WMJ 02 0205

WorldMMeeddiiccaall JJoouurrnnaall
Vol. No.2,June200551
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
Contents
EEddiittoorriiaall
Human health resources and moral responsibilities 29
Saving the lives of Siamese Twins 30
MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
The World Medical Association –
Declaration of Geneva 31
Council of Europe 32
WWMMAA
170th WMA Council meets in Divonne 33
Council Resolutions adopted at the 170th
WMA Council Session, May 2005 38
WMA Dues Reform Proposal 40
WWMMAA SSeeccrreettaarryy GGeenneerraall
„Danger on the safe side“ 42
MMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee
aanndd EEdduuccaattiioonn
Patient Safety highlighted at World
Health Professions’ Reception 43
The Swedish Patient Insurance System –
A No-Fault System 44
New Online Tool Kit On HIV/AIDS
Prevention For Sex Workers 46
Twin Study Reveals Role in Female Infidelity 47
The national UK Multiple Sclerosis tissue Bank
co-ordinates the collection of donated tissue
and distributes samples to scientists conducting
research into the causes and treatment of MS 47
WWHHOO
Dr. Lee addressing the World Health Assembly:
Ends with concern with preparation before Avian
influenza strikes 48
Remarks of Mr Bill Gates at the World Health
Assembly 50
Strengthening health information systems to better
address health needs worldwide 52
The World Health Report 2005 – „Make every mother
and child count“ 53
An Innovative Approach to Health Systems Research 54
Vaccinating African Children against
Pneumococcal Disease Saves Lives 55
RReeggiioonnaall aanndd NNMMAA NNeewwss
Figures and facts from Africa 56
BMA „Call for action“ 56
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers and Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
i see page ii
President-Elect President Immediate Past-President
Dr K. Letlape Dr Y. D. Coble Dr J. Appleyard
South African Med. Assn. 102 Magnolia Street Thimble Hall
P.O. Box 74789 Neptune Beach, FL 32266 108 Blean Common
Lynnwood Ridge 0040 USA Blean, Nr Canterbury
Pretoria 0153 Kent, CT2 9JJ
South Africa Great Britain
Treasurer Chairman of Council Vice-Chairman of Council
Prof. Dr. Dr. h.c. J. D. Hoppe Dr Y. Blachar Dr N. Hashimoto
Bundesärztekammer Israel Medical Association Japan Medical Association
Herbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome
10623 Berlin 35 Jabotisky Street Bunkyo-ku
Germany P.O. Box 3566 Tokyo 113-8621
Ramat-Gan 52136 Japan
Israel
Secretary General
Dr O. Kloiber
World Medical Association
BP 63
France
ANDORRA S
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525/Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA S
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-114) 383-8414/5511
E-mail: comra@sinectis.com.ar
Website: www.comra.health.org.ar
AUSTRALIA E
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA E
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931
Fax: (43-1) 51406-933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA E
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-63
Fax: (3741) 53 48 79
E-mail:info@armeda.am
Website: www.armeda.am
AZERBAIJAN E
Azerbaijan Medical Association
5 Sona Velikham Str.
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS E
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 6802
Fax: (1-242) 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH E
Bangladesh Medical Association
B.M.A House
15/2 Topkhana Road,
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2-9566060/9568714
E-mail: bma@aitlbd.net
BELGIUM F
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
E-mail: absym.bras@euronet.be
Website: www.absym-bras.be
BOLIVIA S
Colegio Médico de Bolivia
Casilla 1088
Cochabamba
Tel/Fax: (591-04) 523658
E-mail: colmedbo_oru@hotmail.com
Website: www.colmedbo.org
BRAZIL E
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 317868 00
Fax: (55-11) 317868 31
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA E
Bulgarian Medical Association
15, Acad. Ivan Geshov Blvd.
1431 Sofia
Tel: (359-2) 954 -11 26/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA E
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 9331/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
CHILE S
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: sectecni@colegiomedico.c
Website: www.colegiomedico.cl
Titlepage: Rigshospital, Oslo: Architecturally a globally unique combination of health care and art. Also combining both academic
medicine and healthcare in one building, on either side of a “main street” running right through the building.
CHINA E
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6524 9989
Fax: (86-10) 6512 3754
E-mail: suyumu@cma.org.cn
Website: www.chinamed.com.cn
COLOMBIA S
Federación Médica Colombiana
Calle 72 – N° 6-44, Piso 11
Santafé de Bogotá, D.E.
Tel: (57-1) 211 0208
Tel/Fax: (57-1) 212 6082
E-mail: federacionmedicacol@
hotmail.com
DEMOCRATIC REP. OF CONGO F
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (242-12) 24589/
Fax (Présidente): (242) 8846574
COSTA RICA S
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA E
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: orlic@mamef.mef.hr
CZECH REPUBLIC E
Czech Medical Association .
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201/202/203/204
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
CUBA S
Colegio Médico Cubano Libre
P.O. Box 141016
717 Ponce de Leon Boulevard
Coral Gables, FL 33114-1016
United States
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK E
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: er@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC S
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686/
533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR S
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fdmedec@andinanet.net
EGYPT E
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A S
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112
Fax: -0324
E-mail: comcolmed@telesal.net
marnuca@hotmail.com
ESTONIA E
Estonian Medical Association (EsMA)
Pepleri 32
51010 Tartu
Tel/Fax (372) 7420429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
ETHIOPIA E
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS E
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) 315388
Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fj
FINLAND E
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 826/Fax-794
Telex: 125336 sll sf
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE F
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel: (33) 1 53 89 32 41
Fax: (33) 1 53 89 33 44
E-mail: cnom-international@
cn.medecin.fr
GEORGIA E
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 398686 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY E
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
Tel: (49-30) 400-456 363/Fax: -384
E-mail: renate.vonhoff-winter@baek.de
Website: www.bundesaerztekammer.de
GHANA E
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I. F
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060
Fax: (509) 245-6323
E-mail: amh@amhhaiti.net
Website: www.amhhaiti.net
HONG KONG E
Hong Kong Medical Association, China
Duke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY E
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36
1443 Budapest, PO.Box 145
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND E
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 8640478
Fax: (354) 5644106
E-mail: icemed@icemed.is
INDIA E
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 337009/3378819/3378680
Fax: (91-11) 3379178/3379470
E-mail: inmedici@vsnl.com /
inmedici@ndb.vsnl.com
INDONESIA E
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND E
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273
Fax: (353-1) 6612758/6682168
Website: www.imo.ie
ISRAEL E
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: estish@ima.org.il
Website: www.ima.org.il
JAPAN E
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN F
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA E
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT E
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA E
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN E
Liechtensteinischer Ärztekammer
Postfach 52
9490 Vaduz
Tel: (423) 231-1690
Fax: (423) 231-1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
LITHUANIA E
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
LUXEMBOURG F
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Association and address/Officers
ii
Association and address/Officers
iii
MACEDONIA E
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
MALAYSIA E
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40418972/40411375
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA E
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO S
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. Cons. 410
Colonia Obispado C.P. 64060
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: fenacomemexico@usa.net
Website: www.fenacome.org
NEPAL E
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 225860, 231825
Fax: (977 1) 225300
E-mail: nma@healthnet.org.np
NETHERLANDS E
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
NEW ZEALAND E
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472-4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA E
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 480 1569,
Fax: (234-1) 493 6854
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
NORWAY E
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA S
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@sinfo.net
PERU S
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores
Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@colmedi.org.pe
Website: www.colmed.org.pe
PHILIPPINES E
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: pmasec1@edsamail.com.ph
POLAND E
Polish Medical Association
Al. Ujazdowskie 24
00-478 Warszawa
Tel/Fax: (48-22) 628 86 99
PORTUGAL E
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: ordemmedicos@mail.telepac.pt
/ intl.omcne@omsul.com
Website: www.ordemdosmedicos.pt
ROMANIA F
Romanian Medical Association
Str. Ionel Perlea, nr 10
Sect. 1, Bucarest, cod 70754
Tel: (40-1) 6141071
Fax: (40-1) 3121357
E-mail: AMR@itcnet.ro
Website: www.cdi.pub.ro/CDI/
Parteneri/AMR_main.htm
RUSSIA E
Russian Medical Society
Udaltsova Street 85
121099 Moscow
Tel: (7-095)932-83-02
E-mail: rusmed@rusmed.rmt.ru
info@russmed.com
SLOVAK REPUBLIC E
Slovak Medical Association
Legionarska 4
81322 Bratislava
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA E
Slovenian Medical Association
Komenskega 4
61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOUTH AFRICA E
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/7
Fax: (27-12) 481 2058
E-mail: liliang@samedical.org
Website: www.samedical.org
SPAIN S
Consejo General de Colegios Médicos
Plaza de las Cortes 11
Madrid 28014
Tel: (34-91) 431 7780
Fax: (34-91) 431 9620
E-mail: internacional1@cgcom.es
SWEDEN E
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610
SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND F
Fédération des Médecins Suisses
Elfenstrasse 18 – POB 293
3000 Berne 16
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch
TAIWAN E
Taiwan Medical Association
9F No 29 Sec1
An-Ho Road
Taipei
Deputy Secretary General
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@med-assn.org.tw
THAILAND E
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: http://www.medassocthai.org/
index.htm.
TUNISIA F
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1082 Tunis Cité Jardins
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: ordremed.na@planet.tn
TURKEY E
Turkish Medical Association
GMK Bulvary,.
Pehit Danip Tunalygil Sok. N° 2 Kat 4
Maltepe
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
UGANDA E
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM E
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6710
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA E
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY S
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE F
Associazione Medica del Vaticano
Stato della Citta del Vaticano 00120
Tel: (39-06) 6983552
Fax: (39-06) 69885364
E-mail: servizi.sanitari@scv.va
VENEZUELA S
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org
E-mail: info@saludgmv.org
VIETNAM E
Vietnam General Association
of Medicine and Pharmacy (VGAMP)
68A Ba Trieu-Street
Hoau Kiem district
Hanoi
Tel: (84) 4 943 9323
Fax: (84) 4 943 9323
ZIMBABWE E
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791/553
Fax: (263-4) 791561
E-mail: zima@healthnet.zw
Editorial
Human health resources and
moral responsibilities
Since the beginning of the 21st
century there has been increasing concern, both nationally and
internationally, about the distribution and shortages of human health resources-doctors, den-
tists, nurses, pharmacists and all other varieties of paramedical professions. In the ‘70s. and
even in the ‘80s. physicians were gloomily predicting an excess number of physicians, and
there were even calls for the reduction of the number of medical students in some countries.
Suddenly all changed, and from a projected excess which had been predicted there was con-
cern about a shortage of doctors and nurses, first at national level and more recently at global
level. Over the past five years there have been a number of demographic studies of the distri-
bution and future needs of the various categories of health workers – not least physicians.
By the year 2003 international bodies were beginning to be concerned not only about the
shortage, but also with the effects of efforts to recruit doctors and nurses from countries
with limited economic resources and which already had serious under supply of health-
care professionals. In 2001, the Commonwealth Ministers of Health considered a paper
prepared by its secretariat and at a pre-World Health Assembly meeting in 2003, the Mini-
sters adopted a Commonwealth Code of Practice for the International Recruitment of He-
alth Workers. The World Medical Association considered the issue and adopted a Statement
on this topic in 2003. At this time the World Health Assembly, noting the Commonwealth
Code, requested the Director-General to explore possible ways forward to improve the situ-
ation concerning international recruitment (including the possibility of a Code of Practice
on international recruitment of health personnel, in particular from developing countries)
The key issues have been concerns that migration of health workers, notably doctors and
nurses from undeveloped and developing countries were not only consuming substantial
numbers of professionals from these countries, but were diminishing the national workforce
in these countries to even more dangerous levels, from their already overstretched and un-
derstaffed position. In the columns of this journal we have already drawn attention to this
situation (see Orvil Adams, WMJ50(3)pp 60-64,2004).
In the early part of this year the concerns were such that the British Medical Association is-
sued a “Call for Action“ and held an international conference at which Medical Associa-
tions notably from America, several African States, Canada and other interested bodies
such as the Commonwealth Secretariat, The World Health Organisation, MEDACT and the
Royal College of Nurses were represented. The resulting statement, together with the Four
Key Points which were identified (see p. 56), were drawn to the attention of the Common-
wealth Conference and other international bodies meeting this summer. Concern this year
has been reflected in the adoption in May of a Council Resolution (reinforcing its earlier
Statement in 2003) by the World Medical Association, by the consideration of this issue
at the WHO World Health Assembly and WHO’s designation of “Human Resources for He-
alth” as the topic for next year’s Annual WHO Health report and of the year 2006 as the be-
ginning of a decade of action on this topic.
That there is a moral issue underlying all this activity is understandable in the light of the
concern about the pattern of affluent countries recruiting health professionals from less de-
veloped and economically weak countries, not only depriving them of healthcare resources,
but also having indirect economic consequences. The cost of training healthcare professio-
nals, especially physicians, is a considerable burden in any society, let alone those whose
economies are already weak. When as much as 50% or more of the graduates from such
countries migrate (often not returning), this spells disaster for care in developing countries
who are economically weak but have already borne the cost of their professional training.
Editorial
29
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
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This expenditure is a complete loss to the
poorer economies which are not in any way
compensated for this loss either financially
or in terms of the professional resources of
which they have been deprived.
Migration for higher training is of course
essential, especially when it is not available
in the home country, and the basic human
right to migrate, whether for better working
conditions or other reasons, is that of every-
one, including physicians. However, while
regard must be paid by health professionals
themselves to the community in which they
have been trained to carry out their profes-
sional responsibilities, it is also the duty of
more affluent communities to have regard
to the more impoverished and deprived
communities in other countries.
Is it morally defensible to recruit health
personnel from deprived communities?
Is it morally acceptable to offer posts where
work and training are accessible to mi-
grants who lack facilities for such training
in their own country and then actively seek
to retain them, rather than encourage their
return to their own country which despera-
tely needs their skills?
Is any recruitment of this nature justifiable
for affluent countries who have simply not
trained enough health professionals to meet
their need, preferring rather to depend on
migrant professionals to make up the short
fall? At a time when affluent developed
countries are beginning to recognise the po-
verty in some parts of the world as unaccep-
table and requiring positive action (such as
has led to the Millenium Goals), is there not
a duty to address these problems in a practi-
cal way?
In the next month the G8 Group will meet.
It has many problems to address, including
that of Poverty – and the link between Po-
verty and Health is clearly undeniable. It is
therefore not surprising that the attention of
this powerful group is being drawn to the
fundamental importance of the need for
international agreement to a positive inter-
national discipline in the field of health pro-
fessionals’ recruitment, and to individual
governments’duties to provide facilities for
training enough healthcare professionals
for their own needs, as well as working
Editorial
30
Saving The Lives Of Siamese Twins
Siamese twins are exceedingly rare,
approximately one in a million live births.
In the 16th and 17th centuries they were
displayed as circus freaks, which has
evolved at the present day into intense
media interest.
Professor Lewis Spitz, Head of Paediatric
Surgery at Great Ormond Street Children’s
Hospital since 1979, has carried out 24 con-
joined Siamese twin separations in his 25-
year surgical career prior to retirement. In
order to ensure that both twins survive,
where one may be a parasite on the other,
the surgery involved can be complex and
difficult, with conglomerate masses repre-
senting fused organs. „Nothing is quite
where you expect it to be“ he says.
Every support is given to ensure survival,
with two surgical teams, one for each twin,
of about 15 nurses, surgical registrars and
theatre assistants under the two leading
paediatric surgeons, Mr Ed Kylie and
Professor Spitz.
The chances that one twin will die on sepa-
ration are nevertheless around 1 in 5.
Major organs like the heart can be fused
together making separation impossible.
At the start of the operation, the skin is
incised down to the level of the bone –
barn-door surgery as Professor Spitz puts it,
rather than keyhole surgery. Skin flaps
remain essential to provide cover later on
against hospital-acquired infection such as
MRSA. It is essential to make sure that
each affected organ has its own survival
line in place, which can be very tricky when
the stage is reached for the body to be
turned over before separation.
Blood loss from dissecting out the liver,
which has a particularly rich blood supply,
can be fatal. Also, the twins may share a
common bile duct, which can lead on to
obstructive jaundice. The dilemma for the
surgeon whether nature be allowed to take
its course or should the surgeon terminate
early? The surgical ethical view is that
conditions which will retain these profes-
sionals in their own countries. Where ne-
cessary this debate must take account of the
need for some countries to assist others to
meet the latter where their resources are in-
adequate to fulfil their requirements.
