted by the 3rd
General Assembly of the
World Medical Association, London, England,
October 1949, latest revision: the 57th
WMA
General Assembly, Pilanesberg, South Africa,
October 2006.
7 The UN Istanbul Protocol (1999): A manual for
the efficient investigation and documentation of
torture and other cruel, inhuman or degrading
treatment; WMA Declaration of Tokyo (1975) –
Guidelines for Physicians Concerning Torture
and other Cruel, Inhuman or Degrading Treat-
ment or Punishment in Relation to Detention
and Imprisonment
Israeli Torture Doctors:
Medical Ethics Betrayed
wmj 3 2012.indd 106 7/18/12 9:47 AM
107
Violence in the Health Care Sector
commit, facilitate or conceal acts amount-
ing to torture.1
Vague National Standards
Despite these clear international standards,
the gap between the national norms and
practice remains too wide.Israeli law and eth-
ical guidelines on this matter are overly vague
in asserting the duty of the doctor to the pa-
tient’s well-being. What is worse, misinter-
pret international standards by including a
‘national security’exception allowing the doc-
tor to compromise the patient’s health in the
face of the security services.2
As such, prison
doctors are being trapped by the so-called
“dual loyalty” conflict: confronted with a pa-
tient who happened to be an Arab detained
in medical need, and their duty towards
their employer security services fighting a
war on terrorism. Balancing these interests
has led to blatant breaches of human rights.
Unfortunately, this ‘dual loyalty’ situation is
not unique for Israeli doctors. In the past
several colleagues have been struggling with
that dilemma.
“Healers”as Torturers:
International Experiences
Extreme cases of torture doctors occurred
in Nazi death camps during World War
II.3
The report considers incidents of medi-
cal complicity in torture in several coun-
tries (the former USSR, South and Central
America, Sri Lanka, etc.).4
More recently
1 Examples based on the United Nations Conven-
tion against Torture (CAT, 1984) and the United
Nations’Human Rights Council recommendation
against torture, A/HRC/10/L32, 20 March 2009.
2 Ibid note 1, pp. 19-26.
3 Eg, M. Lippman, “The Nazi Doctors Trial and
the International Prohibition on Medical In-
volvement in Torture” Loy. L.A. Int’l & Comp.
Law J. (1992-3) 395-441.
4 Ibid note 1, pp. 47–51.
there is participation in the so-called ‘water
boarding’ interrogation techniques in the
US ‘war on terror’ performed in Guantana-
mo Bay and the Abu Ghraib prison in Iraq.5
These cases show a clear ignorance of physi-
cians towards internationals ethics and law.
Educating doctors on human rights,humani-
tarianlawandmedicalethicsappearstherefore
an essential element in the medical curricu-
lum. Inadequate training in human rights is
part of the problem,but alone it cannot justify
the actions or inactions of the prison medical
personnel. Similar as in the Abu Ghraib pris-
on,the Israeli medical system failed to protect
the detainee’s health and failed to accurately
report witnessed or suspected abuse.6
These
failures of the Israeli (prison) medical system
illustrate a more fundamental problem: the
absence of functioning checks and balances
and being subject to professional discipline.7
Role of the International
Community
What can the international community
do to raise its voice against this? Efforts to
eradicate torture should first and foremost
be concentrated on prevention. Therefore,
Israel should be invited to adopt the Op-
tional Protocol to the Convention against
Torture.8
This Protocol introduces a system
of regular visits to places of detention,aimed
at preventing torture and thus strengthen-
ing the rights of the detained. By ratifica-
5 S.H. Miles, Oath Betrayed: America’s Torture
Doctors (2nd
ed. Univ. of California Press, 2009).
6 Compare: P.A. Clark, “Medical Ethics at Guan-
tanamo Bay and Abu Ghraib: The Problem of
Dual Loyalty”, Journal of Law, Medicine & Eth-
ics Fall (2006) 570-580: 573.
7 Ibid note 1, pp. 54–55.
8 Officially, Optional Protocol to the Convention
against Torture and other Cruel, Inhuman or De-
grading Treatment or Punishment, Adopted on
18 December 2002 at the fifty-seventh session of
the General Assembly of the United Nations by
resolution A/RES/57/199. Entered into force on
22 June 2006, see www.ohchr.org.
tion, each State shall allow these visits by
an independent committee, granted with
extended powers, including access to all rel-
evant information, the opportunity having
private interviews with detained persons,
and submitting proposals for legislation.
Apart from prevention, the World Medical
Association (WMA) as the world’s largest as-
sociation representing the international medi-
cal community, should urge the Israeli mem-
ber association to speak out in support of the
fundamental principle of medical ethics and
to investigate any breach of these principles
by their members.9
More important,the voice
of the international medical profession should
urge the Israeli medical association to bring
its ethical guidelines in line with international
standards, which means rejecting the security
exception as a justification for torture. The
message should be univocal: respecting this
core principle is nothing less than is a condi-
tio sine qua non for the WMA-membership.
Conclusion
The report made painfully clear that there
is a fundamental need for improvement and
enforcement of the checks and balances in
the Israeli medical system. In a way, this is
one of the recommendations made by the
Israeli Public Committee against Torture
suggesting the introduction of independent
board of inquiry to examine the full nature
oftheseabuses.10
Internationalpressurefrom
both UNCAT and the WMA could be ef-
fective to realize these changes.
André den Exter, Lecturer in Health
Law, Institute of Health Policy and
Management, Erasmus University
Rotterdam, The Netherlands
E-mail: Denexter@bmg.eur.nl.
9 As they did in the case of Iran, calling to respect
the International Code of Medical Ethics, 18
October 2009 .
10 Ibid, note 1, p. 55.
wmj 3 2012.indd 107 7/18/12 9:47 AM
108
Violence in the Health Care Sector
In October 2010, the Israeli Medical As-
sociation (IMA) first proposed a state-
ment for adoption by the WMA on the
subject of violence in the health sector.The
statement was the result of the worrying
trend of increasing violence against health
professionals by patients and their family
members. Since the initial proposal, this
trend has not abated, and if anything, has
worsened.
Some statistics: According to the US Bu-
reau of Labor Statistics, in 2007 there were
670,600 injuries and illnesses in the health
care and social assistance industry, with an
injury and illness rate of 5.6 per 100 full-
time workers compared with 4.2 for all of
private industry. Nearly half (45.3%) of
these injuries and illnesses required days
away from work, job transfer, or restriction
[1].
In an updated study conducted by the Brit-
ish Medical Association (BMA) and pub-
lished in 2008,almost half of those surveyed,
both GPs and hospital doctors, reported
violence to be a problem in the workplace,
with a third reporting experiencing violence
or abuse in the workplace in the preceding
year. The majority reported cases of verbal
abuse, but almost a third reported (instead
or in addition) physical violence or abuse
[2].
Finally, the 2011 summary of violent in-
cidents in Israeli healthcare workplaces
showed a total of 752 reported cases of
physical violence and another 2406 cases
of verbal abuse, a rise from 2010, although
lower than in 2008–2009. More cases were
reported in hospitals than in ambulatory
clinics, and the department with the most
reported cases was the emergency depart-
ment [3].
The effects of violence,as we reported previ-
ously [4],are devastating and include physi-
cal and emotional stress, anger, helplessness
and anxiety [5], lost work days, low worker
morale, increased turnover and direct and
indirect effects on work ability [6].