The USA calculate that by the year 2020, it
will require an additional 200000 physici-
ans and at present it apparently forsees no
alternative but to continue recruiting as be-
fore. The distribution of physicians in the
USA in 1996 per 10000 population was
26.5 (www consulted June 05) and in Gha-
na it is currently 0.75 per 10000 i.e.1500
physicians for a population of 20 million
population i.e. (personal communication).
As an illustration of disparity in migrant
physician usage, an OECD study in 2002
(Bourassa-Forcier M & Giuffrida A “Inter-
national Migration of Physicians and Nur-
ses…” – OECD Human Resources for He-
alth Care Project 2002), showed that the
percentage of workforce varied from the
UK and New Zealand 34.5% (in 2000),
compared with that Canada 25% (in 1998)
and in Austria which was 1.9% (in 1998).
Clearly physicians and other health profes-
sionals need to be aware of principles be-
hind Codes and Guidelines on Migration
and Recruitment in addition to their indivi-
dual responsibilities as members of their
professions, Of vital importance however,
the situation also calls for a radical re-thin-
king of political attitudes in developed
countries concerning both their responsibi-
lities to developing and deprived communi-
ties, the duty of countries to provide ade-
quate resources to train and retain enough
physicians and other health professionals to
meet their own country’s needs, and also to
assist, where necessary, the desperate needs
of others elsewhere in the world.
Alan Rowe
Siamese twins being stuck together for life
in this age of modern medicine is intolera-
ble. With such a good outlook, there is
every reason for these patients to lead a
normal, independent life-with a normal
lifespan.
Aetiology & future
treatments
If the Siamese twins present as an emer-
gency, the survival rate is comparatively low
at 13%, but where the surgery can be planned
in advance, with MRI scans and the con-
struction of models of affected organs, then
survival is much higher at around 80%. The
surgery is the product of very difficult deci-
sions, where he mass of tissues have to be
separated out and re-wired before being put
back together again in order as intact re-con-
nections. This can take 18 hours or even
longer for, a complex operation.
Causation
At present there are two theories of causa-
tion. The first suggests that at 13 days gesta-
tion or thereabouts, the dividing mass of
embryonic cells in a single pregnancy fails to
separate properly. The second hypothesis
places the emphasis on parts of the develop-
ing embryo which fuse together. Given the
choice, the optimal time to operate for suc-
cessful separation is about 7 months, when
the patients are still very tiny babies,
although every case is different and must be
evaluated on an individual basis.
The future
At the present rate of progress in terms of
medical advances in liver transplant
research, conjoined livers will soon be oper-
able provided that there is no excessive
blood loss from the rich blood supply. With
enhanced powers of cellular regeneration, re-
wired and re-connected twinned livers are
expected to respond very well to treatment in
addition to the present successes of trans-
formed bowels and urinary systems.
Ivan M. Gillibrand
Medical Ethics and Human Rights
31
Amongst the Declarations to which minor editorial changes were approved
at the 170th
Council meeting was the Declaration of Geneva. This was one
of the earliest and fundamental declarations of the World Medical
Association and in view of its importance and worldwide use, the revised
text is reproduced below.
The World Medical Association
Declaration of Geneva
Adopted by the 2nd
General Assembly of the World Medical Association,
Geneva, Switzerland, September 1948 and amended by the 22nd
World
Medical Assembly, Sydney, Australia, August 1968, the 35th
World
Medical Assembly, Venice, Italy, October 1983, the 46th
WMA General
Assembly, Stockholm, Sweden, September 1994 and editorially revised
at the 170th
Council Session, Divonne-les-Bains, France, May 2005.
AT THE TIME OF BEING ADMITTED AS A
MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to consecrate my life to the service of humanity;
I WILL GIVE to my teachers the respect and gratitude that is their due;
I WILL PRACTISE my profession with conscience and dignity;
THE HEALTH OF MY PATIENT will be my first consideration;
I WILL RESPECT the secrets that are confided in me, even after the patient
has died;
I WILL MAINTAIN by all the means in my power, the honour and the noble
traditions of the medical profession;
MY COLLEAGUES will be my sisters and brothers;
I WILL NOT PERMIT considerations of age, disease or disability, creed,
ethnic origin, gender, nationality, political affiliation, race, sexual orienta-
tion, social standing or any other factor to intervene between my duty and
my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT USE my medical knowledge contrary to the laws of humanity,
even under threat;
I MAKE THESE PROMISES solemnly, freely and upon my honour.
The Committee of Ministers of the Council
of Europe (CoE) opened on January 25th,
2005 the Protocol concerning Biomedical
Research for signature.
This Protocol, already signed by 14 mem-
ber states, is the first international legally
binding instrument to regulate research on
man. This framework defines the legal lim-
itations of research on man which need to
be incorporated in law, unlike the
Declaration of Helsinki or recommenda-
tions of CIOMS (see “Biomedical Research
in Europe” WMJ, Vol. 50, 64-66, 2004) etc.
Special attention should be paid to some
very important protective provisions which
are dealt with in a different manner, often
without regulation. These points are
a) research on persons not able to consent
and
b) use of placebo.
For information, these original articles are
printed below. Readers who are especially
interested in accessing the whole protocol
will find this on the CoE website:
http://www.coe.int/T/E/Legal_Affairs/
Legal_co-operation/Bioethics/
CHAPTER V
Protection of persons not able
to consent to research
Article 15 – Protection of persons not
able to consent to research
1. Research on a person without the capac-
ity to consent to research may be under-
taken only if all the following specific
conditions are met:
i. the results of the research have the
potential to produce real and direct
benefit to his or her health;
ii. research of comparable effectiveness
cannot be carried out on individuals
capable of giving consent;
iii. the person undergoing research has
been informed of his or her rights
and the safeguards prescribed by law
for his or her protection, unless this
person is not in a state to receive the
information;
iv. the necessary authorisation has been
given specifically and in writing by
the legal representative or an author-
ity, person or body provided for by
law, and after having received the
information required by Article 16,
taking into account the person’s pre-
viously expressed wishes or objec-
tions. An adult not able to consent
shall as far as possible take part in
the authorisation procedure. The
opinion of a minor shall be taken
into consideration as an increasingly
determining factor in proportion to
age and degree of maturity;
v. the person concerned does not
object.
2. Exceptionally and under the protective
conditions prescribed by law, where the
research has not the potential to produce
results of direct benefit to the health of
the person concerned, such research
may be authorised subject to the condi-
tions laid down in paragraph 1, sub-
paragraphs ii, iii, iv, and v above, and to
the following additional conditions:
i. the research has the aim of contribut-
ing, through significant improve-
ment in the scientific understanding
of the individual’s condition, disease
or disorder, to the ultimate attain-
ment of results capable of conferring
benefit to the person concerned or to
other persons in the same age cate-
gory or afflicted with the same dis-
ease or disorder or having the same
condition;
ii. the research entails only minimal
risk and minimal burden for the indi-
vidual concerned; and any consider-
ation of additional potential benefits
of the research shall not be used to
justify an increased level of risk or
burden.
3. Objection to participation, refusal to
give authorisation or the withdrawal of
authorisation to participate in research
shall not lead to any form of discrimina-
tion against the person concerned, in
particular regarding the right to medical
care.
Article 16 – Information prior to autho-
risation
1. Those being asked to authorise partici-
pation of a person in a research project
shall be given adequate information in a
comprehensible form. This informa-
tion shall be documented.
2. The information shall cover the pur-
pose, the overall plan and the possible
risks and benefits of the research pro-
ject, and include the opinion of the
ethics committee. They shall further be
informed of the rights and safeguards
prescribed by law for the protection of
those not able to consent to research and
specifically of the right to refuse or to
withdraw authorisation at any time,
without the person concerned being
subject to any form of discrimination, in
particular regarding the right to medical
care. They shall be specifically
informed according to the nature and
purpose of the research of the items of
information listed in Article 13.
3. The information shall also be provided
to the individual concerned, unless this
person is not in a state to receive the
information.
Article 17 – Research with minimal risk
and minimal burden
1. For the purposes of this Protocol it is
deemed that the research bears a mini-
mal risk if, having regard to the nature
and scale of the intervention, it is to be
expected that it will result, at the most,
in a very slight and temporary negative
impact on the health of the person con-
cerned.
Medical Ethics and Human Rights
32
Medical Ethics and Human Rights
Council of Europe
Additional Protocol To The Convention On Human Rights
And Biomedicine Concerning Biomedical Research
WMA
33
Dr. Otmar Kloiber opened the meeting, wel-
coming especially the seven new members of
Council, and introduced Dr. Johnson (USA)
Past President of the WMA who gave an
introductory talk for new members on the
structure and functions of Council and its
committees. He stressed the importance of
input into debates, the importance of always
remembering the diversity of cultures and
languages and explained the procedures used
by council and committees. This was warm-
ly appreciated by Council.
The Secretary General called for nominations
for the Chair. Dr. Y. Blachar (Israel) was
elected, with Dr. N. Hashimoto (Japan) as
Vice-Chair, both by acclamation. Dr. Blachar
after expressing his thanks both to council
and all the officers who had supported him
during the past two years continued with the
elections Dr. J. D. Hoppe (Germany) was
elected Treasurer.
Dr. K. Vilmar (Germany) was granted the
honorary title of Treasurer Emeritus.
The following were elected as members of
the Ethics Committee:
Dr. P. Anttila (Finland), Dr E. N. Bagenholm
(Sweden), Dr. H. Haddad (Canada), Dr. N.
Hashimoto (Japan), Dr. J. D. Hoppe
(Germany), Dr. H. Miyazaki
(Japan), Dr. J. C. Nelson (America), Dr. D. J.
Palmisano (America), Dr. B. Selebano
(South Africa), Dr. Viera de Paiva (Brazil),
Dr. Y. T. Wu (Taiwan).
The following were elected members of the
Socio-Medical Affairs Committee:
Dr. J. Haddad (Canada), Dr. L. J. Callo’h
(France), Dr. N. Hashimoto (Japan), Dr. J. E.
Hill (USA), Dr. J. Johnson (USA), Dr. DJ.
Palmisano (USA), Dr. B. Selebano (south
Africa), Dr. K. Vilmar (Germany), Dr. E.
Viera de Paiva (Brazil), Dr. Y. T. Wu
(Taiwan).
Advisers to the committees were also
appointed
The following were elected members of the
Finance and Planning Committee
Dr. J. Nelson (USA), Dr. Antilla (Finland),
Dr. E. N. Bagenholm (Sweden), Dr. J.
Calloc’h, Dr. J. E. Hill (USA), Dr. J. D.
Hoppe (Germany), Mr. J. J. Johnson (U. K.),
Dr. H. Myazaki (Japan), Dr. K. Vilmar
(Germany).
Following the adoption of the Minutes of the
169th Council meetings in Tokyo, the
President then reported on his activities dur-
ing the past months following the Tokyo
General Assembly.
President’s interim report
Dr. Coble reported that he had the privilege
of visiting the Hungarian, Portuguese, Israel,
Indian, Taiwan, China the UK and many
other NMAs during the past year All his con-
tacts with physicians had confirmed his pre-
vious impressions that NMAs were con-
cerned with the care of patients, quality of
care, patients’ access to healthcare and activ-
ity as advocates for patients for whom free-
dom to chose their physicians was fundamen-
tal. There was also concern about physicians’
autonomy. He also referred to his contacts
with and the work of WONCA, the Society
of Internal Medicine and other global groups
in all aspects of medicine. Dr Coble also
referred to important contacts with the other
health professions, in particular through the
World Health Professions Alliance,
emphasing especially the value of relation-
ships with the Nursing Profession.
In referring to the major role of WMA in
Medical Ethics since its foundation in 1948,
he stressed the wider role of WMA as set out
its mission, and stressed that WMAs activi-
ties were more and more having to be extend-
ed into other fields such as improving health
care provision and the quality of healthcare.
Relevant to this was the World Ocean Forum,
which the WMA had founded to discuss the
vital health topic of potable water. This had
been a particular success involving a large
number of interested bodies including the
UN, WHO, and the World Bank. Mentioning
especially the non-governmental bodies, he
referred to International Rotary who had
played a notable role in the provision of
potable water. This Forum illustrated the
strength and real value of public/private ini-
tiatives.
He paid a special tribute to the Japanese
Medical Association for their hospitality in
hosting the highly successful General
Assembly in Tokyo.
2. It is deemed that it bears a minimal bur-
den if it is to be expected that the dis-
comfort will be, at the most, temporary
and very slight for the person con-
cerned. In assessing the burden for an
individual, a person enjoying the special
confidence of the person concerned
shall assess the burden where appropri-
ate.
Article 23 – Non-interference with neces-
sary clinical interventions
1. Research shall not delay nor deprive
participants of medically necessary pre-
ventive, diagnostic or therapeutic pro-
cedures.
2. In research associated with prevention,
diagnosis or treatment, participants
assigned to control groups shall be
assured of proven methods of preven-
tion, diagnosis or treatment.
3. The use of placebo is permissible where
there are no methods of proven effec-
tiveness, or where withdrawal or with-
holding of such methods does not pre-
sent an unacceptable risk or burden.
Prof. Elmar Doppelfeld, MD
Chair of the Steering Committee on “Bio-
ethics” of the Council of Europe
WMA
170th WMA Council meets in Divonne
Dr. Coble also paid particular tribute to Dr.
Myllymaki and Dr. Appleyard, his predeces-
sors for all their work and support.
Turning to the change of Secretary General,
he outlined the process of change. The
Search Committee who considered the
numerous applications for the post eventual-
ly resulting in the appointment of Dr. Otmar
Kloiber, and said that the process of the tran-
sition and hand-over had been smooth and
successful In the course of this, earlier in the
year both Dr. Human and Dr. Kloiber had
met with him on a number of occasions,
notably on two of them to consider the
responses of NMAs on governance and their
co-ordination into a single document. During
these periods there had also been the oppor-
tunity to attend the Executive meeting of
WHO which received Dr. Nabarro’s initial
report on the tsunami, and to meet Dr.
Nabarro on a further occasion which
promised fruitful Opportunities for further
collaboration.
Turning to the “Caring Physicians” project he
gave some details of the project and its
progress. This was a project responding to the
NMAs indication that there was a need for
greater transparency to be given to the “car-
ing role” of physicians which was not as
widely known as it should be. Hence the pro-
ject asked individual NMAs to identify
examples of physicians whose work demon-
strated these qualities, with the intention of
publicising this in book form which he felt
would go some way to emphasise these val-
ues. He had approached the Pfizer
Humanities Division, which felt this to be
this worthy of support and a committee rep-
resentative of the six regions was appointed
to advise on the project. NMAs from 55
countries made a very good response on a
very tight time scale, to an approach to iden-
tify physicians from their own countries who
illustrated these qualities. Following a meet-
ing of the judges in London, appropriate can-
didates were identified and this publication
would be released at the GeneralAssembly in
Santiago.
Referring to the regions, he reported that he
had had contact with the Council of the
Indian Medical Association and there was an
increase in their participation in WMA. The
Chinese Medical Association was more
active and he would be attending a Bio-ethic
Conference there later this year at which the
ethics of transplantation would be on the
agenda. He gave further details of regional
meetings including one which had taken
place, involving 8 of the Sub- Saharan coun-
tries. He had met with and assisted the Iraq
Medical Association concerning the re-estab-
lishment of their Medical Association which
had been illegal under the previous regime,
and attended a number of Regional meetings.
For the future, much would depend on the
Strategic plan but he stressed that his contacts
were very positive for further Regional meet-
ings in various parts of the world, mentioning
South America and South East Asia in partic-
ular, and expressed his concern at the few
members in the Middle East.
Finally he thanked those who had been par-
ticularly helpful with the problems of the
Regional meetings and expressed his thanks
to the Chair and to the new Secretary
General.
Dr. Blachar acknowledged Dr Coble’s exten-
sive work and called for the Secretary
General’s report.
Secretary-General’s report
Dr. Kloiber commented on the transition
from Dr. Delon Human who had held the
office for nearly eight years, finishing his
work with three major projects to be intro-
duced or finalised.
The first was the launching of the initiative
by the President in Tokyo of the “Caring
Physicians of the World” referred to in the
President’s report.
The second was the Ethics Manual which had
been prepared by the Director of Ethics, Dr.
J. Williams, assisted by a committed team of
advisers. This was released at a successful
launch in January 2005 and has received con-
siderable attention. French, Spanish and
German translations are nearly complete, and
other translations under consideration.
The Third was the World Ocean Forum held
in New York 15–16 November 2004. This
was a common endeavour of the World
Ocean Observatory, the Pfizer Medical
Humanities Initiative and the World Medical
Association. It was well attended by scien-
tists and activists from water ecology inter-
ests, and high officials of the UN
Development programme, the UN, national
(USA, Canada, Australia) authorities as well
as the Executive Director of the WHO
Environmental Division, Dr. Kerstin Leimer.
This successful event tragically just preceded
the tsunami disaster, following which the
water and ocean related issues discussed dur-
ing the meeting were illustrated in a most
dramatic fashion (The full report is available
at www.worldoceanforum.org.
Dr. Kloiber commented “these three projects
are just a few examples of the outstanding
service provided by Dr. Delon Human as the
Secretary General over nearly eight years.
We owe him our gratitude and appreciation
for his work.”
Dr. Kloiber used the time between his
appointment in Tokyo and his assumption of
duties as the Secretary General on 1st
February 2005 for the hand-over, including
his introduction to regional organisations, to
the WHO Executive Board meeting and his
participation in the World Ocean Forum.
Reporting on these meetings he expressed
hopes for further co-operation with all such
bodies in the future.
The Governance Working Group continued
as the highest priority, in several meetings
and telephone conferences proposals were
analysed and collated into one report referred
back to Council. The implementation of the
decisions of Council and the General
Assembly would be a major task for the sec-
retariat.
Reporting on the First Global meeting of the
International Alliance of Patients’
Associations (IAPO) in February 2005, he
reported that representatives of the World
Health Professions Alliance (WHPA) had
addressed the question of collaboration
between the two bodies, this had been warm-
ly welcomed by IAPO. Such discussions will
be of importance not only at global but also
at national level (www.iapo.org).
The Secretary General reported on the work
of the European Forum of Medical Associa-
tions and WHO at its meeting in March (see
pp WMJ 51(5)28), on the initiative of the
Standing Committee of European Doctors
WMA
34
(CPME) on Patient Safety and on their iden-
tification of key problems in common with
WHO Regional Scientific Session. In this
connection, systems to identify or report haz-
ards in patients safety net need to be set up; a
safety culture has to be built up that departs
from the blame and shame approach and pro-
vides a blame-free procedure to handle mis-
takes, accidents and “close calls”. The use of
telematics (e-health) should be promoted. It
will allow health care to be made safer, as
demonstrated in the field of drug prescrip-
tion. Senior officials including the Mr
Markos Kyprianou, European Commissioner
for Health, the current Chair of the Council
Health Ministers, and the Director of Public
health of the European Commission, all com-
mitted themselves to EU support for research
and development in the field of patient
safety.
He reported his attendance at several
Assemblies of National Medical
Associations. Dr. Kloiber detailed the objec-
tives for the future incorporated in the
Strategic Plan 2003-2007 namely, to increase
visibility of the WMA at all levels, to
increase both membership and associate
membership by 20%, to focus on agreed
objectives and not pursuing all possible
opportunities, and create a stable financial
position. He detailed the main activities
needed in
– the improvement of medical care and
health in general;
– medical ethics
– human rights
– advocacy
– networking and management
– non-dues revenue,
and the problems associated with achieving
these.
Finally he reported that action had already
been taken on consolidation of the bank
accounts of the Association and the invest-
ment of liquid assets, on a cost analysis of
daily business processes and subsequent cost
reduction, and outsourcing the position of
one translator.
Dr. Masson inquired whether the Chinese
Medical Association adhered to the ethical
standards of WMA, in particular in relation to
Transplantation of organs, and the involun-
tary donation of organs?
Dr. Kloiber responded by indicating that he
repeatedly had contacts with CMA. There
should not be preconditions, but transplanti-
ng of Organs will be in the agenda. The
President commented that talking continues
with the Chinese, and there was cosponsoring
for a meeting in the period June- August.
Following the decision to refer several
motions respectively to the Ethics and
Medico-Social Committees, Council
adjourned until Sunday 15th May.
Medical Ethics Committee
The committee met on 13th May under the
Chairmanship of Dr. Bagenholm, who paid
tribute to the stalwart work of her predeces-
sor Dr. Snaedel.
Following the adoption of the minutes of the
last meeting in Tokyo, Dr. John Williams, in
presenting his report on the work of the
Ethics unit, thanked Dr. Snaedel for all the
work he had done during his Chairmanship
of the committee. He continued by stressing
that the key objective of the unit had been to
make the WMA Ethics activities better
known. The Ethics Manual had been distrib-
uted widely to 125 Medical journals. There
had been many positive reviews of the man-
ual, which had been well received. In addi-
tion to the French and Spanish version being
prepared, there had been offers for Japanese,
Chinese, Armenian, German, Macedonian
and many others Funds were not, however,
available to publish in all these languages,
but he hoped that NMAs who translate will
be able to distribute the version by e-mail,
web, CD ROM etc. Turning to future activi-
ties, these would include continuing the poli-
cy review, promotion of the manual -possibly
web based, and it was hoped that an ethics
education course would be available in
March. Dr. Haddad enquired whether assis-
tance was needed either in terms of finance or
other NMAassistance, to which Dr. Williams
replied that money was needed especially to
produce hard copies and Dr. Kloiber made
clear that funds were not available for distri-
bution of copies.
Policy Review
The committee then considered the recom-
mendations on policies for minor review fol-
lowing consultation with NMAs, and decided
on the following categorisations
Declaration of Tokyo Approved with minor
amendment
Declaration of Oslo – Major review
In discussion, Estonia felt that the document
was too narrow and Bolivia also felt a major
review was required.
The Statement on Human Rights and
Individual Freedom of Medical Practitioners:
following amendment of the title to “Non-
discrimination in professional membership,
and activities of physicians” the statement
was adopted as revised.
Declaration of Madrid on Professional
Autonomy and Self- Regulation, was adopt-
ed, with minor amendments.
The Madrid declaration on Euthanasia was
approved, unamended.
The Resolution on Academic Sanction or
boycotts was approved with minor amend-
ments
The Marbella statement on Physician-assist-
ed Suicide, was approved, unamended.
With minor editorial changes, the revised
statement on Body Searches of prisoners was
approved.
The proposed revised Declaration of
Geneva, with minor changes, was approved
(see p 31).
Statements for major revision:
Dr. Snaedel reported that work on the
International Code of Medical Ethics on
which the Working group established in
Tokyo would continue, and it was noted that
sections on patient autonomy and freedom of
choice, the duties of physicians to keep up to
date, to teach, dual responsibility (e.g. when a
physician acts for a third party), and the
duties of physicians to themselves, would be
proposed as additions to the redraft.
WMA
35
Adv. Malke Borrow introduced the proposed
statement on Genetics and Medicine on
which NMA comments had been received.
The draft produced considerable discussion,
in particular in relation to the use of the word
“regulated” in relation to developments in the
field of Gene therapy and genetic research. It
was finally decided hat this word was not
appropriate and the relevant sentence intro-
ducing guidelines should read “However,
with the continuing development of this field
(Gene therapy and genetic research) it should
proceed, according to the following guide-
lines…”.Anumber of other texts and amend-
ments were introduced and the text adopted
as amended Organ donation and transplant.
The working group would continue its work.
The proposed statement on HIV/AIDS was
referred to NMAs; as was a document on
Telematics, and the Venice Declaration on
Terminal illness.
Although the Statement on Human Organ
and Tissue Donation and Transplant was a
relatively new one, the Danish Medical
Association had proposed an addition in
January 2005. Having received comments on
this from NMAs, it was agreed that this
should undergo general review.
Of the pre- 1995 documents, it was agreed
that the Declaration of Sydney (determina-
tion of Death), the Statements on Freedom to
attend medical meetings (Singapore), the
Statements on Foetal Tissue (Hong Kong), on
Patient Advocacy (Budapest), on Medical
Ethics in the event of Disaster (Stockholm),
and on Animal use in Medical Research
(Hong Kong) should all have major revi-
sion.
The following should be rescinded and
archived:
Statement on Physician Independence and
Professional freedom (Rancho Mirage)
which was- largely covered by Madrid, the
Statement on Genetic Counselling and
Engineering, the Declaration on the Human
Genome Project and the Resolution on
Cloning.
Concerning post 1995 documents, the
Statements on Ethical Aspects of Embryonic
Reduction (Bali), and that on Child Abuse
and Neglect (Singapore) required major
revision.
The Statement on Patients’ rights (Lisbon)
required minor amendment and those on
Mental Illness (Bali), Human Rights (Rancho
Mirage) should be archived.
Human Rights
Dr. Williams referring to his Report on
Human Rights stated that the education pro-
gramme on Doctors and Prisons had been a
great success. The CD-ROM was now avail-
able in Spanish. Members of Council had
participated in the pilot projects on the
Istanbul Protocol. Dr. Appleyard commented
on the importance of ICRC participation and
the support of the European Union. He spoke
about his visit to Uganda where there had
been a conference with participants from 5
countries and training (which included
lawyers) on support and identification of vic-
tims.
Concerning Zimbabwe, both Drs Appleyard
and Letlape stressed the problems and
appealed for help for colleagues in
Zimbabwe. An attempt to organise a regional
meeting including Zimbabwe eventually took
place after some delay. Speaking of the crisis
there, one in eight children die and one in five
children are orphans. Concerning emigration
of healthcare workers it was pointed out that
the number of physicians had dropped from
1400 to 800 for a population of 11 million.
Harare Hospital, the largest in the country,
was literally breaking up and there was insti-
tutionalised violence and torture. CME in
Zimbabwe was now obligatory, and we must
try to connect with colleagues through this.
Dr. Letlape commented on the silence from
the Zimbabwe Medical Association on
Human Rights. There had been a meeting of
the two organisations and there was no call
for help from ZMA. Thus it was not possible
to intervene without a request from the ZMA.
Their autonomy must be respected but he
said, “we therefore must respond to any call.
We want to establish a regional meeting and
he hoped to report further in Chile”.
The committee had further discussion on the
human rights issues in Zimbabwe.
Two members referred to the absence in cer-
tain WMA statements of reference to physi-
cians’participation in torture, actively or pas-
sively. Dr. Nathansen referring to this pointed
out that this had been highlighted in the New
England Journal of Medicine and comment-
ed that the “Dual issues” concerning loyalty
was important in this context…
Professor Blahos who had twice been in
Ethiopia spoke of the situation in the Fistula
Hospital in Addis Ababa and said that the sit-
uation was terrible outside Addis Ababa. Dr.
Haddad felt it important to establish a work-
ing group to inquire into whether there was a
need for additional wording in the
Declarations of Geneva or Tokyo, and this
was agreed.
The Danish Medical Association raised the
issue of removal of organs for sale from pris-
oners in China on which it had received a
report. It would produce a motion for the
General Assembly. Following a lively debate
the Secretary General was asked to look into
this matter.
The Israeli Medical Association proposed a
Council resolution on the situation in Darfur,
where there were 300,00 deaths and over a
million displaced persons. Dr. Blachar said
that “The WMA as an international medical
organisation committed to the protection of
health and human rights for all, has frequent-
ly expressed its support for human rights in
statements, and today we are urging national
medical associations around the world to
press their governments to intervene now to
stop the mass killings and to protect the
health and safety of refugees in the region”.
This was approved and subsequently adopted
by Council.
All the recommendations of the committee
listed above sere subsequently agreed by
Council in adopting the report of the Ethics
committee.
Socio-Medical Affairs
Committee
The committee met on 13 May and Dr.
Haddad was elected Chair of the Committee.
Following the approval of the minutes of the
Tokyo meeting in October 2004, the
Committee considered NMA views on pro-
WMA
36
posed policy changes designated in Tokyo as
requiring minor revision.
The committee recommended approval of
the revision to the Boxing Statement and the
Statement on female Genital Mutilation and
the Declaration on the Abuse of the Elderly
(Hong Kong).
However, it recommended that the Statement
on Adolescent Suicide undergo major revi-
sion.
Concerning those policies requiring major
revision, the committee next considered
reports on the progress, which had been
made.
Dr. Calloc’h reported that in relation to the
Statement on the Role of Physicians in
Environmental and Demographic issues, the
French Medical Association felt that a major
issue needed to be addressed, namely the
need for WMA to adopt policy on achieving
a balance between informing the public and
avoiding public alarm on environmental and
preventive issues, citing Pollution and
Asthma as an example. At the Chairman’s
suggestion the FMA would prepare an appro-
priate document.
Dr. Letlape reported that the South African
Medical Association had decided to delay
revision of the Statement on Access to Health
Care until after the General Assembly discus-
sion of this issue later in the year.
Following considerable discussion and some
amendment, the proposed Statement on
Drugs Substitution was recommended for
approval and forwarding to the General
Assembly for adoption, and that the
Statement on Generic Drug Substitution and
the resolution on Therapeutic Substitution be
rescinded and archived.
A proposed WMA Statement on Medical
Education as amended was recommended to
be forwarded for NMA comment.
Turning to a proposed statement on Medical
Liability Reform, Dr. Palmisano stressed the
seriousness of the situation in the USAwhere,
in the previous week, awards of 20 and 30
million US$ had sent a chill through the pro-
fession. The Swedish delegation stated that
the document as written was unacceptable to
them as they had a “ no-fault system”, and
there was a contribution from Spain which
pointed out that both criminal and civil courts
may consider liability cases where appropri-
ate. “There was however a need to fight
against the criminalisation of liability.”
Following a discussion on these issues a suit-
able form of words was agreed and the pro-
posed WMA Statement on Medical
Liability Reform as amended was recom-
mended for approval and transmission to
the General assembly for Adoption.
Turning to six policies which had not been
classified; the following decisions were
made:
Recommendations concerning Medical care
in Rural Areas – be rescinded and archived
The Statement on Use and Misuse of
Psychotrophic Drugs to undergo major revi-
sion
The Statement on Persistent Vegetative State
be rescinded and archived
The Statement on traffic Injury undergo
major revision
The Statement on Noise Pollution, to under-
go major revision.
The Statement onAlcohol and Road Safety to
undergo major revision (also to include
consideration of drugs and road safety).
Concerning 1995 Socio-medical policies, the
committee recommended the following
The Statement on the Prescription of
Substitute drugs in the Outpatient Treatment
of Addicts to Opiate Drugs to undergo
major revision
The Statement on Health Promotion to
undergo major revision
The Resolution on Testing of Nuclear
Weapons to be rescinded and archived.
Various NMAs accepted responsibility for
revision of some of these policies and the sec-
retariat for two others.
The Irish delegation reported on the progress
of the workgroup on a Statement on Obesity.
Dr. Calloc’h reported that the CPME were
also working on this topic and he called for
something from WMA on Lipids, carbohy-
drates etc.
The Secretariat reported on the development
of an On-line Course on the Treatment of
Drug- Resistant TB, and the South African
Medical Association gave a report on their
progress in co-operation with WHO on this
issue.
The Committee proposed that a statement on
reducing the Global Impact of Alcohol on
Health and Society be forwarded for NMA’s
for comment.
In the discussion of a proposed Council
Resolution on the Healthcare Skills Drain,
The UK reported on the conclusions of a suc-
cessful Conference recently held at the BMA
which included amongst those attending, var-
ious Commonwealth countries as well as oth-
ers including Africa, WHO, the
Commonwealth Secretariat, Nurses and other
interested bodies.
The Canadian Medical Association com-
mended WHO for taking a leadership role in
facing the global challenges of Human Health
Resources. It concluded by stressing the
major ethical implications for health care, the
problem of the northern countries “siphoning
off” resources, and stressed that in the discus-
sions the financial cost of medical studies
should not be overlooked. There was an
impassioned plea from South Africa that doc-
tor substitution was not the only answer, but
it was vital to produce doctors to meet needs
(see page 56).
The Committee was informed that an invita-
tion had been received from WHO to con-
tribute to the WHO Annual report for next
year, which would be on Human Resources
for Health.
The Proposed Council Resolution on
Healthcare Skills Drain was recommended
for approval by Council and NMAs offered
to participate in the work group called for in
the resolution. Council subsequently adopted
the Resolution (see box).
The Committee also recommended that the
proposed Council Resolution on observer
Status for Taiwan to the WHO and its inclu-
sion as a participating party to the
International Health regulations be
approved.