In a personal plaint by a Chinese medi-
cal student following the fatal stabbing of
an intern, she reports her own regret in
choosing medicine as a career and asserts
that many of her fellow students do not
know whether to continue to study medi-
cine or not [7]. Besides the direct effects
of violence, in an era of workplace short-
ages, this is a byproduct we cannot afford
to accept.
Israel has introduced a series of reforms
over the last several years in an effort to
combat this worrisome phenomenon, in-
cluding financial, legal and social initia-
tives. The IMA, in particular, initiated
several important actions, including an
emergency hotline for physicians, a profes-
sional security company that accompanies
physicians perceived to be in danger, and
an ad campaign, including posters and
a video clip that was broadcast on cable
television. In addition, we partnered with
certain hospitals on a pilot “emergency call
button” program.
On the legal front, the IMA proposed two
bills that were subsequently passed into law.
These bills were developed, in part, on the
basis of a successful action plan implement-
ed in England in 2000 in order to reduce
violence against medical staff.
In 2011, the law preventing violence in
healthcare institutions in Israel was passed
[8]. This law allows a hospital or clinic to
warn family members or accompanying
persons of patients, who previously en-
gaged in verbal or physical violence against
hospital/clinic personnel or destroyed in-
stitutional property, that if they repeat such
an act they will not be permitted on the
hospital/clinic grounds for a period of 3–6
months unless they themselves need medi-
cal care.
The second law was an amendment to the
Penal Code that lengthens the punishment
for one who attacks medical personnel in
the ER or while they are trying to treat
someone in serious danger from three years
to five years [9].
The legal system also, indirectly, helped re-
duce some of the pressures that lead to vio-
lence when, in June 2008, the district court
in Tel Aviv ruled that doctors are not al-
lowed to include budgetary considerations
in their medical decisions [10]. It is hoped
that this decision will restore the doctor’s
professional autonomy and minimize the
tension between doctor and patient.
As we noted in our previous article, verbal
aggression is more insidious and no less
problematic than physical aggression. Al-
though the results may be less dramatic –
clearly a fatal or disfiguring attack has more
immediate and dramatic consequences
Violence in the Health Care Sector —
an Updated Look
Malke Borow
wmj 3 2012.indd 108 7/18/12 9:47 AM
109
Violence in the Health Care Sector
than verbal attack – because verbal aggres-
sion is more prevalent, over time it erodes
worker confidence, morale and feelings of
safety in the workplace. In these types of
cases, training to deal with aggressive pa-
tients can be especially effective [11], per-
haps because it is easier to equip people
with tools to handle verbal aggression than
physical aggression.
One issue that was hotly debated among the
National Medical Associations (NMAs)
was the issue of violence among psychiat-
ric patients. It was recognized that this is
a unique problem that cannot be addressed
in the same way as other violent events. In
a study conducted in Egypt, 80% of workers
in psychiatric departments reported expo-
sure to one or more violent incidents in the
previous year as compared to 23% of work-
ers in internal medicine departments. In
both departments, verbal violence was the
most common type reported, followed by
threat and then physical violence. Also, in
both departments doctors and nurses were
exposed to more violence than social work-
ers or psychiatrists [12].
It does appear that mental illness raises the
likelihood of violent behavior. This is nec-
essary knowledge not to further stigmatize
the community of mentally ill patients but
in order to give health workers a realistic
understanding of the risk and the precau-
tions they should take. One survey showed
a 5% lifetime risk of schizophrenia among
people convicted of homicide, a prevalence
that exceeds the rate of schizophrenia in the
general population. Nonetheless, it is im-
portant to note the difficulty of establishing
an accurate profile of people committing
acts of workplace violence, and to acknowl-
edge the risks associated with generaliza-
tion and stereotyping in this area.
Conclusion
A key motive in preparing the statement for
adoption by the WMA was to raise aware-
ness of the issue among the NMAs and to
build greater understanding among health
care professionals of the causes and associ-
ated risks of workplace violence.
There was general consensus among the
NMAs as to the importance of such a state-
ment and the need for action on the part
of NMAs, medical institutions and govern-
ments, including the allocation of appropri-
ate funds to combat the problem.
Prevention is as important as the provision
of tools and strategies to deal with violence
when it occurs. Effective reporting mecha-
nisms are also crucial in order to keep tabs
on the scope and characteristics of the prob-
lem.
It is hoped that the adoption of this state-
ment by the General Assembly in October
will lead to renewed commitment among
governments and health care workers to ad-
dress the problem on all levels and slowly
reverse the worrisome trend that leads to
physical and emotional debilitation and
eventual attrition of the healthcare work-
force.
References
1. Janocha J, Smith RT. Workplace Safety and
Health in the Health Care and Social Assis-
tance Industry, 2003-07. http://www.bls.gov/
opub/cwc/sh20100825ar01p1.htm (accessed June
13, 2002).
2. Violence in the workplace-The experience of
doctors in Great Britain. Health Policy and Re-
search Unit, BMA, January 2008.
3. Summary of violent incidents in the healthcare
system-2011. Israeli Ministry of Health (2011).
4. Blachar Y. Violence in the health care sector-a
global issue. WMJ (2011); 57(3): 87-89.
5. Shalom-Azar S, Liben A. The writing was on
the wall-coping with violence against the staff.
Paper presented at the Second International
Conference on Violence in the Health Sector,
October 2010.
6. Privitera M, Arnetz J. Workplace violence
(WPV): Effect on staff, institution and quality
of care. Paper presented at the Second Interna-
tional Conference on Violence in the Health
Sector, October 2010.
7. Jie L. New generation of Chinese doctors face
crisis. www.thelancet.com vol. 379 May 19,
2012.
8. Prevention of Violence in Medical Institutions
Act-2011.
9. Israeli Penal Code section 382A (c), amended
2010.
10. Appeal No. 001199/07 Dr. Zvi Raviv v. Ministry
of Health.
11. Herath P, Forrest L, McRae I, Parker R. Patient
initiated aggression. Australian Family Physi-
cian (2011); 40 (6): 418.
12. Hady A, El-Hawary A, Shoada M. Workplace
violence against psychiatrist health care staff in
Mansoura, Egypt. Paper presented at the Sec-
ond International Conference on Violence in
the Health Sector, October 2010.
Malke Borow, Director,
Division of Law and Policy,
Israeli Medical Association
wmj 3 2012.indd 109 7/18/12 9:47 AM
110
Medical Research
The main themes at the MedicReS World
Congress June 6–9, 2012, at Hofburg Palace
in Vienna,were Good Medical Research and
Good Biostatistical Practice which had been
introduced to the medical literature by Med-
icReS for the first time at the MedicReS In-
ternational Conference 2011 in Istanbul [1].
At the MedicReS World Congress 2012,
these themes were made open for contrib-
uted discussions for all medical scientists
working at different stages of medical re-
search. This is the first time that authors,
editors, reviewers, ethical board members,
research education professionals, publishers,
clinical research organizations and manage-
ment teams of medical sector were brought
together to discuss the concept of “Good
Medical Research”.
20 invited and 30 contributed speakers and
more than 50 presentations from 37 dif-
ferent countries took part in the Scientific
Program of the MedicReS World Congress.
Discussions about ethical issues and global
ethics training, handling with bias, creating
good evidence, turning evidence to good
policy, publication policies for medical jour-
nals, good publication practice measure-
ments, the future of electronic publishing,
statistical consulting, and differences be-
tween peer review systems of journals have
been discussed.
Report on
MedicReS World Congress 2012 on Good Medical Research
MedicReS International Conference on Good Biostatistical Practice
E. Arzu Kanik
Table 1. MedicReS Good Biostatistical Practice (GBP) Guide (GBRS release 1.2)
Main Parts Subtitles 
Part I
“Design – Good Planning”, consisting
of 20 subtitles in the form of Expanded
PICOS (E-PICOS); E-PICOS
• 7P: Purpose & Population & Patients
& Participants & Power & P value &
Protocol (7 subtitles)
• 2I: Intervention & Interpretation (2 sub-
titles)
• 4C: Comparators & Controls & Covari-
ate & Confounding (4 subtitles)
• 2O: Outcomes & Outputs (2 subtitles)
• 5S: Study Design, Sample Size, Sum-
mary Statistics, Statistical Software and
Submitting (5 subtitles)
Part II
“Analysis – Good Executing”, this part of
GBP consists of 12 subtitles of 4D (Data
Collecting, Data Control, Data Analysis,
and Data Interpretation)
• Data Collection (2 subtitles):  Valid-
ity,  Reliability
• Data Control (2 subtitles):  Missing
values, Outliers
• Data Analysis (4 subtitles):  Preparing
data for analysis, Calculating summary
statistics, controlling assumptions, de-
ciding statistical methods for testing
hypothesis
• Data Interpretation (4 subtitles):  Pa-
rameter estimating, Interpretation of p
values, Clinical significance vs. statistical
significance, Small sample size vs. large
sample size
Part III
“Publication – Good Reporting and Re-
viewing “,consisting of 8 main parts from
the MedicReS Good Biostatistical Review-
ing Standards, GBRS. GBRS also endorse
Good Reporting Guidelines from Equator
Network
GOOD BIOSTATISTICAL REVIEW-
ING STANDARDS (GBRS release 1.2)
wmj 3 2012.indd 110 7/18/12 9:47 AM
111
Medical Research
Table 2. MedicReS Good Biostatistical Reviewing Standards (GBRS release 1.2)
GBRS Subtitles GBRS Questions ? 
1. Study Design Was a suitable design used to achieve the objective?
Was/Were reporting guideline(s) suitable for the study design used? (GBRS also endorse Good Report-
ing Guidelines from Equator Network )
Was an appropriate control group used?
Were any efforts made to avoid potential sources of bias?
2. Sample Size Was the minimum sample size needed calculated?
If calculated, was the pre-study calculation of the sample size reported?
3. Participants Were the socio-demographic characteristics of participants and those who didn’t wish to participate
reported in the study?
Were withdrawals from the study independent of the study groups and/or doses?
Was a flow diagram of participants given for all stages of the study?
4. Summary Statistics Were the validity and reliability of the measurement methods used reported in the study? (Gold stan-
dard, inter-rater agreement)
Was the analysis of randomness of missing values and outliers made?
Were appropriate summary statistics used?
Were there any misuses of standard error?
Were confidence intervals calculated for all of the summary statistics used in the study?
Were the terms ‘relation’, ‘correlation’, ‘difference’ and risk terms used correctly?
5. Statistical Analysis Were statistical methods compatible with the study design and variables, used in this study?
Were any assumptions of statistical methods violated?
Was the choice of parametric or nonparametric test correct?
Were all statistical methods used in the study reported in the methods section of the paper?
Was it stated in the study which statistical method was used for which hypothesis?
Were a covariant and the effect of mixing variables considered during the analysis? If necessary, was a
multiple data analysis conducted?
Was a multivariate analysis necessary? If necessary, was it used correctly?
Were subgroups constituted during the data analysis?
Were the method and the aim of subgroup analysis correct?
Were cutoffs used for quantitative tests? If used, how were they determined?
Were subjective criteria used for qualitative tests? If used, how were they determined?
Was the sample size sufficient for subgroup analysis?
6. Tables and Graphics Was the number of significant digits in the tables used correctly?
Were the graphics selected compatible with the data analysis?
Were the indications and interpretations of ratios and percentages in the tables in accordance with the
content?
Were both significant and non significant p-values given in the tables? (to avoid publication bias)?
7. Statistical Interpretation Were the indication, interpretation of p-values in the study and generalizations made correctly?
Were both statistical and clinical significance values of the results discussed?
8. Statistical Ethics Was the statistical or commercial software used? If commercial, was this usage legal?
Was there a statistical expert contribution in the material? If so, was this contribution valued?
wmj 3 2012.indd 111 7/18/12 9:47 AM
112
Medical Research
At the MedicReS World Congress, the
subject “ethics” was handled within the
frame of showing respect to humans, ani-
mals, women, child, patients, and their rela-
tives in the planning stage. Ethics in the
analyzing stage of data collecting, analyz-
ing and interpreting processes was consid-
ered within the frame of respect for science
and self-respect. Subjects on research eth-
ics and biostatistical ethics were discussed
and new concepts were put forward related
to electronic publishing in the publishing
stage. In the sessions discussing the struc-
tures of global and local ethics boards the
time, place and way of training on ethics
in undergraduate and graduate levels were
also debated [3].
Another important issue that was high-
lighted at the Congress was the impor-
tance of guidance of researchers, ethical
board members, referees, and editors who
are in charge of practice and publishing.
One of the most important results of the
MedicReS World Congress was certifi-
cation of researchers. As to the programs
the following were certified: Good Medi-
cal Researcher Certificate program and
Good Ethical Practice, Good Biostatisti-
cal Practice, and Good Reviewing Practice
Certificate. These programs should be of-
fered locally in small interactive classes and
should be controlled by the center as well.
It is advised that trainings on good medical
research should be updated every five years
because of their dynamic methodological
infrastructure. The aim of these certificate
programs is to maintain the reliability of
medical research in the eyes of the media
and the readers.
The Lancet wrote that “MedicReS aims to
educate researchers and provoke discussion
about good scientific method,statistics,eth-
ics, publication, and education. Faced with
stifling bureaucracy, competition for funds,
and employer pressure to deliver results,
finding the time and space to produce the
best research can seem an arduous process”
(9 June 2012 issue [2]).
According to MedicReS, researchers should
have sufficient knowledge not only in their
own disciplines but also on ethical, biosta-
tistical and methodological principles while
conducting their research. MedicReS also
aims at putting into practice Good Medical
Research philosophy and its components,
namely,good planning, good analyzing,
good reporting, good reviewing and good
publishing, creating good evidence, turning
evidence to good policy, developing a cur-
riculum for good medical research educa-
tion, defined not only as ethical and unbi-
ased, but also powerful.
MedicReS Guide for Creating Evidence
was named as Good Biostatistical Practice
(GBP) and introduced into the medical
literature for the first time by MedicReS
when it opened for discussion all the items
at the contributed sessions at the MedicReS
World Congress.The ratio of the three main
parts of GBP are as follows: Design – Good
Planning (50%), Analysis – Good Execut-
ing (30%), Publication – Good Reporting
(20%) (Table 1). This guide contains three
main parts: Part I is “Design – Good Plan-
ning”, consisting of 20 subtitles in the form
of Expanded PICOS (E-PICOS); E-PI-
COS includes the follow-up From Purpose
to Submitting; Part II is “ Analysis – Good
Executing” which consists of 12 subtitles of
4D (Data Collecting, Data Control, Data
Analysis and Data Interpretation); the
last part, Part III is “ Publication – Good
Reporting and Reviewing”, consisting of
8 main parts from the MedicReS Good
Biostatistical Reviewing Standards, GBRS
(Table 2).