A Proposed Council Resolution on
Implementation of the WHO Framework
convention on Tobacco Control was recom-
WMA
37
WMA
38
WMA Council Resolution on
genocide in Darfur
Adopted at the 170th WMA Council Ses-
sion, Divonne-les-Bains, France, 15 May
2005
WHEREAS, a reported 300,000 Darfuri-
ans have been killed and one million refu-
gees displaced since early 2003, on the ba-
sis of racial or ethnic origins; and
WHEREAS, there have been official re-
ports of savage killing, torture, rape and
mutilation of men, women and children by
the Government of Sudan and its allied mi-
litia; and
WHEREAS, many of these reports, inclu-
ding that of the UN Commission of Inquiry
on Darfur, have only recently been publici-
zed; and
WHEREAS, genocide, as defined by the
1948 UN Convention on the Prevention
and Punishment of the Crime of Genocide,
is the killing or destroying of populations
on the basis of their racial or ethnic identi-
ty; and
WHEREAS, the WMA, as an international
medical organization committed to the pro-
tection of health and human rights for all,
has expressed its support for human rights
in statements and resolutions, among them
the Resolution on Human Rights, adopted
by the WMA in Rancho Mirage during the
42nd General Assembly and amended by
the 45th, 46th and 47th GeneralAssemblies,
THEREFORE, BE IT RESOLVED, that
the WMAcondemns the genocide in Darfur
and calls upon its member NMAs to urge
their governments and the international
community to take immediate action to
stop the mass killings, expulsions, rape and
destruction in Darfur and to protect the he-
alth and safety of refugees in the region.
WMA Council Resolution on
the healthcare Skills Drain
Adopted at the 170th WMA Council Ses-
sion, Divonne-les-Bains, France, 15 May
2005
Recognising that the lack of healthcare
workers in developing countries, particu-
larly those in sub-Saharan Africa, is one of
the most serious global problems of today
and that the impact of healthcare worker
migration from developing to developed
countries is a significant component in the
crisis,
Therefore, be it resolved:
1. That the WMA reaffirms its 2003 State-
ment on Ethical Guidelines for the Inter-
national Recruitment of Physicians, par-
ticularly para. 14: “Every country
should do its utmost to educate an ade-
quate number of physicians, taking into
account its needs and resources. A coun-
try should not rely on immigration from
other countries to meet its need for phy-
sicians”; and para. 15: “Every country
should do its utmost to retain its physici-
ans in the profession as well as in the
country by providing them with the sup-
port they need to meet their personal and
professional goals, taking into account
the country’s needs and resources.”
2. That developed countries must assist de-
veloping countries to expand their capa-
city to train and retain physicians and
nurses, to enable developing countries
to become self-sufficient.
3. That action to combat the skills drain in
this area must balance the right to health
of populations (Universal Declaration of
Human Rights (1948), Article 25.1;
International Covenant on Economic,
Social, and Cultural Rights (1976), Arti-
cle 12.1.) and other individual human
rights.
4. That the WMA reconvene the expert
working group on physician resources
to coordinate development of WMA in-
put to WHO preparations for the decade
on human resources for health.
5. That the WMA commend WHO for ta-
king a leadership role in the global chal-
lenges of human resources for health;
commend to WHO the afore-mentioned
principles (1, 2 and 3); and call upon
WHO to convene a global roundtable to
discuss HHR issues.
WMA Council Resolution on
observer Status for Taiwan to
the World Health Organiza-
tion (WHO) and inclusion as
participating party to the
International Health Regula-
tions (IHR)
Adopted at the 170th WMA Council Ses-
sion, Divonne-les-Bains, France, 15 May
2005
Preamble
1. The ethical obligation of health profes-
sionals is to serve all human beings irre-
spective of their political or religious af-
filiation or any other factor. The goal of
all nations must be the protection of he-
alth of all human beings without any
discrimination. Protection of human he-
alth can only be achieved if all people
and health care systems collaborate.
WHO must be able to invite all people
and health care systems to participate in
the fight against disease and premature
death. Protection of human health must
be separated from politics.
Council Resolutions adopted at the 170th WMA Council Session,
May 2005
WMA
39
mended forApproval, and was subsequent-
ly adopted by Council.
Dr. Appleyard drew attention to a report on
the Prevention of Chronic Disease in
Children, which would be launched in
London in October. He urged that NMAs
promoted this and stressed the importance of
how best to ensure successful interventions
in schools the report should be distributed to
all NMAs when it was available.
Dr. Letlape suggested that the workgroup on
Human Healthcare Resources should be
reconstituted. i.e. members from AMA,
BMA and CMA, together with representa-
tion from the East.
Finance and Planning
Committee
Dr. Nelson was elected to the Chair of the
Committee by acclamation. He thanked the
committee for its confidence and stated what
a pleasure it had been to work with the
Secretary General and Dr. Vilmar. The work
had been considerable, involved lots of tele-
phone consultation and had been done well
and accurately.
The minutes of the meeting in Tokyo 2004
were approved
Dr. Kloiber spoke about the question of Dues
(see p. 40) and the problem of the non-
payers, some for as long as 2 years. The
Statutes required erasure of the member
association after this period. A solution was
needed for Santiago.
After a considerable debate the committee
recommended that WMA waive all dues in
arrears prior to 2005.
The Committee also considered a report on
WMA Dues Structure Reform Proposal (see
p. 40) and recommended that it be sent
to NMAs for comment, the Secretary
General to report to the next Committee
meeting.
After presentation and detailed discussion it
was recommended that the Preliminary
Financial Statement for 2004 be approved
The Committee then engaged in a lengthy
and detailed debate on the report of the
2. A burning example of discrimination in
the recent years has been Taiwan. There
are 23 million people living in Taiwan,
of which a significant number required
medical assistance or help from interna-
tional relief organizations in the after-
math of the 1999 earthquake. In addi-
tion, Taiwan was significantly affected
and suffered several deaths due to the
SARS epidemic during 2002 and 2003
and is under threat by the current out-
break of Avian Flu in South East Asia.
3. There are 23 million people who are
willing and take pride in contributing to
international relief efforts when other
people are in need, as demonstrated
again by generous donations and signi-
ficant humanitarian aid support in the
aftermath of the tsunami disaster during
2004.
4. 23 million people should not be exclu-
ded from the work of the World Health
Organization, but without taking a stand
as to the legal status of Taiwan.
Resolution
5. The World Medical Association
(WMA), as a non-governmental organi-
zation in official relations with WHO,
calls on WHO to grant Taiwan observer
status to WHO;
6. The WMA calls on WHO and all its
Member States to ensure that Taiwan is
included as a participating party to the
WHO International Health Regulations;
7. The World Medical Association further
urges its members to call on their natio-
nal governments to advocate for obser-
ver status for Taiwan at WHO, as well
as inclusion as a participating party to
the WHO International Health Regula-
tions.
WMA Council Resolution
on implementation of the
WHO Framework
Convention on tobacco
control
Adopted at the 170th WMA Council Ses-
sion, Divonne-les-Bains, France, 15 May
2005
The World Medical Association
Welcomes the recognition of the essential
role of health professionals in tobacco con-
trol as the focus of World No Tobacco Day,
31 May 2005;
Recognises the importance of the WHO
Framework Convention on Tobacco Con-
trol (FCTC) in furthering the campaign to
protect people from exposure and addic-
tion to tobacco;
Encourages national medical associations
to work assiduously and energetically to
get their governments to ratify and imple-
ment the FCTC;
Urges governments to introduce regulation
and other measures as set out in the FCTC.
Governments should also introduce a ban
on smoking in enclosed public places and
work places as an urgent public health
intervention;
Recognises the vital role of health profes-
sionals in public health education and in
support for smoking cessation;
Commits, with the other members of the
World Health Professions Alliance, to mo-
bilise health professionals in the fight to
implement the FCTC and to reduce the hu-
man cost of tobacco.
Governance Committee. Dr. Coble, in intro-
ducing the report commented that the work-
ing group had representation from all regions
and there had been very good input into the
report. They had divided the issues into three
groups, namely (a) those for which the was
general agreement on, (b) those on which
there appears to be no answer and (c) those
which were rejected by consensus There was
also the need to look at the Bye- laws and
other standing documents which needed to be
consolidated. Finally he referred to Council
reports which had not been put into policy.
In the opening discussions the need for the
governance review was expressed forcibly by
several members, in particular stressing the
need for a clear structure setting out where
authority lies and likewise where responsibil-
ity lies. The Secretary General pointed out
that there was a clear understanding that gov-
ernance was being worked on urgently. Other
speakers urged that the work go forward and
the committee then engaged in a detailed
debate on the report before them, as a result
of which the following Recommendations
were made and later adopted by Council:
That an Executive Committee with an adviso-
ry role, be established, comprising the Chair
and Vice-Chair of Council and the Chairs of
the three Standing committees, the Secretary
General being a non- voting member. This
committee would also undertake the Chief
Executive Officer review process.
The Chair of Council to establish an “ad
hoc” committee to review, consolidate and
update WMA bye-laws, rules of procedures
and operating policies.
One committee should make a trial of the use
of a “consent calendar”.
A proposal for the possible consolidation of
the positions of Treasurer and Chair of
Finance and Planning Committee be circu-
lated to NMAs for comment.
A proposal for the timing of leadership tran-
sition be circulated to NMAs
That approval be given for a proposal to
restrict the term of office of all Chairs of
Council and Standing Committees and
Treasurer to three two year terms (6 years
“in toto”) for each position.
Council later endorsed all the recommenda-
tions of the Finance and Planning
Committee.
Council, in addition to endorsing the reports
listed above from the committee agreed that
a proposed statement on reducing the Global
impact of Alcohol on Health and Society be
referred to NMAs for comment. Council,
also discussed possible dates and venues for
future meetings of the General Assembly and
Council, and other many other internal
issues. It received reports on the forthcoming
General Assembly in Santiago and a presen-
tation on the 2006 Assembly in South Africa
at Sun City.
At the end of the Council meeting tributes
were paid to Drs Aarima and Palmisano who
were attending their last Council meeting and
to Dr. Moon and Dr. Vilmar for their contri-
butions during their many years as Officers
of the WMA.
WMA
40
Introduction
The current dues structure is based on a
membership fee per physician represented
by the member organisation. Thus, organi-
sations representing more physicians pay
higher dues than those representing lower
numbers of physicians. In turn, voting
rights are coupled to the number of physi-
cians represented. Currently, 10,000 physi-
cians equal one vote in the General
Assembly, while 50,000 give entitlement to
one seat in the Council for a term of two
years. Smaller countries can also have a
seat on council if their votes from other
countries support them on the occasion of
the Regional Elections of the WMA
Council. This mechanism in principle pro-
vides proportional representation of the
physicians of the world in the WMA
through their national medical associations.
According to the statutes, the most repre-
sentative physicians’ association of a coun-
try is eligible for membership in the WMA.
Depending on the national situation, the
degree of representation of the different
national medical associations varies consid-
erably: while membership of the national
medical association is obligatory in some
countries (100% membership), private as-
sociations with voluntary membership can
represent only a share of the physicians in
their countries
Moreover, membership status in the con-
stituent organisations varies as well, with
some associations having only one mem-
bership level, while others have several
membership levels, with different contribu-
tions. Overall, physicians’ contributions to
their national associations vary even more:
not only is there a vast difference in the
contributions between poorer and richer
countries, but the service package con-
stituent organisations deliver to their mem-
bers is also not comparable. Some are not
only associations, but also unions, some
provide retirement funds, some have
extended membership perks that others do
not provide. For these reasons, strict cou-
pling of the WMA dues to the number of
enlisted members of constituent organisa-
tions would not only be unfair, it would also
make it impossible for poorer medical asso-
ciations to participate in the WMA. The
national membership organisations are
therefore free to determine the number of
physicians they wish to notify to the WMA
as their represented membership.
WMA Dues Reform Proposal
This paper sets out a proposal for reforms of the WMA Dues and has been circulated
to all NMAs. It was prepared by the Treasurer Emeritus, Dr. K. Vilmar and endorsed by
Dr. J.-D. Hoppe, the Treasurer.
Criticism of the current
situation
Due to the fixed contribution rate per noti-
fied member physician of the constituent
organisation, smaller and poorer nations
have less voting power in the General
Assembly and fewer seats to occupy in the
Council. While the first reflects the general
idea of a representational democracy, the
latter is indeed challenging the democratic
understanding of the institution.
A more transparent system with a higher
degree of fairness should allow the finan-
cially less potent medical associations the
same chance of representing their physi-
cians as the richer ones.
Furthermore, the potential unfairness of the
dues structure in relation to poorer associa-
tions and the fact that Council membership
is determined only every two years, has led
to disappointments and concern, as some
constituent organisations pay a higher share
in the year the Council seats are deter-
mined, reducing it significantly in the fol-
lowing year, thereby remaining in the
Council without contributing the proper
dues.
Previous attempts at change
During the last fifteen years, major changes
in the dues structure were attempted twice.
They aimed both to increase the dues
income and to improve the fairness of the
dues structure and representation. (The
free-rider effect mentioned above was not
addressed.) A first task force in the late 80s
delivered a moderate change, when the
number of votes in the General Assembly
was changed from one vote per 5,000 noti-
fied members to one vote per 10,000 noti-
fied members. Although especially the
question of unfairness was addressed at that
time, it was neither changed then nor by a
later working group in the late 90s.
Several models for a new dues structure
were analysed in these attempts:
• A one-country-one-vote principle would
fail, as stronger medical associations
were not prepared to pay a higher share
than others with the same voting rights.
On the other hand, an equal (flat-rate)
contribution of all constituent organisa-
tions would have clearly overcharged
the smaller organisations. Therefore, and
for lack of proportional and adequate
representation, the one-country-one-vote
principle was not followed up. (It exist-
ed before in the 70s and was abandoned,
because large associations decided to
move out or reduce their commitment.)
• A contribution based on the membership
and economic strength of the country
appeared neither possible nor truly fair
for several reasons: the economic data
are not reliable. During the last decade,
some countries changed their reported
gross domestic product (GDP) following
political changes or new calculations.
Moreover, poorer countries in particular
have huge differences in individual
income. While people in general may
have a very low income, thus yielding a
small GDP, physicians may live as rela-
tively wealthy people, meaning that
assessment of the WMA dues solely in
relation to the GDP would be unfair
compared to other nations with more
balanced national wealth.
• A stratified model of flat-rate dues based
on a rough economic stratification
model was not followed, because it
would not have allowed proportional
representation and would have over-
charged smaller associations.
Conditions for change
Although increasing the dues income of the
WMA will be important in the future to
maintain the independence and functional
capacity of the WMA, a first step must be
taken to make the dues structure fairer and
stable. Many national member associations
may find that a dues structure of the WMA
that fails to give adequate consideration to
their financial situation or capabilities
deters them from applying for membership
or paying a higher contribution. Therefore,
a solution to this problem may be a door-
opener for new constituent organisations
and for fairer representation of financially
less powerful organisations.
On the other hand, a change in the dues
structure must not lead to a drop in overall
dues. What is more, it should not reduce the
willingness of each single constituent
organisation of the WMA to contribute its
own dues.
Furthermore, a new dues structure or the
distribution of voting rights should not
encourage the free rider phenomenon in the
Council mentioned above.
Solution
A. Access and fairness
In order to maintain the dues income of the
WMA and the principle of democratic repre-
sentation, and in order to acknowledge the
different levels of ability to contribute to the
WMA, both the coupling of dues to the
number of notified physicians and the free-
dom of the associations to determine the
number of physicians being notified may
have to remain. However, they should be
supplemented by recognition of the financial
power of the respective country, making
access to the WMA and representation in the
WMA fairer for associations with less
money.
However, as explained earlier, data on the
economic strength of the nations is of only
relative value due to comparability prob-
lems and relevance for the profession in the
respective country. Individual calculation
of the economic power of each country
would be possible, but impractical in the
framework of an organisation with more
than 80 members.
Therefore, and in order to enable associa-
tions from countries with less financial
power to obtain a higher share of represen-
tation, the contribution rate per member
should be stratified from € 2.00 (current
amount) in four levels (Category A, € 0.40;
Category B, € 0.90; Category C, € 1.50; and
Category D, € 2.00), depending on the
gross national income of the respective
country. Thus, the four Categories (A to D)
would reflect the wealth or economic power
of a country, assuming that the financial sit-
uation of the physicians is roughly propor-
tional to that.
41
WMA
42
The pictures are dreadful – pictures of
patients who have died because of medical
errors! Sir Liam Donaldson, chief Medical
Officer of England and Chairman of the
WHO World Patient SafetyAlliance starts his
standard presentation with such images and
also allegorical images of several crashed
Jumbo Jets as equivalents for the calculated
number of people who reportedly die every
day because of medical errors.
I have doubts as to whether or not these
images are helpful, as they divide the World
into the “Good-ones” showing or painting the
images, and the “Bad-ones” making the mis-
takes. Secondly, the images suggest that those
talking about the mistakes know how to avoid
them. But do they?
“If aviation produced as many dead as health
care does – nobody would fly anymore, the
operations would be shut down immediate-
ly!” So, why don’t we shut down health care
institutions and resume business only when
we are sure that no more mistakes happen?