One of the new themes that will be featured
in the Third MedicReS World Congress on
Good Medical Research which will take
place in Vienna next year is clinically signif-
icant range for outcomes. Clinically signifi-
cant range for primary outcomes is an input
required for estimating the sample size of
research, yet it does not have a standard.
Although this subject is the most impor-
tant tool for a powerful research, there is no
guide for determining clinically significant
effect sizes based on diseases and popula-
tions.
We hope to meet medical researchers from
all over the world next year June 13–15 in
Vienna for the Third MedicReS World
Congress.
References
1. Kanik EA. Good Biostatistical Practice (GBP),
MedicReS International Conference Proceed-
ings Book, on Good Medical Research, March
25-27, 2011, Istanbul, p. 85.
2. “The Truth about Good Medical Research “,The
Lancet, Volume 379, Issue 9832, p.2118, 9 June
2012, doi:10.1016/S0140-6736(12)60924-6.
3. Wolf D. Global Research Ethic Training, Medi-
cReS World Congress Proceedings Book, on
Good Medical Research, June 06-09, 2012 in
Vienna.
E. Arzu Kanik, PhD, Professor and
Chair Department of Biostatistics and
Bioinformatics, University of Mersin, Mersin;
Scientific Coordinator of MedicReS and Chair
of MedicReS World Congress 2012, Vienna
www.medicres.org,
E-mail: info@medicres.org
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113
Climate and Health
The First Global Climate and Health Sum-
mit was held on 4th
December 2011, in
Durban parallel to the UNFCCC climate
negotiations. The summit was organized by
Health Care Without Harm (HCWH) in
partnership with more than 10 major health
organizations from around the world in-
cluding the World Medical Association
(WMA) to raise awareness of health risks
of climate change and urge delegations to
take immediate and bold action to tackle
the climate change issue.
The summit was very successful with a high
turnout of over 250 participants mostly
from the health sector and from more
than 40 countries. Speakers at the summit
warned that climate change will be a disas-
ter to health crises if governments don’t take
immediate strong action and stressed that
ambitious commitments have many health
benefits. In a panel discussion following
the keynote speeches, ways to commit to
mitigating the climate change were dis-
cussed from various viewpoints from green
management of health sectors to dietary
changes.As a result of all the discussion, the
participants issued the Durban Declaration
urging substantial progress in governmental
talks, and A Global Call to Action (www.
climateandhealthcare.org) urging the health
sector to play increased roles in advocacy
and capacity building in addressing the is-
sue.The voices collected at the summit were
delivered to the participants of the UN-
FCCC meeting at a press conference of the
UN meeting with a performance of doctors
taking the temperature of a model earth and
finding that it was overheating.
Representing the WMA, I had an oppor-
tunity to introduce the WMA’s commit-
ments to tackling health impacts of climate
change including the Delhi Declaration
and a lobbying action with the NMAs to
make health an inherent component of
governmental climate talks. I approached
the issue especially focusing on the role
of the organized medicine and leadership:
encouraging the NMAs to press their gov-
ernments to fully consider the issue, get-
ting physicians and patients involved in the
commitment for a healthy climate, foster-
ing studies and research on the burden of
disease caused by the climate change and
impact of the climate change on the most
vulnerable population, strengthening col-
laboration with other health organizations
and NGOs.
As strategies to effective action plans, I
pointed out strengthening professional edu-
cation on environmental health and physi-
cians’ obligation and responsibilities for the
commitment, getting physicians engaged
in networks and groups that can work to-
gether, and raising physicians’ involvement
in the development of policies to protect the
health from the climate change.The partici-
pants expressed high hopes in the WMA’s
further commitments and leading roles as
the only body representing physicians over
the world.
Although governmental delegations to the
UNFCCC meeting in Durban reached
a consensus to extend the Kyoto Protocol
and draft a universal legal agreement to be
adopted and come into force by 2020, it
failed to take an immediate action to save
the burning planet.This slow progress gives
organizations in the health sector around
the world the responsibility to collaborate
and strengthen their voices.
Realizing the responsibilities, at a post-
conference strategy meeting, the partici-
pants agreed to establish a network among
the organizations that attended the summit
and work on follow-ups to promote aware-
ness in the health sector on the health and
climate change and continue to urge gov-
ernments to make substantial progress in
reducing greenhouse gas emissions, capital-
izing on collective influences of the network.
Along with political pressure, the network
can step up research on co-benefits of the
climate change mitigation and adaptation.
Gathering momentum on the initiative, the
hosting organizations plan to continue the
global climate and health summit annually
in parallel to the UNFCCC meeting.
Exchanging ideas and experiences with oth-
er participants representing various medical
professionals,I felt the WMA needs to draft
a second phase action plan for the health
and climate change, if we call the adoption
of the Delhi Declaration as the first phase.
Organized medicine through the WMA
and NMAs can effectively raise individual
physician’s interests and involvement in
protecting health from the climate change.
Collective knowledge and action can achieve
far better results than separate efforts. Par-
ticipating in the network is also important
for the WMA to move its initiatives on the
health and climate change to the next level.
It will widen its horizon in drafting future
plans and strengthen collectivity.
Prof. Dong Chun SHIN, MD, PhD,
Yonsei University College of Medicine,
Department of Public Health
The First Global Climate and Health Summit
Dong Chun Shin
wmj 3 2012.indd 113 7/18/12 9:47 AM
114
Influenza
Bangkok, 12th
June 2012 – A group of more
than 200 leading international influenza ex-
perts will meet in Bangkok during 12 & 13
June for an information sharing exercise,the
first of its kind for the region. Concerned
about the low influenza vaccination levels
in the region, the experts will discuss the
need to improve awareness and implement
influenza control policies to protect those at
greatest risk for serious complications.They
will also underscore the importance of an-
nual influenza vaccination to control the
disease and improve influenza pandemic
preparedness.
Each year, approximately 5 to 10% of adults
and up to 30% of children worldwide will
suffer from seasonal influenza, resulting in
medical visits, hospitalization and death,
as well as millions of lost work and school
days. It is estimated that seasonal influenza
causes up to 1 million deaths annually but
many of these go undiagnosed or misdiag-
nosed leaving the influenza that underlies
other conditions unrecognized. Health au-
thorities, scientific institutions and profes-
sional organizations worldwide undertake
a variety of seasonal influenza vaccination
initiatives. Despite these efforts, vaccine
coverage rates vary greatly between coun-
tries and between different targeted groups.
What’s more, it has been shown that ro-
bust annual influenza vaccination programs
are an important foundation for pandemic
vaccination capabilities, while also helping
to protect against annual epidemics. “Pan-
demic influenza poses an ongoing threat to
global public health and the Asia-Pacific
region is not immune to it.” – says Prof
Prasert Thongcharoen,Chairman of the In-
fluenza Foundation Thailand. “Vaccination
is the best way to fight this risk. However,
vaccinating large populations during a pan-
demic is highly challenging and requires
robust vaccine production, distribution and
administration capabilities. Seasonal vac-
cination can provide an important founda-
tion for this infrastructure, while also help-
ing to protect against annual epidemics”, he
added.
Experts are concerned that not enough is
being done to protect those most at risk for
serious complications. “Vaccination levels
among the Asian-Pacific population, in-
cluding health care professionals, are still
much too low”, says Prof Jennings, Chair-
man of the Asia-Pacific Alliance for the
Control of Influenza (APACI). “We hope
the meeting will stimulate policy and advo-
cacy approaches to improve influenza vac-
cine uptake in high-risk groups and health-
care workers in the region”, he went on to
say.