Indeed, who would travel with a plane when
the pilot doesn’t know how much fuel he has
on board, fly a passenger plane without
knowing where the journey is heading for, or
take a plane whose engines are badly main-
tained or even burning?
Who entrusts himself or herself to pilot a long
distance flight without maps, without naviga-
tion system, or would fly with a pilot who had
been on duty for more than 24 hrs? Which
airline would take on board a significant
number of passengers who cannot pay?
Which pilot would start knowing that he
never can make it, or take a woman in labour
on board? And who would join a travelling
party, where politicians and leaders sing the
song: “Put the passenger in the driver’s seat”?
But this is exactly the situation which physi-
cians encounter every day in the real world:
Starting to work without having appropriate
resources – saving peoples’ lives and health
and being blamed and often even charged for
spending “too much”. -caring for severely
suffering patients and having not having a
confirmed diagnosis available. Caring for
patients with chronic diseases where physi-
cians are far away from understanding the
disease – not to mention healing it! Taking
care of and comforting those with terminal
illness. Treating high risk patients and taking
insurmountable responsibility on their own
shoulders. Doctors do this even after having
worked 36 hours already, because of the
need, for example, to deal with the patient
with a ruptured aneurysm which can’t wait
until tomorrow. All this, taking also into
account individual differences, wishes, pref-
erences, emotions and personalities. Ever
tried this with a fully loaded Jumbo Jet?
Most of the main contributors to the WMA
(in financial terms) would be classed in
Category D and therefore would not see
any change in their contributions and vot-
ing rights. The constituent organisations
from economically less powerful countries
would not receive a reduction in their dues
amount, but they would get more voting
rights.
Only if a country that has already notified
the real number of physicians were to be
classified in Categories A to C, would the
income of the WMA possibly be reduced in
the future. This is currently not the case.
B. Fairness and sustainability
As the financial situation of each medical
association may vary over time, the princi-
pal option of determining the number of
physicians notified to the WMA should not
be given up. However, those associations
seeking representation in the Council
should commit themselves for the full peri-
od of Council activities (2 years). Thus, an
artificial increase in the number of mem-
bers notified in the year of Council consti-
tution, and a reduction in the following
year, should be avoided, as this procedure is
unfair to the other payers and puts the
finances of the WMA in jeopardy. There are
several options for change:
1. Maintenance rule
In addition to constitution/election every
two years, there should be an eligibility
rule saying that the representation
demonstrated at the time of election – a
minimum of 50,000 reported members –
must be maintained during the period of
office. Otherwise, the office will be ter-
minated or, alternatively, voting rights
will be suspended. This would apply
equally to Council members from con-
stituent organisations notifying more
than 50,000 members, and to those
elected with the votes from several con-
stituent organisations.
The maintenance rule would also apply
to Council seats awarded for a fraction
of 50,000 notified physicians.
2. Look-back option
Council seats would be awarded for
notified or cumulative representations of
50,000 physicians during the last two
years before the election. (Alternatively:
in the year of election and the year
before the election.) This model would
give stability. However, it may discour-
age members notifying 50,000 members
or more for the first time, as they would
have to wait for one or two years.
The look-back option would also apply
to Council seats awarded for a fraction
of 50,000 notified physicians. Thus, the
average number of notified physicians
for the last two years (alternatively: the
year of election and the year before the
election) would be counted for the elec-
tion process.
* Details concerning country classification
are available from the WMA Secretariat.
(wma@wma.net)
WMA Secretary General
WMA Secretary General
From the desk of the Secretary General
“Danger on the safe side!”
43
But this comparison can even be topped by
those who have the answer as to why aviation
is so much safer – those who really know
about medicine and aviation: “Doctors don’t
get hurt when they make mistakes – pilots
do.“
Isn’t that simple?
But what about those who acquired infections
while treating patients ever though they were
being careful; or those ending up in the ditch
when returning to the hospital in a cold win-
ter night on icy streets, or when seeing their
patients when called for an emergency? What
about those who are killed in combat zones of
conflicts they had nothing to do with. What
about those who are burnt out and depressive
after virtually working to death? What about
those suffering from the emotional stress they
encounter every day? There are far more doc-
tors getting hurt from their work than pilots.
But these are statistics nobody is interested in.
Perhaps flying a plane and
treating a patient isn’t all that
similar
First, of all we usually fly for fun or business.
In times of trouble both of these can wait.
However no-one sees a doctor for fun. And
let’s not forget: The (health) problem exists in
the first place. Health Care systems are crisis
management systems.
Secondly, when flying a plane there is for
each (critical) situation one (!) ideal way to
handle it. As a pilot you should know it by
heart and everybody can look it up in the
flight manual. Unfortunately, patients don’t
bring their manuals with them and “standard
patients” only exist in theoretical examina-
tions. In the end flying an aeroplane is oper-
ating a machine. Treating a patient is caring
for a human being!
Thirdly, a flight is a planned procedure. Each
flight can and should be planned for its nor-
mal performance from the beginning to the
end. Deviation from that rule is the exception.
In health care this only sometimes happens.
While it would be wrong to disregard statis-
tics, but physicians’ first care is for the
patient. Those who work a lot, make mis-
takes. We would be negligent if we ignored
this.
What can we do apart from
regreting the situation?
Flying is not the same as treating patients. But
aviation has inherent dangers as has medicine
and aviation has dealt with many of these
dangers very efficiently. Most of these solu-
tions cannot be applied to medicine but some
key elements can. These include reporting
mistakes, accidents and near misses and
analysing them, making materials and struc-
tures safer, and processes clearer and simpler.
Also setting or changing rules in order to
avoid mistakes and making systems more
error-tolerant.
We are far away from this in medicine. In a
„blame and shame“ culture nobody wants to
admit his or her mistakes. Instead of learning
from mistakes we punish for mistakes.
Instead of making procedures clearer and
simpler, we are confusing many processes
more and more. When we set rules, they still
are of a disciplinary nature and not made for
safety from the beginning. Instead of making
life saving systems more error-tolerant, we
make them more economic, which in most
cases doesn’t serve the purpose of safety.
A non-punitive system for reporting is need-
ed. The process of reporting must be protect-
ed by law so that attorneys don’t see it as a
fishing ground. What has been reported must
be analysed. While this is expensive, it is cer-
tainly also a good investment in health.
A reporting system ensuring a certain degree
of protection for the reporting person will
have to provide some kind of amnesty. The
reporting system in aviation depends on this.
If someone fears being punished for reporting
a mistake, nobody will report mistakes.
However a non-punitive system can be no
waiver of responsibility. Negligence and
unresponsiveness must be subject to sanction;
there can be no “carte blanche” for reckless-
ness and stupidity. This approach can be
achieved and examples are already working.
Another problem may be more difficult:
Patients claim the right to be informed about
safety. They want not only to know about the
safety of the procedure they may undergo, but
they also want to know about the quality and
safety standards and results of an individual
institution. They want to know whom to trust.
If reporting is to become a shame and blame-
free process, this may be difficult to reconcile
with the patients’ request for information.
Maybe the current misconception is a misun-
derstanding of “transparency”. Nora O’Neil
in her 2002 Reith Lecture “A Question of
Trust” gave some clues to this. “In fact, our
clearest images of trust do not link it with
openness or transparency at all. Family life is
often based on high and reciprocal trust, but
close relatives do not always burden one
another with full disclosure of their financial
or professional dealings, let alone with com-
prehensive information about their love lives
or health problems; and they certainly do not
disclose family information promiscuously to
all the world. Similarly, in trusting doctor-
patient relationships (that’s the sort we sup-
posedly no longer enjoy), medically relevant
information was disclosed under conditions
of confidence. Mutual respect precludes
rather than requires across-the-board open-
ness between doctor and patient, and disclo-
sure of confidential information beyond the
relationship is wholly unacceptable. Perhaps
it is not then surprising that public distrust has
grown in the very years in which openness
and transparency have been so avidly pur-
sued. Transparency certainly destroys secre-
cy: but it may not limit the deception and
deliberate misinformation that undermine
relations of trust. If we want to restore trust
we need to reduce deception and lies rather
than secrecy. Some sorts of secrecy indeed
support deception, others do not.
Transparency and openness may not be the
unconditional goods that they are fashionably
supposed to be. By the same token, secrecy
and lack of transparency may not be the ene-
mies of trust.
WMA Secretary General
44
Dr. Bernhard Grewin (Past President) and
Mr Gunnar Lonnquist (International
Secretary), Swedish Medical Association.
Continuing our series on medical liability,
this paper, presented at the Oslo EFMA/
WHO meeting in March 2005, describes the
system which has been in existence in Sweden
since 1975, and is now obligatory for all
health care providers
Voluntary Insurance
A patient insurance – no-fault compensation
scheme – has been in existence in Sweden
since 1975. It was developed jointly by some
of the large insurance companies and the pub-
lic health care providers. The insurance was
based on a voluntary commitment on the part
of the health care providers to financially
compensate patients for injuries caused to
them in connection with diagnostic and ther-
apeutic interventions. The majority of private
health care providers also joined the insur-
ance scheme.
Insurance Regulated by Law
From 1 January 1997 the patient insurance
scheme has been regulated by law. According
to the law all health care providers in Sweden
are obliged to have a patient insurance. The
County Councils (regional political bodies
entrusted with the responsibility for planning,
financing and delivering health care services
to their populations) are by far the biggest
healthcare providers in Sweden. They pay 45
Swedish kronor (SEK) or approximately 4.90
€ per county inhabitant per year to the insur-
ance scheme. No other factors, such as spe-
ciality and kind of treatment have an impact
on this fixed amount.
The administration of the insurance and the
payment of compensation is handled by a
company jointly owned by the Swedish pub-
lic health care providers i.e. the County
Councils.
For private medical care, which is rendered
without any formal cooperation agreements
between the private provider and the
Counties, the private provider has to take a
patient insurance of his own. This is usually
done as part of a group insurance.
Payment of compensation due to injuries
within this genuinely private health care field
is administered by the respective insurance
companies from whom the doctor or the
medical unit has purchased the insurance pol-
icy.
The right to financial compensation (dam-
ages) for injuries incurred is independent of
the regulations laid down by tort law. This
means e.g. that the patient, in order to get
compensation, need not prove that the injury
has been caused by fault or negligence on the
part of any health care personnel.
For injuries caused by pharmaceutical prod-
ucts (side-effects) a voluntary scheme is still
operating, regulating the financial compensa-
tion.
Requirements for
Compensation
1. Patient-injury compensation can be grant-
ed for injuries – both physical and men-
tal – that have occurred in connection
with providing health care services in
Sweden – including injuries occurring
during transport e.g. ambulance trans-
port.
2. Personal injuries: physical as well as
mental injuries can be compensated.
3. Causal connection: The injury must
have arisen as a result of the health care
procedure performed.
4. Types of injuries compensated:
a) Treatment injuries; provided that the
injury could have been avoided either
by using another medical method or
by using the method applied in anoth-
er manner.
b) Material-related injuries: this refers to
situations where the medical devices,
Medical Science, Professional Practice and Education
The Swedish Patient Insurance System –
A No-Fault System
”The World Health ProfessionsAlliance host-
ed a reception in Geneva for Ministers attend-
ing the 58th
World Health Assembly on 16th
May 2005. The three presidents of the profes-
sions (Nurses, Pharmacists, Physicians) in
welcoming the guests spoke briefly about
their concerns and activities.
The guests were addressed by the keynote
speaker, Sir Liam Donaldson, who spoke
about the important subject of Patient Safety.
He referred to the research by Professor Pittet
analysing and reporting on Risk Prevention.
As Chairman of the World Alliance for
Patient Safety, Sir Liam stressed the impor-
tance of the five essential challenges which
need to be met. The first of these to be tack-
led in the first two year programme was
Infection. Under the network title „CLEAN
CARE IS SAFE CARE“, the initiative would
be launched this year. He emphasised that
basic actions such as adequate hand washing,
cleanliness in hospitals, buildings and homes,
clean instruments were all essential, and that
both health professionals and individual citi-
zens need to take this seriously.
This message about cleanliness was endorsed
by Professor Didier Pittet, Director of
Infection Control, University of Geneva
Hospitals, who gave more details of the prob-
lems, Among the most telling facts presented
was that one in ten patients entering hospital
developed an infection! What was essential
was safe sterilisation, education and training,
safe blood, safe injections and safe surgery,
together with improved resources to achieve
these. WHO would be producing guidelines
for better provision of this aspect of Patient
Safety.
Medical Science, Professional Practice and Education
Patient Safety highlighted at World Health
Professions’ Reception
apparatus etc. have been defective in
some way or that they have been
used/handled in the wrong manner.
c) Diagnostic injuries; if a wrong diagno-
sis has resulted in injuries to the
patient.
d) Infection injuries: a clear condition is
that the infection must have been
acquired as a result of the medical care
situation. If the patient already had this
infection it cannot be compensated. Of
importance is also whether the risk of
an infection could be foreseeable or
not. The patient’s basic illness and
general medical condition are taken
into account here.
e) Accident injuries: due to accidents in
connection with diagnostics, care,
treatment, transport or other accident
specifically related to the medical care
provided.
f) Medication injuries: these refer to
injuries resulting from wrongful han-
dling of the medications – wrong
dosage or other mistakes. As men-
tioned above side-effects of drugs are
not part of this insurance. They are
compensated by means of a specific
drug insurance.
g) Compensation is not possible for
injuries resulting from medical proce-
dures which had to be taken in emer-
gency situations without the possibili-
ty of adhering to normal routines.
5. Principles for Compensation Amounts
The compensation follows the principles
laid down in tort law pertaining to person-
al injuries.
Economic loss (e.g. loss of income) as
well as non-economic loss (pain and suf-
fering) can be compensated.
A limited self-risk payment is involved in
all cases compensated.
6. Patient Claims Panel
This body can give its opinion on various
insurance cases. Patients, insurers, health
care providers or courts of law can ask for
its opinion.
The Panel consists of seven members.
The Chairperson should be or at least
have been a judge. The other six persons
should represent the patients (3), be med-
ically qualified (1), be specifically knowl-
edgeable on health care issues (1) and
have good experience of settlement of
claims concerning personal injuries with-
in the insurance field.
7. Limitation Period for Claims
Claims for compensation must have been
filed at the latest 3 years after the patient
was informed of the possibility of claim-
ing compensation, and definitely within
10 years after the injury occurred. Claims
for compensation are most often made by
the injured patient him/herself, but can
also be made by a relative, should the
injury render the patient incapable of fil-
ing the claim.
8. Number of Cases
The number of claims have during the last
years been around 9,000/year. Ten years
ago the corresponding figure was around
5,000.
Approximately 45% of the claims will
result in compensation.
9. Compensation Levels
The amount of the compensation is based
on the rules laid down in the Swedish tort
law.
The most common compensation will be
up to 20,000 SEK (2,162 €) per injury.
The average figure though is around
110,000 SEK (11,892 €). This is due to
the fact that there are also cases which
will result in much higher compensation.
There is an absolute ceiling on how high
the compensation might be in any indi-
vidual [one singular] case. That limit is at
present 7,500,000 SEK (810,811 €). Such
an amount might be considered e.g. if a
brain damage occurs in connection during
a child’s birth resulting in life-long inva-
lidity and life-long loss of income.
10. Total Cost
The total cost for the insurance compen-
sation might be expressed in two ways:
In 2003 the total sum of compensation
was 290,000,000 SEK (31,351,350 €)
and for 2004 this figure is estimated
to be around 310,000,000 SEK (33,
513,515 €).
The compensations paid out in a certain
year do not usually (not) pertain to the
injuries incurred that year, since it takes
time to process the claim.
In conclusion one might state that the
existence of a no-fault patient insurance
has considerably enhanced the possibili-
ties for patients who have been injured in
connection with health care treatment to
get a reasonable financial compensation,
and to get this compensation without hav-
ing to resort to court of law procedures
with the difficulty of proving that some-
one has been at fault and also risking los-
ing such a tort law case resulting in some-
times heavy fees for legal counselling.
Liability Insurances for
Doctors
Doctors also have individual Liability
Insurances. These insurances cover e.g. possi-
ble costs for a tort law process but a small part
of the premium is also a premium to the
Patient Insurance Scheme. A tort law process
against an individual doctor would be very
rare in Sweden. The general Patient Insurance
is one reason for that. Another reason is that
claims in a tort law process would be primar-
ily directed against the doctor’s employer – if
employed – according to the principle of vic-
arious liability – or against his company if
he/she performs his work in that organisation-
al form.