The Summit is modeled on the success-
ful European (ESWI) and United States
(CDC/AMA) Influenza Summits held in
2011. Key aims of the Summit are to review
the current state of official seasonal influen-
za control policies in Asia-Pacific countries,
and to establish collaborative relationships
to promote best practices for the control of
influenza. “Even though awareness of the
burden of influenza on public health con-
tinues to develop in the Asia-Pacific region,
there is presently no consensus on the best
way to prevent and treat the disease”, –add-
ed Prof Lance Jennings. “A meeting such as
this one will help to ensure that policies for
the use of seasonal influenza vaccines and
specific treatments are in place”he also said.
APACI is leading a partnership with the
Influenza Foundation of Thailand (IFT)
and the Department of Disease Control
(Thailand), to present the Inaugural Asia-
Pacific Influenza Summit.
Thailand is one of the countries in Asia that
has developed an effective influenza control
program that communicates the health and
economic impacts of influenza as well as the
benefits of prevention to healthcare work-
ers and high risk groups, including children,
the elderly and those with chronic diseases.
However the program had not been with-
out its challenges in particular in relation to
acceptance of vaccination among healthcare
workers.
Dr. Porntep Siriwanarangsun, Director
General at the Department of Disease
Control in the Ministry of Public Health
of Thailand added: “In view of all the chal-
lenges there is no doubt that continuous
studies about influenza, including policy
development, are important. No one can do
it alone. We need networks’ and partners’
collaboration to brainstorm, share experi-
ence and support each other. This summit
is a perfect occasion for this and its work
will serve not only Thailand, but the whole
Asia-Pacific region.”
For more information, please contact:
Kim Sampson
Executive Director
Asia-Pacific Alliance for the
Control of Influenza (APACI)
E-mail: kim@apaci.asia
Tamara Music
Manager, Influenza Vaccines
& Code Compliance
International Federation of Pharmaceutical
Manufacturers & Associations (IFPMA)
E-mail: t.music@ifpma.org
Asia-Pacific Influenza Summit
Experts at inaugural Asia-Pacific Influenza Summit warn that
annual influenza vaccination levels are too low
wmj 3 2012.indd 114 7/18/12 9:47 AM
115
Influenza
There are more than 59 million health
workers worldwide and the nature of our
work leaves us exposed to a complex vari-
ety of health and safety hazards every day.
Yet, as our job is to care for the sick we
sometimes fall into the trap of not thinking
about ourselves and believing that we are
“immune” to illness. We live and work by
the adage that the patient comes first.How-
ever, influenza does not share this point of
view. It is a risk to us as well as our patients.
Furthermore, if we do not protect ourselves,
then we increase the risk to our patients. So,
in fact, the fight against influenza in health
care settings starts with us.
According to the World Health each year,
approximately 5 to 10% of adults suffer
from seasonal influenza [1]. At the same
time, rates of 11–59% have been reported in
healthcare workers caring for infected pa-
tients [2].What it means in clinical practice
is that we can get influenza from patients
and coworkers, as well as from family and
other contacts outside the workplace. Some
of us are also at risk of the more severe ef-
fects of influenza, such as pregnant health-
care professionals or those with underlying
medical conditions. We get sick and then
we pass it on!
Healthcare professionals can act as vectors
for influenza viruses. Some dedicated pro-
fessionals actually avoid taking sick leave
thinking that they cannot stop providing
support to their patients. In fact, they are
also likely to pass the disease to their pa-
tients. However, influenza may be asymp-
tomatic while still posing a transmission
risk. In one study, 23% of healthcare work-
ers tested positive for infection following a
mild season, while 59% of these workers did
not remember having influenza and 28%
did not recall any respiratory illness [3, 4].
Therefore, as well as staying home when
they are sick, health care workers need to
make sure they don’t get infected them-
selves, if they are to protect their patients.
Sickness comes first to our mind when we
think about influenza. Yet, the infection
has also a potentially serious impact on the
health care services and related costs. In
extreme cases, it forces medical centers to
limit or stop admissions. This was the case
described in a study where an influenza
outbreak in a 19-bed internal medicine unit
prevented emergency admissions for 11
days and led to the postponement of eight
scheduled admissions [5].
Although influenza presents a major chal-
lenge, there is substantial evidence for its
control. Vaccination is safe and the most
effective way to prevent influenza [6]. The
WHO estimates that vaccination can pre-
vent 70–90% of influenza illness in healthy
adults.
Several studies have also associated health-
care worker immunizations with enhanced
patient outcomes. A US study found that
increases in healthcare worker vaccina-
tion from 4% to 67% were associated with
significant reductions in both the relative
frequency of influenza cases among staff
and the proportion of hospitalized patients
acquiring nosocomial infections. In this
particular study, nosocomial influenza rep-
resented 32% of cases amongst the patients
at the beginning of the study period and
subsequently fell to 0% [7, 8].
Robust annual influenza vaccination pro-
grams are also an important foundation for
pandemic vaccination capabilities. In the
case of the healthcare workers, they help
ensure the continuity of the health services
during pandemics.
Yet, despite all this evidence, many people,
including us – those involved in caring for
others, the healthcare workers – do not get
vaccinated.
Stakeholders around the globe are increas-
ingly aware that in order to succeed in
the fight against this disease, we need to
increase the seasonal influenza vaccina-
tion levels among the general public and
especially among the most vulnerable and
health-care workers. This is consistent with
the recent recommendations of the WHO
Strategic Advisory Group of Experts as
well as with the conclusions of high level
influenza summits held in different regions
of the world,the most recent being Asia Pa-
cific Influenza Summit in Bangkok, which
built on successful European and US sum-
mits from 2011.
As far as healthcare workers are concerned
the experts advising healthcare policy
makers suggest different approaches to
preventing influenza and increasing vac-
cination levels – from the use of declina-
tion forms, to providing free or subsidized
vaccines to the priority groups or more
drastic measures such as mandatory vac-
cination. Regardless of the preferred policy
approach, there seems to be one point that
Effective Fight Against Influenza Starts in
Our Daily Practice and Hospitals!
Lance Jennings
wmj 3 2012.indd 115 7/18/12 9:47 AM
116
SOUTH AFRICAProfessionalism in Health Care
Central to health care practice and the mor-
al contract between the public and the pro-
fession lies professionalism and professional
integrity.The purpose of health care practice
is to always care for the ailing and the sick,
promote health interests and well-being
and strive towards healing environments.
Professionalism, which sets the standard
of what a patient should expect from his or
her health care practitioner, is an ideal that
should be sustained [1]. Health care practi-
tioners are important agents through which
scientific knowledge is applied to human
health, thereby bridging the gap between
science and society. But health care practice
goes beyond just clinical or technical excel-
lence. It is more than just knowledge about
disease. It is also about experiences, feelings,
and interpretations of human beings in of-
ten extraordinary moments of fear, anxiety
and doubt. In this very vulnerable position,
professionalism underpins the public’s trust
in health care practitioners [2] and profes-
sional integrity and honesty should be a
measure of the extent to which the profes-
sional’s reputation and credibility remains
assured and untainted.
Political, social and economic factors to-
gether with advances in science and tech-
nology have reshaped attitudes and ex-
pectations of the public and health care
practitioners, whose roles and professional
responsibilities up till now were clear and
unequivocally well understood. In addition,
What does Professionalism in Health Care
Mean in the 21st
Century?
Ames Dhai David J McQuoid-Mason
resonates strongly with all experts – the
need to raise awareness, communicate and
educate healthcare workers on the neces-
sity of vaccination not only for themselves
but more importantly for their patients.
Part of this process should also include
listening to healthcare workers concerns’
and responding to false beliefs that might
prevent them from both getting vaccinated
and recommending influenza vaccination
to their patients.
I have been dealing with influenza for many
years now and I strongly believe that vac-
cination among healthcare workers is a nec-
essary and effective way forward in fight-
ing this disease as well for preventing and
controlling future pandemics. As healthcare
workers, responsible both for our own and
our patients’health, we must get vaccinated.
We should also be at the forefront of rais-
ing the awareness among patients as to why
influenza vaccination is the best option for
them and their families as well as for the
society at large.
References
1. WHO. Influenza vaccines, WHO position pa-
per. Weekly Epidemiol Rec 2005:33:279-287;
2. Salgado C, Farr B, Hall K et al. Influenza in the
acute hospital setting. Lancet Infect Dis 2002;
2:145-155.
3. Elder A, O’Donnell B, McCruden E et al. In-
cidence and recall of influenza in a cohort of
Glasgow healthcare workers during the 1993-4
epidemic: results of serum testing and question-
naire. BMJ 1996; 313:1241-1242.
4. CDC. Influenza Vaccination of Health-Care
Personnel, Recommendations of the Healthcare
Infection Control Practices Advisory Commit-
tee (HICPAC) and the Advisory Committee
on Immunization Practices (ACIP). MMWR
2006; 55(RR-2):1-16.
5. Sartor C, Zandotti C, Romain F et al. Disrup-
tion of services in an internal medicine unit due
to a nosocomial influenza outbreak. Infect Con-
trol Hosp Epidemiol 2002; 23:615-619.
6. Fiore AE, Uyeki TM, Broder K, et al. Preven-
tion and control of influenza with vaccines:
recommendations of the Advisory Committee
on Immunization Practices (ACIIP). MMWR
Recomm Rep 2010;59(RR-8):1-62.
7. CDC. Influenza Vaccination., op.cit.
8. Salgado C, Giannetta E, Hayden F et al. Pre-
venting nosocomial influenza by improving the
vaccine acceptance rate of clinicians.Infect Con-
trol Hosp Epidemiol 2004; 25:923-928.
Assoc. Prof Lance Jennings,
Chairman of the Asia-Pacific Alliance
for the Control of Influenza
(APACI)
wmj 3 2012.indd 116 7/18/12 9:47 AM
117
SOUTH AFRICA Professionalism in Health Care
several notorious failures of professional-
ism, including avaricious pursuits, with
concomitant adverse media coverage have
undermined public trust in health practice
and have led to a questioning of traditional
values and behaviour, challenging charac-
teristics that were once seen as the hallmark
of health practice [2]. Professional integrity
can easily be tainted when the nature of
the practitioner-patient relationship starts
to become transactional and patients are
viewed as customers and health care as a
commodity. Moreover, we have progressed
to an era where professional autonomy has
had to give way to accountability. Percep-
tions of practitioners as healers have also
been eroded by error and iatrogenic injury
[3]. What’s more, an emphasis on litiga-
tion as a tool in social justice has led to a
greater level of public awareness of the
harms that practitioners can be guilty of [4].
Without doubt, trust is critical to successful
care and where patients cannot trust their
practitioners, the quality of their care could
be seriously jeopardised. It is not because
practitioners have special knowledge and
technologies that they should be trusted.
They are trusted only if this knowledge
and technology is firmly attached to values
that are explicit, understood and altruistic.
The principal objective of practitioners is to
treat their patients well. Unfortunately, sur-
vey data over decades reveal that the level
of confidence and trust that was accorded
the profession several decades ago has been
substantially eroded [5].
Compassion, competence and autonomy
are judged to be core foundational values
in the practice of health care. Understand-
ing and concern for a person’s distress is es-
sential in this context. An extremely high
degree of competence is expected and re-
quired of practitioners. This is not limited
to scientific knowledge and technical skills,
but also includes ethical knowledge, skills
and attitudes, and an understanding of hu-
man rights and health law. As new ethical
issues arise with changes in practice and its
social and political environment, it is im-
portant that knowledge and skills are regu-
larly updated and maintained in this arena.
Autonomy has changed the most over time,
with practitioner autonomy being moder-
ated by governments and other authorities
and patient autonomy gaining widespread
acceptance[6].
The ethical and moral duties accorded to
health practitioners impose an obligation
of effacement of self-interest on the prac-
titioner that distinguishes health practice
from business and most other careers or
forms of livelihood [7]. Pellegrino states
that there are at least three things specific to
health practice that have led to this position.
Firstly, it is the nature of illness itself with
patients being in a uniquely dependent,
anxious, vulnerable and easily exploited
state,being forced into a position of trusting
the practitioner in a relationship of relative
powerlessness. Furthermore, when practi-
tioners offer to put knowledge at the service
of the sick, they invite that trust. Hence,
a health need in itself constitutes a moral
claim on those equipped to help. Secondly,
the knowledge gained by the practitioner
is not proprietary as it is acquired through
society sanctioning certain invasions of
privacy, e.g. experimenting with humans
and allowing for financial subsidisation of
health education. The practitioner’s knowl-
edge is therefore not individually owned
and should not be used primarily for per-
sonal gain, prestige or power. Finally, the
oath that is taken at graduation is a public
promise that the practitioner understands
the gravity of her/his calling and promises
to be competent and use that competence
in the interests of the sick [8].
Professionalism in health practice matters
just as much in the 21st
century as it did at
the time of Hippocrates over 2 500 years
ago. It has its roots in almost all aspects
of modern health care. Practitioners must
accept that financial and personal gain
are not all-important and need to look at
other ways to think about what else mat-
ters. Moreover, social responsibility, social
conscience and a resilience to external pres-
sures, political or otherwise, that interfere
with the ‘best interests’ principle are more
important now than ever before. Core val-
ues, principles and competencies must be
reflected upon and the question of what
it means to be a health care professional
and what is required to claim all privileges
granted by society to health professionals
should be re-appraised.
The South African Journal of Bioethics
and the Law has been launched to provide
a forum for experts and health care prac-
titioners to engage with their colleagues in
debate about the pressing ethical and legal
issues confronting the medical world during
the 21st
century.
References
1. Cruess RL, Cruess SR, Johnston SE. Profes-
sionalism: an ideal to be sustained. Lancet 2000;
356: 156-169.
2. Royal College of Physicians. Doctors in Society.
Medical Professionalism in a Changing World.
Report of a Working Party of the Royal College
of Physicians of London. London: RCP, 2005.
3. Institute of Medicine. Crossing the Quality
Chasm: A New Health System for the Twenty
First Century.Washington,DC: National Acad-
emy Press, 2001.
4. Association of American Medical Colleges. A
Flag in the Wind. Educating for Professional-
ism in Medicine. 2003. mwhitcombe@aamc.org
(accessed 16 March 2008).
5. Schlesinger M. A loss of faith: the sources of
reduced political legitimacy for the American
medical profession. Milbank Q 2002; 80: 185–
236.
6. World Medical Association. Medical Ethics
Manual. 2005.