Therefore the premiums for doctors’ liability
insurances are very limited in an internation-
al comparison. Today (April 2004) the annu-
al premiums charged by the most used insur-
ance company for these matters are as fol-
lows:
Not yet licensed doctors 500 SEK (54 €)
Employed licensed doctors 550 SEK (59 €)
Licensed doctors employed and with
other practice part-time 2392 SEK (259 €)
Licensed doctors full time private
Practice 3572 SEK (386 €)
Note: 1 € = 9.25 SEK
45
Medical Science, Professional Practice and Education
GTZ, WHO and sex workers networks
share information and lessons learned.
Berlin/Geneva – The German technical
cooperation (GTZ) and the World Health
Organization, in collaboration with sex
work networks around the world, are
launching the first ever online tool kit
aimed at helping sex workers to protect
themselves and their clients from infection
with HIV and other sexually transmitted
infections. The tool kit is intended for use
by people working with female, male and
transgender sex workers including pro-
gramme managers, field workers and peer
educators. This is the first time this exper-
tise has been formally documented and
made widely accessible.
“Thanks to this innovative project, people
working on HIV/AIDS prevention for sex
workers can now learn what does and does
not work from Poland to Papua New
Guinea. Targeted HIV/AIDS prevention
and care programmes are urgently needed
for sex workers, injecting drug users and
other vulnerable groups and we welcome
GTZ’s leadership and support in this often
under funded area,” said Dr Jim Yong Kim,
WHO’s Director of HIV/AIDS.
Included in the online sex work tool kit are
practical “how to do it” documents like
“Hustling for Health” and “Making Sex
Work Safe”, written by experienced sex
worker groups to support programme man-
agers in setting up and maintaining pro-
jects. “Of Veshyas, vamps, whores and
women” for example, is based on experi-
ences from an Indian NGO and gives prac-
tical advice on how to build up a network of
peer educators in brothels and deal with the
brothel owners, how to set up condom dis-
tribution networks and how to structure
payment incentives for peer educators.
Despite proof that prevention programmes
are useful in sex work settings, currently
only 16% of sex workers have access to
these services. Around the world, poor ser-
vices generally mean higher HIV preva-
lence.
“Sex workers know better than anyone
about the problems they face, the kind of
language and programs that are effective.
Only by involving them can both male and
female sex workers and clients be motivat-
ed to make use of condoms and health clin-
ics,” said Friederike Strack from Hydra —
one of the sex worker organizations collab-
orating on the tool kit.
The tool kit also includes valuable data and
analysis which can be shared across regions
and used to design better HIV/AIDS pre-
vention programmes for sex workers, for
example “Police and Sex Workers in Papua
New Guinea”. A report on “Meeting the
sexual health needs of men who have sex
with men in Senegal” gives valuable insight
into dealing with the cultural sensitivity
surrounding male homosexuals in West
Africa, how their lives are characterized by
violence and rejection and that many find it
easier to get help and treatment from clinics
than traditional healers.
WHO and GTZ worked closely with sex
work networks and organizations to pro-
duce an online collection of more than 130
easily-accessible documents, manuals,
reports, and research studies. The aim of the
tool kit is to make vital information about
sex work interventions more accessible to a
wider audience and to share lessons learnt
to contribute to global efforts which will
develop and increase effective HIV preven-
tion and care interventions among sex
workers.
“Targeted programmes make a difference
— in Germany we have shown over the last
15 years that these kinds of interventions
can really work. It’s important to share
knowledge across borders and within com-
munities to help save lives within one of the
oldest professions in the world. We are
pleased to support this initiative,” said
Thomas Kirsch-Woik, Senior Consultant
HIV/AIDS, GTZ.
In many countries, sex workers are fre-
quently exposed to HIV and other sexually
transmitted infections (STIs). Where sex
workers have poor access to HIV preven-
tion, HIV prevalence can be as high as 60-
90%. Evidence shows that targeted preven-
tion interventions in sex work settings can
turn the epidemic around.
In Thailand and Cambodia for example,
condom use rose to over 80% and HIV and
STIs declined dramatically thanks to large
scale programmes targeting sex workers and
clients. In Nairobi, Kenya, strengthened
interventions with sex workers – including
peer support, condom promotion and STI
services – led to falls in HIV incidence,
from 25-50 % to 4 % in Nairobi sex work-
ers.
“To really have an impact on the epidemic,
it is important for services and policies to
be made more user-friendly and to be
adapted to the reality of the sex work as
well as to regional differences. Injecting
drug use and sex work are closely linked in
Eastern Europe and it is essential to inte-
grate the services”, said Monica Ciupagea
from the Open Society Institute Hungary
which also collaborated on the tool kit
development.
The HIV/AIDS Sex work tool kit brings
together over a decade’s worth of research
and practical experience on what does and
not work to change behaviour and protect
sex work and clients from HIV/AIDS. Now
online, it will also be available as CD-ROM
and hard copy in early 2005.The kit is a liv-
ing document and will continue to be updat-
ed as new resources are released.
The Sex Work tool kit is one of a series of
online tool kits produced by WHO and
GTZ and can be found at
www.who.int/hiv/toolkit/sw. The
Antiretrovrial (ARV) Tool kit: A public
health approach for scaling up ARV treat-
ment (www.who.int/hiv/toolkit/arv) and the
Tool kit for scaling up HIV Testing
and Counselling services
(www.who.int/hiv/ toolkit/ tc) are also
available online.
46
Medical Science, Professional Practice and Education
AIDS
New Online Tool Kit On HIV/AIDS Prevention
For Sex Workers
47
A confidential survey of more than 1,600
pairs of female twins has revealed that
genetic factors have a substantial impact on
how likely women are to cheat on their
partner and how many sexual partners they
will have.
This is the first ever study to look at the
genes underlying these influences in
humans.
The results of the new research – led by
Professor Tim Spector, Director of the Twin
Research Unit at St Thomas’ Hospital,
London – were revealed by Professor
Spector during a press briefing at the
Science Media Centre.
Female twins from the Twin Research Unit
database answered a range of questions in a
confidential questionnaire relating to their
sexual attitudes and behaviour. They report-
ed previous episodes of infidelity, total life-
time number of sexual partners and also
their attitudes towards infidelity.
The average age of respondents was 50,
their average number of sexual partners was
between four and five, just over 20% admit-
ted to infidelity, 25% were divorced and
98% were heterosexual.
Professor Spector says: “Not surprisingly,
the average number of sexual partners was
significantly higher among respondents
who had been unfaithful compared with
those who had remained faithful – a mean
of eight compared with four.”
Headline findings of the research study
include:
• Genes are an important influence in
explaining variation between women in
both infidelity and number of sexual
partners – with a heritability of 41% and
38% respectively.
• Further analysis of these results failed to
support the hypothesis that a gene impli-
cated in previous research into patterns
of sexual behaviour among rodents
(AVPR1A or vasopressin gene) could
explain the observed variation in human
sexual behaviour.
• However, the study did find some evi-
dence that genes in three other chromo-
somal areas (chromosomes 3, 7, 20)
could be implicated.
• In contrast, attitudes to infidelity are not
influenced to any significant degree by
genetic factors – environmental factors
including society, education or religion
prevail.
• Believing infidelity was wrong in prin-
ciple prevailed even in a significant pro-
portion of those women who admitted
having been unfaithful, highlighting the
distinction between attitudes and actual
behaviour.
Professor Spector says: “By demonstrating
the heritability of female infidelity and
number of sexual partners in humans, this
study justifies additional genetic and mole-
cular research on human sexual behaviour.”
“The fact that psychosocial traits such as
number of sexual partners and infidelity
appear to behave as other common complex
genetic traits in humans, in that they have a
heritable component, lends support to evo-
lutionary psychologists’ theories on the ori-
gins of human behaviour.”
Professor Spector believes that the logical
conclusion of his team’s new research may
be that infidelity and other sexual behav-
iours persist because they have been evolu-
tionarily advantageous for women.
Medical Science, Professional Practice and Education
Twin Studies
Twin study reveals genetic role in female
infidelity
MS
A UK national Multiple Sclerosis tissue Bank, funded by the
MS Society, co-ordinates the collection of donated tissue and
distributes samples to scientists conducting research into the
causes and treatment of MS.
While other techniques can be used to study
MS – such as experimental animal models,
MRI and cell culture, they are not an ade-
quate substitute for studying samples of tis-
sue that have actually been damaged by
MS. The bank not only takes donations of
tissue from people with MS, but also from
people without MS, which are vital for
comparison purposes.
“The UK MS Tissue Bank exists only
because of the foresight and generosity of
people who have pledged their tissue to
research,” says Professor Richard
Reynolds, its Scientific Director. “It is an
act of pure altruism that will be of no bene-
fit to the individual, but helps future gener-
ations.“
Located at Charing Cross Hospital in
London, the tissue Bank has put in place
procedures allowing collection of tissue as
quickly as possible after death to minimise
deterioration – within 24 hours wherever
possible.
“For a donation to work efficiently a lot of
people need to work together, such as the
relatives, GPs, funeral directors, hospital
pathologists and tissue bank staff who
retrieve the samples,” says Dr Abhi Vora,
Manager of the Tissue Bank. “We all pull
out all the stops, seeing it as something pos-
itive and lasting to come out of a sad
event.”
48
Since it was set up in 1998, 1700 people
have so far registered as tissue donors. To
date, 84 people with MS and 14 people
without MS donated tissues, which are
being used in a total of 27 different
research projects around the world.
“Donations from a single brain and spinal
cord can be dissected to yield 200 different
samples that can be supplied to many dif-
ferent research projects,” says Dr Vora.
Projects benefiting from the tissue bank
include those aiding better diagnosis.
Scanning slices of brain containing MS
lesions, which are then examined under a
microscope will allow any changes on the
MRI to be directly compared with what is
going on in the brain. Ultimately such pro-
jects may help scientists to understand
more from MRI scans about the type of MS
a person has and make it possible to target
treatments more effectively.
Brain tissue is being used to see whether
viruses and bacteria can be detected.
Research teams from the Royal Free
Hospital and the Imperial College School
of Medicine in London, have developed
sensitive techniques to see if the virus
human herpes virus 6 (HHV6) and the bac-
terium Chlamydia pneumoniae are present
in MS lesions donated to the tissue bank.
Identifying agents that may trigger the
damage in MS could mean that treatments
may be developed to neutralise them.
Researchers from Belfast believe that an
early step in the formation of a lesion is a
subtle change in microglial cells that are
normally resident in the brain. The group
are currently characterising these cells in
brain tissue from MS patients containing
lesions at different stages of development.
The study hopes to find out whether
changes in the microglia herald the forma-
tion of an MS lesion.
Chemical messengers, Cytokines, released
by cells within a developing lesion are cen-
tral to the cascade of events that leads to
demyelination. Understanding the role of
these molecules is the goal of a number of
projects supported by the Tissue Bank.
Such research could form the basis of
developing ways of knocking out the criti-
cal messengers and stopping damage.
WHO
• providing samples of brain tissue to
MSresearchers worldwide
• identifying targets of myelin damage
• identifying unique protein n myelin
• how to switch off damaging activity in
MS
• finding ways to encourage repair of
myelin
• identifying genes that make people sus-
ceptible to MS
• the role of viruses in MS
• identifying cells that could be used for
the repair of myelin
• investigating how nerve fibres can be
protected against MS
• finding ways to monitor disease activity
in MS
• protecting the brain from leakage
through the blood-brain barrier in MS
• identifying novel drugs that can help
nerves work better in MS
• supporting the world’s first MRI scan-
ner dedicated solely to MS research
• the role of social support for carers of
people with MS
• identification of the role of a herpes
virus in MS
• understanding how myelin is made
• using new imaging methods to look at
nerve fibre damage in MS
• how to improve nerve function in MS
• how growth factors promote repair in
MS
• identifying cells for transplantation to
repair myelin
• potential role of hepatitis B virus in MS
• clinical trial treatment of incontinence
• setting up a research centre in rehabili-
tation of people with MS
• setting up new centres for MS research
in Glasgow and Aberdeen
• education programme for people to help
manage their MS
• looking at bone mass in people with MS
• identifying how to encourage repair of
myelin
• helping people to cope with wheelchairs
• supporting the trial of cannabis in treat-
ing spasticity in MS
• clinical trial of whether cannabis can
help control on continence
• investigate health provision needs in
Northern Ireland
• helping people cope with entering long
term residential care
MS Society sponsored research projects
Some of the many research projects supported financially by
the MS Society
WHO
Dr. Lee addressing the World Health
Assembly: ends with concern with preparation
before Avian influenza strikes
In his address to the World Health
Assembly (WHA) in Geneva 21st May
2005, the Director General of WHO drew
analogies between the discussions 60 years
ago on how to assure the wellbeing of
humanity after the Second World War and
the situation before the World Health
Assembly. Sixty years ago it was necessary
to consider how to apply the knowledge
acquired at the price of the devastating fight
of the previous years. Amongst other con-
clusions this resulted in the UN system. In
our turn the WHA was meeting to learn the
lessons of the past and put them into prac-
tice. The condition of the world continued
to change and our institutions continue to
adapt themselves. The agenda of the 58th
WHA reflected the changes and bore wit-
ness to the continuing importance of the
fight against sickness and the improvement
of health essential for a viable world.
While the Millenium Goals placed Health
at their centre,, the translation of them into
reality was very far from completion and
progress towards them was not reassuring.
„Unless we succeed in bringing about the
major changes we are working for in the
near future, the targets for reducing child
mortality will not be achieved by 2015“. In
some areas death rates have actually risen
as a result of extreme poverty and epi-
demics. While the necessary technical and
practical know-how exists, we have not
found ways of applying it on a large enough
scale.“ While funding for health develop-
ment had risen steeply, it remained a small
fraction of that needed.
Aiming at reinforcing the positive trend of
improving results in countries, the budget
shows increases in the areas of epidemic
alert and response, maternal and child
health, non-communicable diseases, tobac-
co control, and response to emergencies.
Dr. Lee stressed the importance of creative
dialogue and negotiation as exemplified by
the Convention on Tobacco Control. With
64 parties engaged in the Convention-now
in force -the goal was the greatest possible
number of Member states becoming
Contracting Parties to maximise the effect
of the Convention and to save lives.
Referring to the International Health regu-
lations, if the WHA reached agreement on
them this would be a landmark event for
public health. He said that their significance
would only be realised when they are in
place, observed and implemented.
The Strategic Health Operations Centre, set
up last year, had provided a valuable asset
to global coordination.It provided instant
communication between Member States
and technical partners, with 60 offices,
including the Emergency Network.
Following the Tsunami in Asia, our Health
Action in Crises unit used it to maximum
advantage to coordinate responses.
Currently it was enabling health workers to
contain the Angolan Marburg haemorrhag-
ic fever outbreak. At the Thailand Tsunami
Conference he had made clear that the
warnings on possible cholera, malnutrition
and epidemics in Thailand had avoided the
escalation of the disaster by taking rapid
action to ensure water safety, adequate
nutrition, and reliability of disease surveil-
lance. This was an unprecedented effort of
collaboration including the government,
non-governmental and private sector
efforts.
The Global Outbreak Alert and Response
Network, now comprising 130 institutions,
has responded to more than 50 major dis-
ease outbreaks.Major demands included
Avian influenza, Ebola, Marburg, meningi-
tis, myocarditis and plague, and the
Network was also involved in establishing
the early warning system following the
Tsunami disaster.
The success of the global effort to maintain
and increase security depends on reliable
information being available and clear to
those who need it. The Health Metrics
Network, a new partnership with support
from the Bill and Melinda Gates
Foundation, hosted by WHO, will provide
extremely valuable support for this effort.
Progress on the core information function
in all activities is also highlighted by a new
publication „World Health Statistics“,
which provides national, regional and glob-
al information on 50 health indicators.
The Director General urged the need for
research and the urgent need for new diag-
nostics, vaccines and treatments stressed at
the Ministerial Summit on Health Research,
held in Mexico. After consensus building
meetings “we are ready to move forward
with the International Clinical Trial
Registry“ which will strengthen the
research process and its ability to win pub-
lic trust.“
The Commission on Social Determinants of
Health launched in March, with leading
practitioners from all six regions contribut-
ing, has the task of devising initiatives to
make health systems work effectively and
fairly in the context of defining and con-
fronting major underlying causes of ill-
health in the 21st century.
He stated that this year the focus of the
World Health Report and World Health Day
on the health of Mothers, newborn and chil-
dren also reflected the importance of part-
nership. In this case the key partnership was
with UNICEF and he welcomed Mrs
Veneman its new Executive Director (who
addressed the Assembly).
Referring to creative solidarity in health as
one of the millenium goals, he said that
combining expertise and resources was cur-
rently the greatest need, as well the basis
for hope. The WHO goal of universal
access to effective health is attainable,
working with partners in fighting major
infectious diseases, polio eradication, pre-
venting and treating chronic diseases. He
illustrated this with the campaign for treat-
ment of 3 million people living with
HIV/AIDS by the end of this year. This was
a first step towards universal access to treat-
ment.
While treatment of TB success rate had
reached 82% , detection still lagged at 45%.
The “reach and cure more patients“ meant
adopting WHO policies for HIV-linked TB
,drug-resistant disease and bolstering ser-
vice quality“
He expressed concern that in two countries
polio had recurred. The urgent need is to
achieve Polio eradication.
The strategy to achieve adequate malaria
control continues ,with the new
artemesinin-based combination therapies
and long lasting insecticide repellent nets
which are effective.
He referred to the growing threat to health
systems from shortage of adequately
trained staff. In 2006 the World Health
Report will be on Human Resources for
Health , which will be the theme of World
Health Day. The Report will launch the
decade of Human Resources for Health.
Dr. Lee ended by highlighting the serious
threat to the world today – Avian influenza .
„The timing cannot be predicted, but rapid
international spread is certain once the pan-
demic virus appears.“ The Spanish pan-
demic in 1918 gave some idea of its poten-
tial magnitude. He continued “By good for-
tune we have had time, and still have the
time , to prepare for the next global pan-
49
WHO
50
Mr. Gates said that in his view – and there
was no diplomatic way to put this: “The
world is failing billions of people. Rich
governments are not fighting some of the
world’s most deadly diseases because rich
countries don’t have them. The private sec-
tor is not developing vaccines and medi-
cines for these diseases, because develop-
ing countries can’t buy them. And many
developing countries are not doing nearly
enough to improve the health of their own
people”.
To be frank. “If these epidemics were rag-
ing in the developed world, people with
resources would see the suffering and insist
that we stop it. But sometimes it seems that
the rich world can’t even see the developing
world. We rarely make eye contact with the
people who are suffering – so we act some-
times as if the people don’t exist and the
suffering isn’t happening.
All these factors together have created a
tragic inequity between the health of the
people in the developed world and the
health of those in the rest of the world.”
He would speak about how the world,
working together, could dramatically
reduce this inequity.
I first learned about these tragic health
inequities some years ago when I was read-
ing an article about diseases in the develop-
ing world. It showed that more than half a
million children die every year from
“rotavirus”. I thought, ‘Rotavirus’? – I’ve
never even heard of it. How could I never
have heard of something that kills half a
million children every year!?”
When reading an article about diseases in
the developing world he learnt that millions
of children were dying from diseases that
had essentially been eliminated in the
United States. “Melinda and I assumed that
if there were vaccines and treatments that
could save lives, governments would be
doing everything they could to get them to
the people who needed them. But they
weren’t. We couldn’t escape the brutal con-
clusion that – in our world today – some
lives are seen as worth saving and others
are not. We said to ourselves: This can’t be
true. But if it is true, it deserves to be the
priority of our giving.”
Today, in malaria; AIDS; tuberculosis;
nutrition; maternal, newborn, and child ill-
ness; and so many other health problems,
the world was not doing enough to deliver
the solutions we do have, and we’re not
spending enough to find the solutions we
don’t have. As a result, millions of people
die every year. This didn’t tell a flattering
story. But the story wasn’t over. In fact, the
story is starting to change.
He believed we were on the verge of taking
historic steps to reduce disease in the devel-
oping world. What will make it possible to
do something in the 21st century that we’ve
never done before?
Science and technology
Never before have we had anything close to
the tools we have today to both spread
awareness of the problems and discover
and deliver solutions.
Global communications technology today
can show us the suffering of human beings
a world away. As the world becomes small-
er, this technology will make it harder to
ignore our neighbors, and harder to ignore
the call of conscience to act.
We are seeing the power of conscience in
efforts such as the United States’
Emergency Plan for AIDS, the United
Kingdom’s Commission on Africa, and the
Global Fund for AIDS, TB and Malaria.
But the desire to help means nothing with-
out the capacity to help – and our capacity
to help is increasing through the miracles of
science. Again and again, over and over,
scientists make the impossible possible.
Recent advances in basic research, particu-
larly the sequencing of the genome, give us
a foundation for much better progress
against all disease. If we match these accel-
erating capacities of science with the
emerging moral awareness of global health
inequities – we have an historic chance to
build a world where all people, no matter
where they’re born, can have the preventive
care, vaccines, and treatments they need to
live a healthy life.
To build this world, I see four priorities:
First, governments in both developed and
developing countries must dramatically
increase their efforts to fight disease.
The wealthy world’s governments must not
be content to merely increase their commit-
ment every year. They need to match their
commitment to the scale of the crisis. Yet
this will not happen unless we see a dramat-
ic increase in the efforts of developing
countries to fight the diseases that affect
their people.
Countries in sub-Saharan Africa spend a
smaller percentage of their gross domestic
product on health than other regions of the
world. A stronger commitment from devel-
oping countries will inspire a stronger com-
mitment from the rest of the world.
Priority number 2. The world needs to
direct more scientific research to health
issues that can save the greatest number of
lives – which means diseases that dispro-
portionately affect the developing world. In
the early 1900s, Nobel Prizes were awarded
demic, because the conditions for it have
appeared before the outbreak itself. We
must do everything is our power to max-
imise that preparedness. When this event
occurs, our response has got to be immedi-
ate, comprehensive and effective.“
WHO
Remarks of Mr Bill Gates, co-founder of the
Bill and Melinda Gates Foundation, at the
World Health Assembly
for discoveries about the causes of both
tuberculosis and malaria. Yet, more than a
hundred years later, we don’t have effective
vaccines for either one. It’s not because the
problem is unsolvable; it’s because we
haven’t put our scientific intelligence to the
task. The world can change this – for malar-
ia, tuberculosis, and many other diseases.
In order to get the world’s top scientific
minds to take on the world’s deadliest dis-
eases, in 2003 our foundation launched
“The Grand Challenges in Global Health.”
We asked top researchers to tell us which
breakthroughs could help solve the most
critical health problems in the developing
world. Scientists from more than 80 coun-
tries sent in thousands of pages of ideas,
which led to 14 specific Grand Challenges
in Global Health. Once we published these
challenges, more than 10,000 scientists
submitted proposals for research. They
included ideas such as vaccines that don’t
need refrigeration, handheld microdevices
that health workers can use with minimal
training to detect life-threatening fevers,
and drugs that can attack diseases that hide
from the immune system. The quality of the
ideas and the volume of the response
showed us that when scientists are given a
chance to study questions that could save
millions of lives – they flock to it. We were
so taken with the response that today we are
announcing an increase of our commitment
to these Grand Challenges from 200 million
dollars to 450 million dollars.
I am optimistic. I’m convinced that we will
see more groundbreaking scientific
advances for health in the developing world
in the next ten years than we have seen in
the last fifty.
We’re already seeing exciting advances.
We’re seeing today a new, safe, cheap drug
for visceral leishmaniasis, a disease that
kills more than a quarter of a million people
per year.
We’ve seen a demonstration this past year
that we can have a single vaccine for pneu-
monia that could reduce all deaths in Africa
by 15 percent. seeing older malaria drugs
make way for new, more effective drugs –
including new drug combinations that are
extremely effective with only 3 days of
treatment.
Malaria vaccine in trials last year showing
promise of preventing severe malaria.
And also progress this year towards the first
new drug for sleeping sickness in 50 years
– a new oral drug that was 100 percent
effective and showed no toxicity in phase
two trials.
Of course, one of our most daunting chal-
lenges is to create an effective vaccine to
prevent HIV/AIDS. Some of the world’s
top scientific minds are working on this
challenge, but many of the researchers are
isolated, under pressure for immediate
results, and unaware of their colleagues’
discoveries.
Refering to the challenge of creating an
effective vaccine to prevent HIV/AIDS he
commented that, over the past two years the
global scientific community has come
together under the HIV Vaccine Enterprise to
coordinate AIDS research under one strategy
– to help eliminate duplication, identify the
gaps, and maximize the synergy from so
many brilliant minds. There is new energy
around this global HIV Vaccine Enterprise,
and our foundation has recently announced
400 million dollars in funds to implement
critical parts of this plan. It is time that the
energy and commitment to find an HIV vac-
cine matches the magnitude of the pandem-
ic.
Not everyone shared this enthusiasm. We
have been criticized for emphasizing the
health discoveries that will come in the near
future. Research into big health break-
throughs. Some point to the better health in
the developed world and say that we can
only improve health when we eliminate
poverty. And eliminating poverty is an
important goal. But the world didn’t have to
eliminate poverty in order to eliminate
smallpox – and we don’t have to eliminate
poverty before we reduce malaria. We do
need to produce and deliver a vaccine – and
the vaccine will save lives, improve health
and reduce poverty. Improving health
improves education; it expands productivi-
ty; it results in people having smaller fami-
lies, so that resources go further. When
health improves, life improves by every
measure. That’s why we will continue to
invest a significant percentage of our
resources in searching for low-cost, life-
saving breakthroughs, especially through
vaccine research – and we encourage
wealthy governments to do the same.
The foundation would continue to invest
life saving breakthroughs and he urged gov-
ernment to do the same.
Priority number 3. The world has to devote
more thinking and funding to delivering
interventions – not just discovering them.
“Imagine that one day there is worldwide
rejoicing over the discovery of an effective
AIDS vaccine. But imagine this too: we
discover the vaccine, but don’t distribute it.
And millions continue to die.
What a horrifying thought. Most people
would say we’d never let that happen. But,
in a sense, we already are! That’s what the
world has been doing for decades in the
case of diseases like measles, diphtheria,
tetanus, and hepatitis B. In the past 5 years,
more than 30 million children every year
went unvaccinated with the basic vaccines
that are widely used in the industrialized
world. As a result, more than a million chil-
dren die from vaccine-preventable diseases
each year.
Getting the intervention to the people who
need it should never be an afterthought; it
should be built into the design of the new
discovery.”
We need an emphasis on “breakthroughs
you can use” or what we like to call
“deliverable technology” – which means
getting it to the people who need it. At the
very outset, researchers should be seeking
interventions that are not only effective, but
also inexpensive to produce, easy to distrib-
ute, and simple to administer.
If we can go from 20 pills a day to three
pills a day, why can’t we go from three pills
a day to a once-a-month treatment?
Today, we have tuberculosis drugs that you
have to take for 9 months. Why can’t we
find one that works in 3 days?
His background was in information tech-
nology very different from global health.
“But it does give us a useful lesson: early in
51
WHO
the computer age, computers were very
large and costly, which limited the number
of people who could use them. The contin-
uous process of discovering new designs
helped make the technology smaller and
cheaper so that someone like me could
declare the goal of a computer in every
home and on every desk. Millions more
people can get the benefits of new discover-
ies if you make delivery a priority, and if
delivery shapes the design.”
“Priority number 4. To find new discoveries
and deliver them, we need to make political
and market forces work better for the
world’s poorest people.”
Political systems in rich countries work
well to fuel research and fund health care
delivery, but only for their own citizens.
The market works well in driving the pri-
vate sector to conduct research and deliver
interventions, but only for people who can
pay.
Unfortunately, these political and market
conditions that drive high quality health
care in the developed world are almost
entirely absent in the rest of the world. We
have to make these forces work better for
the world’s poorest people.
There is a model in the Global Alliance for
Vaccines and Immunization – an effort we
launched in 2000 to address the tragedy of
millions of children dying every year from
vaccine-preventable diseases. When the
project began, vaccines were sitting on the
shelf as kids were dying from those very
diseases. Other necessary vaccines were not
being manufactured at all. The market
wan’t working to bring people what they
needed because there wasn’t enough money
to create a demand and guarantee a supply.
Since 2000, eleven governments have pro-
vided hundreds of millions of dollars for
vaccine purchase and distribution. This has
given companies a market incentive to
manufacture these vaccines. As a result, in
five short years, four million additional
children have been immunized with basic
vaccines, 42 million with hepatitis B, five
million with haemophilus influenzae type
B, and over three million with yellow fever
– saving more than 700,000 lives.
“We hope even more funding will be made
available through the proposed
International Financing Facility for
Immunizations proposed by the United
Kingdom; with support pledged by France,
Germany, Sweden, and Italy, this initiative
would provide developing countries with
the reliable funding they need, year after
year, to buy vaccines, which gives the pri-
vate sector the market incentive to make
them and deliver them.” He believes that if
we act on these four priorities, we can build
a world where all people, no matter where
they’re born, can have the preventive care,
vaccines, and treatments they need to live a
healthy life.
Governments in developed countries
should match their financial commitments
to the scale of the crisis – and make sure
their efforts get results.
Governments in developing countries
should make health a priority by dramati-
cally increasing the percentage of their bud-
gets they commit to health – particularly in
their efforts to build health systems that can
adopt and deliver low-cost interventions.
Citizens around the world should petition
their governments to put up money to make
market forces work better for the world’s
poorest people.
“It’s one thing to define the goals and
design the tasks, it’s quite another to get
them done. An important duty falls to the
health ministers in this room.“
He appealed to Health Ministers present.
They occupied a crucial position between
the people who make funding decisions and
the people suffering from disease. They can
make an immense difference by urging the
world to make eye contact with the people
who are suffering and can also show the
world that there are solutions that work.
One key to this is the new Health Metrics
Network, which will be announced tomor-
row and which the foundation are proud to
support. This network will work to
strengthen health information systems in
countries so that health efforts are based on
evidence, not speculation.
“There is no bigger test for humanity than
the crisis of global health. Solving it will
require the full commitment of our hearts
and minds. We need both. Without compas-
sion, we won’t do anything. Without sci-
ence, we can’t do anything. So far, we have
not applied all we have of either. I was opti-
mistic that in the next decade, people’s
thinking will evolve on the question of
health inequity and people would finally
accept that the death of a child in the devel-
oping world is just as tragic as the death of
a child in the developed world.“
52
WHO
A new global partnership that will work to
improve public health decision-making
through better health information was
launched on 18 May 2005 at the World
Health Assembly (WHA). The Health
Metrics Network (HMN), a partnership
comprised of countries, multilateral and
bilateral development agencies, founda-
tions, global health initiatives and technical
experts will increase the availability and
use of timely, reliable health information by
catalyzing the funding and development of
core health information systems in develop-
ing countries.
Today, despite the efforts of many country,
regional and global partners, there are sig-
nificant gaps in the health information that
is available to policy-makers and health
practitioners. “In some areas of the world,
even basic facts such as a person’s birth,
their death and cause of death are not
recorded,“ said Dr. LEE Jong-wook,
Director-General of the World Health
Organization (WHO). The Health Metrics
Network will work to close this gap by
Strengthening Health Information Systems to
better address health needs worldwide
helping countries improve their ability to
gather this vital health information.
Accurate data is critical to identifying prob-
lems and implementing effective solutions
for people’s health.“
HMN brings together health and statistical
constituencies to build capacity and exper-
tise for strengthening health information
systems so that local, regional and global
decision-makers have quality data on which
to base decisions to improve health.
“Health information is not simply an end in
itself but provides the basis for better deci-
sion-making,” said Dr. Richard Klausner,
Executive Director, Global Health, the Bill
& Melinda Gates Foundation. “Good data,
quality reporting and tracking, thoughtful
analysis and consistent health information
systems will enable decision-makers to
make informed and therefore better deci-
sions on disease control and human devel-
opment.”
HMN responds to a need for evidence-
based policy-making that can enable coun-
tries to make more efficient use of health
budgets. In addition, other global initiatives
including the Millennium Development
Goals, the Global Fund to Fight AIDS,
Tuberculosis and Malaria, Global Alliance
for Vaccines & Immunization (GAVI) and
the President’s Emergency Plan for AIDS
Relief (PEPFAR) have increased the
demand for sound health information.
HMN partners have agreed to align their
individual efforts around a common health
information framework thereby reducing
overlapping and duplicative demands that
have burdened fragile information systems
in developing countries in the past.
“We have agreed to better coordinate and
align our investments in the development of
health information systems in accordance
with the broader development agenda
including the Millennium Development
Goals,” according to a statement endorsed
by the HMN partners.
The initial HMN partners include: African
Population and Health Research Center;
Bill & Melinda Gates Foundation, Centers
for Disease Control and Prevention of the
U.S. Department of Health and Human
Services, Danish International
Development Agency, Department for
International Development (U.K.), Euro-
pean Commission, Ghana Health Services,
Global Fund to fight AIDS, Tuberculosis
and Malaria, GAVI, Ministry of Health,
Mexico, Ministry of Public Health, Thai-
land, Organisation for Economic Co-
Operation and Development, Statistics
South Africa, Swedish International
Development Agency, Uganda Bureau of
Statistics, UNICEF, United Nations
Statistics Division, U.S. Agency for Inter-
national Development, World Bank and
World Health Organization.