7. Pellegrino ED, Thomasma DC. The Good of
the Patient: The Restitution of Beneficence in
Medical Ethics. New York: Oxford University
Press, 1987.
8. Pellegrino ED. Altruism, self-interest, and med-
ical ethics. JAMA 1987; 258: 1939–1940.
Ames Dhai, Editor of SAJBL;
David J McQuoid-Mason,
Co-Editor of SAJBL
2 June 2008, Vol. 1, No. 1 SAJBL
wmj 3 2012.indd 117 7/18/12 9:47 AM
118
Medical Ethics
With the institutional support of the re-
gional communities of the Economic Com-
munity of West African States (ECOWAS)
and particularly its department responsible
for health – the West African Health Or-
ganization (WAHO) – the Orders doc-
tors in the region that regroup 15 countries
including Anglophone, Francophone and
Portuguese countries, started in 2008 and in
2011resulted in the finalization of the har-
monization of the codes of ethics.
While elaborating two harmonized codes,
one for the French-Portuguese space and
the other for the English-speaking, it has
been found that the major ethical principles
were similar in the respective national codes.
Differences, particularly between the Eng-
lish-speaking and French-Portuguese con-
cern details; indeed, the inspiring ethical
codes of France are enunciative but not limi-
tative. The actions, even if they are not spe-
cifically detailed in the articles,are amenable
to disciplinary actions if they go against the
customs and practices of physicians.
Map of ECOWAS (15 countries – population
around 275 million)
Managers of medical Orders, in real-
ity pioneers, showed consensual spirit
undeniable to harmonize and to final-
ize the 02 codes in the common area.
We should pay homage to Professor Odu-
sote Kayode, former director of the De-
partment of Health and Professor Diallo
Abdoulaye, current director, who have con-
sistently demonstrated selflessness and ded-
ication in their tasks to arrive at the con-
clusion of this harmonization The difficulty
for recognizing the harmonized codes could
have come from Franco-Portuguese dental
surgeons most of whom have separate codes
of physicians while the English doctors and
dental surgeons have the same code.
The political leaders of ECOWAS welcomed
this advance which resulted in this harmoni-
zation, and stating that teachers in medical
schools have managed to develop a common
curriculum of general medical training, it
was ordered to continue working at integra-
tion for attaining the WAHO objective – the
realization of a unified code of ethics. This
is an exciting and a more difficult challenge
because the final objective is to ensure that
doctors and dental surgeons both Anglo-
phone and French-Lusophone recognize
and incorporate the provisions of the new
unified code.
The ad-hoc committee composed of Dr. Sal-
lah, Tapsoba, Abdulmumini, and Ekra and
chaired by Dr. Aka Kroo Florent has a chal-
lenge. The task will be facilitated by the fact
that it is based on harmonized codes that will
be developed in the Uniform Code by retain-
ing the similarities while taking into account
the specific differences to be adapted.
Dr. Aka Kroo Florent
President of the National
College of Physicians of Côte d’Ivoire
E-mail: florent.aka@medecins.ci
The Uniform Codes of Ethics in the Focus of Physicians and Dental
Surgeons of ECOWAS after Harmonization
Kroo Florent
The pioneers of harmonized codes with the ends and standing.
Prof.Abdoulaye Diallo left and Prof. Kayode Odusote right.
wmj 3 2012.indd 118 7/18/12 9:47 AM
119
WMA news
Background
The World Medical Association (WMA)
Junior Doctors Network (JDN) represents
the world’s first international body of junior
doctors, operating under the auspices of the
organization recognized as the voice of phy-
sicians worldwide.It provides junior doctors
with a global forum to exchange ideas, col-
laborate, and conduct research relevant to
issues they face in their training and career
development, while providing them the op-
portunity to participate and contribute to
the wider policy and advocacy work of the
WMA.
Founded in 2010 after acceptance at the
WMA General Assembly in Vancouver,
the JDN’s Draft Terms of Reference were
subsequently accepted at the 188th
 Council
Meeting in April 2011 in Sydney, Australia.
This groundwork allowed the growth of a
number of initiatives and culminated in the
successful inaugural JDN meeting, held in
conjunction with the 2011 WMA General
Assembly in Montevideo, Uruguay.
What is the Junior
Doctors Network?
The JDN is made up of junior doctors who
independently join the World Medical As-
sociation as Associate Members. Any ju-
nior physician may join and participate. As
the representative voice of young doctors
worldwide, the JDN attracts many mem-
bers who also hold leadership positions in
the resident or junior doctor sections of
their respective National Member Associa-
tions.
The JDN founding members were largely
alumni participants from the International
Federation of Medical Students’ Asso-
ciations (IFMSA) alumni. Other notable
founding members included junior doctors
from the Korean Interns and Residents As-
sociation, Australia Medical Association
Doctors-in-Training Council, Doctors-in-
Training New Zealand Medical Associa-
tion, American Medical Association, Brit-
ish Medical Association, Canadian Interns
and Residents Association, Brazilian Medi-
cal Association Junior Doctors, Singapore
Medical Association, and the Permanent
Working Group of European Junior Doc-
tors.
Why the Junior
Doctors Network?
The JDN acts as a forum for experience
sharing, policy discussions, and resource
development putting focus on issues per-
taining to junior doctors. Before the JDN,
there was no global forum directly voicing
the concerns and views of junior doctors,
interns, residents, and fellows at a global
level.This left a void in representation in the
middle of young physicians’ continuum of
training, since the interests of medical stu-
dents were represented by the IFMSA, with
the WMA representing physicians globally.
The development of the JDN now provides
a natural progression, further developing
the existing relationship between the IFM-
SA and the WMA. It fulfills the very im-
portant role of representing junior doctors
at a global level. Recognized in official rela-
tions, the JDN also supports the IFMSA
by strengthening the recruitment and de-
velopment of the IFMSA alumni network.
Finally, the JDN offers participants an op-
portunity to make an impact and to con-
tribute to the many levels of global health
via policy change at the WMA and with
the WMA’s partner organizations, such as
the WHO.
Junior Doctors Network
From the left :Thorsten Hornung, Lawrence Loh, José Luiz Gomes Do Amaral, Xaviour Walker
wmj 3 2012.indd 119 7/18/12 9:47 AM
120
WMA news
Defined functions and
objectives
The Junior Doctor Network has the follow-
ing functions and objectives:
1. Participate, advocate, and consult with
Constituent and Associate members of
the WMA on issues of interest to junior
doctors.
2. Collaborate with Constituent and As-
sociate members of the WMA and oth-
er stakeholders to increase the number
of junior doctors registered as Associate
members of the WMA.
3. Develop reference materials on issues
of interest to junior doctors, including
(but not limited to) literature reviews,
surveys, reports, and policy papers.
4. Communicate information on emerg-
ing issues of interest to junior doctors
internationally,in collaboration with the
National Medical Associations of the
WMA and other stakeholders.
5. Organize professional development ac-
tivities and develop resources for junior
doctors
6. Coordinate and disseminate informa-
tion on global health research and clini-
cal elective opportunities and resources
for junior doctors worldwide.
7. Develop and implement relevant ju-
nior-doctor led projects and programs.
Current projects and work
The JDN identified social media as an ini-
tial area of interest and expertise among
junior doctors, and one of the first proj-
ects undertaken was the development of a
white paper to provide additional scientific
detail for the WMA Policy on the Profes-
sional and Ethical Use of Social Media.
Subsequent projects are focused on other
issues of concern to junior doctors and
trainees, and include reviews of physi-
cian well-being and the ethical consider-
ations surrounding global health training.
The JDN also works in concert with other
WMA workgroups on identified issues of
interest to its members, such as the current
WMA workgroup on the ethics of physi-
cian strikes.
The JDN members participate as repre-
sentatives of the WMA at a number of
high profile conferences worldwide as well.
Members of the JDN have been actively in-
volved in working with the WMA team at
the World Health Assembly and other con-
ferences such as a recent patient centered
conference in Geneva, Switzerland.
Where to from here?
The JDN continues to grow and adapt to
the increasing interest and commitment
from members all over the world.The orga-
nization is presently undergoing a structural
review to improve its capacity and workflow
as the network grows. An important struc-
tural change concerns focusing on regional
growth, particularly related to the WMA
meeting venues in different continents. The
JDN hopes to support the development of
a website, as well as electronic resources and
virtual participation for its members. The
JDN also hopes to inspire and support the
growth of new national junior doctor bod-
ies as part of national medical associations,
to ensure that those residents, interns, and
trainees have a voice during this critical
phase in their career. Recently the JDN was
identified as a potential resource for two
new junior doctor bodies in the Asian re-
gion.
The JDN is working hard to develop sus-
tainable structures prior to the WMA
October General Assembly in Bangkok,
where the current committee is targeting to
increase the involvement and contribution
level of Asian junior doctors to wider activi-
ties of the WMA.
Xaviour Walker, MD
Lawrence Loh, MD MPH
Thorsten Hornung
E-mail: chair.jdn@wma.net
wmj 3 2012.indd 120 7/18/12 9:47 AM
III
Over the past weeks, we have witnessed
the intimidation of two prestigious Roma-
nian doctors, who were heard for 7 hours
at the National Anticorruption Directorate
(DNA), regarding the interception of the
dialogue between the doctors and the pa-
tient’s family.At the same time,the patient’s
diagnosis was made public and the whole
case had unallowable media coverage.
The context
The background of this national situation
relates to the case of the former Prime Min-
ister of Romania, Adrian Năstase, and his
suicide attempt. Mr. Năstase was sentenced
to two years in prison (after 8 years of trial).
On the night the Police came to his house to
arrest him, the former Prime Minister tried
to commit suicide by firing a bullet into
his head. To prevent it, one of the police-
men grabbed his hand and the bullet passed
through his neck.He was taken to Floreasca
Hospital where he was hospitalized.
Doctors’ intervention in the case
The next day, both Dr. Şerban Brădisteanu
(cardiologist at Floreasca Hospital and the
performer of the first human heart trans-
plant in Romania), and professor Ioan Las-
car (famous surgeon and Chairman of the
Bucharest College of Physicians) were part
of the multidisciplinary team that operated
on Mr Nastase after his suicide attempt.
The leader of the surgical team Dr. Bradis-
teanu said after the surgery that the patient
is under medical treatment and psychologi-
cal counseling at Floreasca Hospital, pre-
senting a high heart attack risk.The doctors
said that the former Prime Minister needed
14 days of hospitalization.
Dr. Bradisteanu was intercepted by the
DNA while telling to the patient’s family
that he was in a good condition.The doctor
is suspected of covering up the real condi-
tion of Adrian Nastase and of emphasizing
it for the media and for the public opin-
ion. Giving the context, the state institu-
tions accused the doctors that they kept
Mr Năstase in Floreasca longer than it was
needed.They wanted to transfer him to the
penitentiary immediately after the surgery.
Mr Nastase remained in Floreasca Hospi-
tal only 4 days.
In this case, the doctors who provided him
medical assistance were summoned to the
DNA. Thus, the DNA started the prosecu-
tion against Dr.Serban Bradisteanu because
of the absence of a medical expertise with a
conclusion on the real state of health of Mr
Nastase. Furthermore, Prof. Dr. Ioan Las-
car, Chairman of the Bucharest College of
Physicians, was summoned to be a witness
in this case.
On the second day after the admission to
the hospital, MEP Monica Macovei said
publicly that she did not trust the diagnosis
because Dr. Bradisteanu is a former PSD
senator. Also, Prosecutor General Codruta
Kovesi voiced suspicions concerning the
diagnosis made by the doctors. One day
before the experts of the Institute of Legal
Medicine made their expertise, the doctors
from Floreasca were forced to sign the re-
lease of Adrian Nastase, so that he could be
moved to the penitentiary at 11 p.m.This is
the most clear-cut case in which the doc-
tors are intimidated and threatened by the
DNA, but it is not the only one.
Official position of the Romanian
College of Physicians
The Romanian College of Physicians draws
attention to the extremely severe situation
of the medical professionals whose inde-
pendence is affected by the national investi-
gating committees.
In doing so, the investigators impose to
the medical professionals an illegal atitude,
unconformable with the doctor’s role in so-
ciety. The violent action, extensively propa-
gated through the media, does anything but
passes to the physicians the message that
whenever a medical act in the authorities’
view might have an impact on public in-
terests, the respective doctor is likely to be
summoned and stigmatized.
In this particular case, the patient’s rights
were infringed, the physician–patient-
family confidentiality relationship (accord-
ing to the law on patients’ rights) was vio-
lated. The diagnostic communication and
the dialogue between the doctor and the
patient or his familiy, without the consent
of the patient, violate the privacy stipulated
by law.
All these happenings constitute serious vio-
lations of human rights.
It has become a practice in Romania that
“incommodious” doctors are threatened
with criminal cases. The Romanian doctors
consider that such practices are unaccept-
able in a European country. Therefore, the
Romanian College of Physicians,requested
the Superior Council of Magistracy to be-
gin an investigation in the matter.
Luminiţa Vâlcea
Romanian College of Physicians
The Position of the Romanian College of
Physicians Regarding the Attempts to Violate
the Professional Independence of Doctors
Regional and NMA newsROMANIA
wmj 3 2012.indd III 7/18/12 9:47 AM
IV
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
White Paper On Ethical Issues Concerning Capital
Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
World Health Assembly Report, 2012,
Geneva, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Statement of World Health Professional Alliance
adressed to World Health Assembly . . . . . . . . . . . . . . . . . 92
Speech given by the US Secretary of Health and Human
Services Kathleen Sebelius at the WMA Luncheon in
Geneva, Switzerland, May 22, 2012 . . . . . . . . . . . . . . . . . . 95
“To Run and Not Grow Weary” . . . . . . . . . . . . . . . . . . . . . 97
Squeezing Out the Doctor . . . . . . . . . . . . . . . . . . . . . . . . . 101
50 Years of Cardiothoracic Surgery . . . . . . . . . . . . . . . . . . 104
Israeli Torture Doctors: Medical Ethics Betrayed . . . . . . . 106
Violence in the Health Care Sector –
an Updated Look . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Report on MedicReS World Congress 2012 on Good
Medical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
MedicReS International Conference on Good
Biostatistical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
The First Global Climate and Health Summit . . . . . . . . . . 113
Asia-Pacific Influenza Summit . . . . . . . . . . . . . . . . . . . . . . 114
Effective Fight Against Influenza Starts in Our Daily
Practice and Hospitals! . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
What does Professionalism in Health Care Mean
in the 21st
Century? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
The Uniform Codes of Ethics in the Focus of
Physicians and Dental Surgeons of ECOWAS after
Harmonization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Junior Doctors Network . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
The Position of the Romanian College of Physicians
Regarding the Attempts to Violate the Professional
Independence of Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . III
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