HMN will meet its objectives through a
range of activities. Low- and middle-
income countries will be eligible to apply
for grants of up to US$ 500 000 for health
information system strengthening and can
call upon HMN partners for technical assis-
tance.
By 2011, HMN expects that at least 80
countries will be able to report on agreed,
standardized global health goals and indica-
tors in a timely and sound manner.
HMN has received an initial grant of US$
50 million over seven years from the Bill &
Melinda Gates Foundation and additional
contributions from other donors including
the Department for International
Development (U.K.), U.S. Agency for
International Development and Danish
International Development Agency.
For more information contact:
Christine McNab
Telephone: +41 22 791 4688
Email: mcnabc@who.int
53
WHO
This year`s World Health Report focuses on
Maternal and Child Health under the title
„Make every mother and child count.“ This
highlights the fact that there is only a decade
left to achieve the Millennium Development
Goals which, in particular, highlights access
to care and improvement in health, particu-
larly in the context of reduction of poverty.
The extensive analysis which precedes the
Appendix of global basic statistical informa-
tion, this year focuses especially on mater-
nal and child health, reflecting the needs and
problems in implementing the progress that
is still required to ensure full implementa-
tion of the technical knowledge which, if put
in place, would reduce mortality and mor-
bidity in mothers and children alike. The
overview preceding the seven chapter com-
mentary refers at an early stage to the 3.3
million or more stillbirths, the 4 million plus
deaths within 28 days of birth, the 6.6 mil-
lion children dying before their fifth birth-
day, and the 529 thousand maternal deaths
in pregnancy and during or following child-
birth.
While referring to the increase in countries
who have improved maternal and child
health recently, depressingly, it states that
those countries who had the highest burden
of mortality and ill-health made the least
progress in the 90’s. For some, progress has
even slowed down.
In analysing why progress is patchy and list-
ing the many factors contributing to this,
including inability to invest adequately in
health systems, stress is laid on the dispari-
ties between countries and also between rich
and poor within countries.
The seven chapters analyse not only the his-
tory of maternal and childcare, the progress
as well as failings, but also outlines ways
forward for progress, and the financial and
other resources required to achieve this.
They make compelling reading and hopeful-
ly will meet with an adequate response from
both the wealthy industrialised nations as
well as those still at various stages of devel-
opment, and other international agencies.
The World Health Report 2005 –
„Make every mother and child count“
Science Can Do More – Research To
Bridge The “Know-Do” Gap
Geneva – Health Systems Research has the
potential to produce dramatic improvements in
health worldwide and to meet some of the
major development challenges in the new mil-
lenium. Effective research could prevent half of
the world’s deaths with simple and cost-effec-
tive interventions, the World Health
Organization says in a new world report on
global health research.
The WHO World Report on Knowledge for
Better Health: Strengthening Health Systems
highlights aspects of health research that, if
managed more effectively, could produce even
more benefits for public health in future. It sets
out the strategies that are needed to reduce glob-
al disparities in health by strengthening health
systems.
Inequities in health are among the major devel-
opment challenges in the new millenium and
malfunctioning health systems are at the heart
of the problem. Moreover, the culture and prac-
tice of health research should reach beyond aca-
demic institutions and laboratories to involve
health service providers, policy-makers, the
public and civil society.
The report also argues that science must help to
improve public health systems and should not
be confined to producing drugs, diagnostics,
vaccines and medical devices. Biomedical dis-
coveries cannot improve people’s health with-
out research to find out how to apply them with-
in different health systems and diverse political
and social contexts, thus ensuring that they
reach those who need them the most.
“There is a sense that science can do more,
especially for public health,” said Dr LEE Jong-
wook, WHO Director-General. “There is a gap
between today’s scientific advances and their
application – between what we know and what
is actually being done. Health systems are
under severe pressure and there is an urgent
need to generate knowledge for strengthening
and improving them.”
A team of 12 internationally prominent health
researchers in both developed and developing
countries, coordinated by Dr Tikki Pang, WHO
Director for Research Policy & Cooperation,
developed the 143-page World Report on
Knowledge for Better Health over 18 month.
Based-on a wide-ranging consultative process
and on previous reviews of global health
research, the report advocates that health equity
can only be achieved through better manage-
ment of health research and increased invest-
ment in health systems research.
Health systems research suffers from a poor
image and has been under-funded compared to
biomedical research despite widespread recog-
nition of its importance. The field attracts less
than one tenth of 1% of total health expenditure
in low-income countries.
The lack of attention given to this field is also
reflected in the fact that only 0.7% of scientific
articles published globally in the year 2000
were in the area of health systems research.
“It is extremely important to get this report out
now. The report demonstrates the enormity and
complexity of the problem and outlines a way
to go forward,” said Eva Harris, President of the
Sustainable Science Institute based at the
University of California, Berkeley, USA. “It
anticipates how the global community can get a
handle on the problem in a constructive manner
instead of lamenting a lack of action.”
In Africa, for example, it is estimated that only
between 2-15% of children slept under bed-nets
in 2001 – a simple, effective and proven method
to prevent malaria. “We need to put a stronger
emphasis on translating knowledge into actions
– health systems research will help us to bridge
this “know-do” gap”. Also, that research is an
investment, not a cost”, said Dr Pang.
The report also illustrates how health systems
research can strengthen human resources for
health, health financing, as well as information
and delivery of health services, with some pro-
jects already yielding impressive results.
Among the research projects mentioned in the
report is the Tanzania Essential Health
Interventions Project (TEHIP) which was set up
to find new ways to plan, set priorities and allo-
cate resources as part of a major reform of the
country’s health-care system. The aim was to
evaluate the impact of health interventions in
terms of burdens of disease and per capita cost.
Researchers found that in two Tanzanian dis-
tricts, malaria alone accounted for 30% of all
healthy years of life lost due to deaths in 1996-
97. In response, government planners increased
the budget for malaria prevention and treatment
programmes from 10% to 26% by 2000-2001.
Overall, the research has resulted in a better
match between disease burden and health bud-
get allocation, and the child mortality rate has
been reduced by more than 40% since the late
1990s.
“Health systems should nurture a stronger cul-
ture of learning and problem-solving to tackle
the major health challenges of our times,” said
Tim Evans, Assistant Director-General, WHO.
“This could be achieved by understanding how
elements within a health system interact with
each other and by finding innovative ways to
solve complex problems.”
What is a health system?
A health system includes all actors, organiza-
tions, institutions and resources whose primary
purpose is to improve health. In most countries
a health system has public, private, traditional
and informal sectors. Although the defining
goal of a health system is to improve health,
other goals are to be responsive to the popula-
tion it serves. This responsiveness is determined
by the environment in which people are treated,
and should ensure that the financial burden of
paying for health is fairly distributed. Four key
functions determine the way inputs are trans-
formed into outcomes that people value:
resource generation, financing, service provi-
sion and stewardship. The effectiveness, effi-
ciency and equity of national health systems are
critical determinants of population health status.
Ministerial summit on health
research
Ministers of Health from more than 30 nations
as well as representatives of research institu-
tions, academia, non-governmental organiza-
tions, pharmaceutical companies and various
key stakeholders in health/medical research
gathered in Mexico City, Mexico, from 16-20
54
WHO
Sustainable Health Systems
An Innovative
Approach To Health
Systems Research
55
Geneva – The World Health Organization has
welcomed the results of a pneumococcal con-
jugate vaccine trial conducted in the Gambia
which are published in the Lancet comment-
ed as follows:
Dr LEE Jong-wook, Director-General,
WHO, declared:
“The results of this vaccine trial hold great
promise for improving health and saving
lives in resource-poor populations. The inter-
national community’s task now is to continue
to work together productively to make the
pneumococcal conjugate vaccine widely
available to children in Africa, as lives are
lost every minute to pneumococcal disease.
Immunizing children with pneumococcal
conjugate vaccine in developing countries
will be a critical intervention towards achiev-
ing a two-thirds reduction in the under-five
mortality rate, a Millennium Development
Goal.”
Dr Felicity Cutts, principal investigator of the
trial who is currently based at WHO, said:
“The trial results are highly positive and
promising, and provide us with a clearer pic-
ture of the pneumococcal disease burden in
Africa. The trial confirms that pneumococcal
pneumonia, meningitis, and sepsis are major
causes of death and serious illness among
African infants and young children. Most
importantly, it demonstrates that pneumococ-
cal vaccination can prevent many of these
serious infections even in a rural African set-
ting. This is great news for children and par-
ents in rural areas everywhere.”
A similar vaccine has had a dramatic impact
on reducing pneumococcal disease in the
United States. The Gambia vaccine trial has
now clearly demonstrated that a significant
proportion of illness, disability and death in
African children can be averted through vac-
cination against this disease, a leading killer,
especially of young children in developing
countries.
Dr Thomas Cherian, Team Coordinator in the
WHO Initiative for Vaccine Research stated:
“Experience has shown that in areas where
health systems are unable to provide hard to
reach, rural populations with round-the-clock
access to high-quality curative care, immu-
nization can be delivered through outreach
services to great benefit. The pneumococcal
vaccine will therefore be particularly impor-
tant to save lives in the most disadvantaged
populations.”
The trial was supported by a broad coalition
of international partners including the WHO
Initiative for Vaccine Research, the National
Institute of Allergy and Infectious
Diseases/National Institutes of Health; the
British Medical Research Council/United
Kingdom working with The Gambia
Government; the London School of Hygiene
and Tropical Medicine; the U.S. Agency for
International Development; the Centers for
Disease Control and Prevention of the United
States Health and Human Services
Department; Wyeth-Lederle Vaccines; the
Program for Appropriate Technology in
Health (PATH) Children’s Vaccine Program,
as well as WHO.
In the Gambia and other African countries,
rates of invasive pneumococcal disease
(severe forms of the disease, where bacteria
are isolated from blood, spinal fluid or anoth-
er site in the body where bacteria are not usu-
ally found), are up to ten times higher than in
industrialized countries and the disease is a
major cause of hospital admissions and
deaths. WHO estimates that between 700,000
and 1 million children under five die from
pneumococcal diseases each year.
A randomized, controlled, double-blind trial
of a pneumococcal conjugate (made from
linking purified polysaccharides or complex
sugars from the coat of a disease-causing
bacterium to a protein carrier) vaccine took
place in eastern Gambia starting in August
2000. 17,437 children aged 6-51 weeks were
enrolled in the study. Those 8719 children in
the control group received a diphtheria-
tetanus-pertussis-Haemophilus influenzae
serotype b vaccine. 8718 children received
pneumococcal conjugate vaccine, mixed
with the tetravalent vaccine received by the
control group.
Results of the trial indicated that in the group
of children who received pneumococcal con-
jugate vaccine, there were:
• 37% fewer cases of pneumonia (as con-
firmed by chest X-ray);
• 15% fewer hospital admissions
• 16% reduction in overall mortality; and
• half the rate of laboratory-confirmed
pneumococcal pneumonia, meningitis
and septicaemia.
Moreover, the vaccine was 77% effective in
preventing infections caused by nine
serotypes (strains) of pneumococcal bacteria
whose sugar capsules make up the vaccine.
To summarise, in this rural African setting,
pneumococcal conjugate vaccine was shown
in this trial to be highly effective against
pneumonia and invasive pneumococcal dis-
ease. It can substantially reduce admissions
and improve child survival.
Full details of the trial are available in a
Lancet 26 March 2005 Dr Felicity T. Cutts et
al. “Efficacy of nine-valent pneumococcal
conjugate vaccine against pneumonia and
invasive pneumococcal disease in the
Gambia: randomised, double-blind, placebo-
controlled trial.“
November 2004, to address the vital role of
research in strengthening health systems and
how it can better serve the health needs of the
global population. Hosted by the Government
of Mexico and the World Health Organization,
the Ministerial Summit on Health Research
focussed on the “know-do gap” – how to trans-
late knowledge into action to improve health.
The Summit also discussed research needed to
achieve the health-related Millenium
Development Goals (MDGs) by 2015.
By gathering a large number of players in
health research, the Summit represents a
unique opportunity to develop a platform of
specific initiatives to strengthen health sys-
tems and to improve imformation access. The
key recommendations of the Summit have
been incorporated into the “Mexico Agenda
on Health Research.”
WHO
Vaccinating african children against
pneumococcal disease saves lives
56
In the course of a presentation on Migration
of Health Workers at the BMA Conference
reported above, Professor Agyeman Badu
Akosa, Director General of Health Services
Ghana and President of the Commonwealth
Medical Association ,described the organisa-
tion of healthcare in Ghana and identified
three problems of Human Resources, These
were
a) Poor retention of staff
b) Inadequate production of staff
c) Maldistribution.
After elaborating on these, setting out the rea-
son why there is a brain drain from this coun-
try and possible factors which might reverse
this, he addressed more generally the situa-
tion concerning the migration of physicians
in the Sub-Saharan countries, quoting figures
from Hagopian et al 2004, and his analysis of
migration to the USA.
Of the 771491 physicians (2002), 23%
trained in low- income or lower middle-
income countries, 5335 physicians were from
Sub-Saharan Africa. This represented more
than 6% of the physicians currently practic-
ing in Sub-Saharan Africa now.
Of 87 medical schools in the Region, it
appears that ten medical schools in four
countries (South Africa, Ghana, Nigeria and
Ethiopia) produce 79.4% of the émigré
physicians to the USA (targeting these 10
medical schools could therefore be of greater
value than addressing the problem in 47
countries).
The cost of training physicians who subse-
quently migrate was estimated to be 9 million
$US a year for Ghana and 20 million $US for
Nigeria. (Hagopian & Ofosu et al, unpub-
lished 2003)
(Medical students contribute 5% only of the
costs of their medical education)
It is of interest to note that the U.N.
Commission for Trade and Development
estimates that each professional leaving
Africa costs the continent 184000 $US or 4
billion $US a year. The loss of tax revenue
from absent physicians also represents a sig-
nificant economic loss.
Compared with affluent countries the
distribution of physicians in he population is
Africa is dramatically demonstrated by the
following:
Country Physicians per
100,000 population
USA 279
Canada 229
Australia 240
UK 164
Uganda 4
Zambia 7
Ghana 6
South Africa 57
Regional and NMA News
Regional and NMA News
Figures and facts
from Africa
(extracted from a paper
given at the BMA “Call for
Action“ Conference)
The healthcare skills drain – a call to action
On 14 April 2005, the British Medical
Association organised an international con-
ference on the global health workforce in
association with the Commonwealth, and
with participants from the American Medical
Association, the American Nurses Associa-
tion, the Canadian Medical Association, the
Federation, Health Canada, the Medical
Council of Canada, the Royal College of
Nursing and the South African Medical
Association. The conference agreed the fol-
lowing principles and recommendations.
The lack of healthcare workers in developing
countries, particularly those in sub-Saharan
Africa, is an emergency that demands urgent
action. The impact of healthcare worker
migration from developing to developed
countries is a significant component in this
crisis.
All citizens have a right to enjoy the highest
attainable standard of health, and this, along
with the prevention and treatment of ill
health, is central to sustaining poor people`s
ability to escape poverty. Measures to realise
these aims are essential to the Millennium
Development Goal of poverty reduction.
Therefore, recognising that:
•all countries need an adequate healthcare
workforce strategy and the means to manage
this, and that the workforce represents the
most important investment in healthcare
systems;
•many countries have actual and projected
shortages of health workers. Examples
include a projected deficit by 2020 in the
USA of 200000 doctors and 800000 nurses,
and one million health workers in Sub-
Saharan Africa to meet the Millennium
Development Goals (MDGs) by 2015.
•In countries which already have severe
shortages of healthcare workers (fewer than
one health worker per 1000 population) fur-
ther loss of such workers through premature
death or migration is very likely to result in
loss of health services and loss of life in the
countries` populations;
•Billion dollar funds amassed to address
overwhelming global health problems (such
as HIV/AIDS) are constrained primarily by
the lack of healthcare professionals;
the conference agreed on the following four
key points:
1) All countries must strive to attain self-
sufficiency in their healthcare work-
force without generating adverse con-
sequences for other countries;
2) Developed countries must assist devel-
oping countries to expand their capaci-
ty to train an retain physicians and
nurses, to enable them to become self-
sufficient;
3) All countries must ensure that their
healthcare workers are educated, fund-
ed and supported to meet the health-
care needs of their populations;
4) Action to combat the skills drain in this
area must balance the right to health1
of populations and other individual
human rights.
1 Universal Declaration of Human Rights (1948),
Article 25.1; International Covenant on Economic,
Social an Cultural Rights (1976), Article 12.1.