WMJ_01_2024

Official Journal of The World Medical Association, Inc. Nr. 1, March 2024
vol. 70
Contents
Editorial   3
Interview with the President of the World Veterinary Association  4
Two Models of Approaching the Goals of Medicine: The Dilemma that Sparks
Different Perspectives in Conscientious Objection   7
Strengthening Health Systems’ Quality in the
World Health Organization European Region 12
Bioethicists in Public Health: A Chance to Counter Misinformation?   15
Our Moral Obligations vis a vis Climate Change   18
E-professionalism of Healthcare Professionals: An Ongoing Challenge   21
Navigating the Public Health Information Space: Responding to
Disinformation with Global Expert Insights and Potential Strategies   25
WMA Members Contribute Insight on Global Vaccination Efforts 28
World Medical Association’s Participation at COP28 Dubai   38
Strengthening Global Health Security Dialogue
at the 74th WMA General Assembly in Kigali, Rwanda   45
Research with Vulnerable People: A Targeted Interdisciplinary
Discussion within the Scope of the WMA Declaration of Helsinki Revision   54
WORLD MEDICAL ASSOCIATION OFFICERS,
CHAIRPERSONS AND OFFICIALS
Dr. Lujain ALQODMANI
President
Kuwait Medical Association
123 Fifth Avenue,
1202
Kuwait
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Jack RESNECK
Chairperson,
Finance and Planning Committee
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chicago, Illinois
United States
Dr. Ashok PHILIP
President-Elect
Malaysia Medical Association
4th Floor, MMA House,
124 Jalan Pahang
53000 Kuala Lumpur
Malaysia
Dr. Tohru KAKUTA
Vice-Chairperson of Council
Japan Medical Association
113-8621 Bunkyo-ku, Tokyo
Japan
Dr. Zion HAGAY
Chairperson,
Socio Medical Affairs Committee
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Osahon ENABULELE
Immediate Past President
Nigerian Medical Association
8 Benghazi Street,
off Addis Ababa Crescent
Wuse Zone 4, P.O. Box 8829
Wuse, Abuja
Nigeria
Mr. Rudolf HENKE
Treasurer
German Medical Association
(Bundesärztekammer)
Herbert-Lewin-Platz 1
(Wegelystrasse)
10623 Berlin
Germany
Dr. Jacques de HALLER
Chairperson,
Associate Members
Swiss Medical Association
(Fédération des Médecins Suisses)
Elfenstrasse 18, C.P. 300
3000 Berne 15
Switzerland
Dr. Jung Yul PARK
Chairperson of Council
Korean Medical Association
Samgu B/D 7F 8F 40
Cheongpa-ro,
Yongsan-gu
04373 Seoul
Republic of Korea
Dr. Steinunn
THÓRDARDÓTTIR
Chairperson,
Medical Ethics Committee
Icelandic Medical Association
Hlidasmari 8
201 Kópavogur
Iceland
www.wma.net
OFFICIAL JOURNAL OF THE WORLD
MEDICAL ASSOCIATION
Editor in Chief
Dr. Helena Chapman
Milken Institute School of Public Health, George Washington University, United States
editor-in-chief@wma.net
Assistant Editor
Mg. Health. sc. Maira Sudraba
Latvian Medical Association
lma@arstubiedriba.lv, editor-in-chief@wma.net
Journal design by
Erika Lekavica
dizains.el@gmail.com
Publisher
Latvian Medical Association
Skolas Street 3, Riga, Latvia
ISSN 0049-8122
Opinions expressed in this journal – especially those in authored contributions –
do not necessarily reflect WMA policies or positions
3
Editorial
Editorial
BACK TO CONTENTS
Our global medical community welcomes the new year with
renewed enthusiasm to contribute expertise on pressing global
health and medical ethics topics that impact patient care, health
professionals’training, and overall health system preparedness.To
maintain robust policy statements, World Medical Association
(WMA) members have contributed to the collaborative,
inclusive, and transparent review process of the Declaration of
Helsinki at three regional expert meetings in Tokyo in November
2023, Vatican City in January 2024, and Johannesburg in
February 2024. WMA leadership has also stressed its call for
medical neutrality, condemning any violations of international
humanitarian law and demanding health workforce and public
safety, in response to the ongoing conflict in Gaza and Israel.
As the World Health Organization (WHO) has reported that
providing health services in crisis and conflict remains one of
the 13 urgent challenges for this current decade, the economic,
environmental, political, and social impacts of crisis and conflict
will continue to be unveiled in the upcoming months.
According to the World Economic Forum’s Global Risks Report
2024,published in January 2024,four systemic elements – climate
change, demographic bifurcation, technological acceleration, and
geostrategic shifts – will influence the management of global
risks during this decade. Notably, three primary climate issues
include extreme weather events, critical change to Earth systems,
and biodiversity loss and ecosystem collapse. The document
has presented a ranked list of the perceived severity of diverse
short- and long-term risks, as they relate to the global security
landscape, stakeholder groups, and age, including climate and
ecosystems, societal or political polarisation, misinformation and
disinformation, inflation and economic uncertainty, and adverse
outcomes of generative artificial intelligence technologies. Hence,
these findings offer a call to action for global leaders and citizens
to adopt the One Health concept to address these complex
challenges affecting human, animal, and environmental health.
By recognising these emerging global health challenges, WMA
members can offer valuable insight and perspectives on existing
knowledge and practice gaps that hinder the delivery of high-
quality medical and surgical services to patients across nations.
As they represent more than 114 national medical associations
(NMAs), they can propel global discourse that promotes the
formation of multidisciplinary and multisectoral partnerships
that incorporate innovative technology to reinforce national and
global health security. These scientific contributions will support
collective discussions on issues affecting global physicians,notably
at the 226th WMA Council Session,which will be held in Seoul,
Republic of Korea, from 18-20 April 2024.
In this issue,Dr.Rafael Laguens shared personal reflections about
veterinary medical education and key priorities for the WMA and
World Veterinary Association. Dr. Jaime Hernandez-Ojeda and
Dr.Pablo Requena described perspectives related to conscientious
objection in medicine. Dr. Christos Triantafyllou and colleagues
discussed opportunities to strengthen health systems’ quality in
the WHO European Region. Dr. Daniel Lucas expressed how
bioethicists can help counter misinformation in public health.
Dr. Chantal Patel stressed the importance of adopting a moral
approach to combat climate change. Dr. Tea Vukušić Rukavina
and Dr. Marko Marelić commented on the challenges related to
e-professionalism of health professionals. Dr. Natalia Solenkova
offered insight on responding to public health misinformation
and disinformation. Dr. Ankush Bansal and colleagues provided
a high-level summary of the WMA delegation’s participation at
COP28 in Dubai. Finally, Dr. Damas Dukundane and colleagues
presented a high-level summary of the Global Health Security
session presented at the 74th WMA General Assembly.
We fully recognise the inspirational leadership contributions
that WMA members offer throughout their daily clinical
and community practice. In this issue, the German Medical
Association invites WMA members and relevant guests to
attend the Research with Vulnerable People conference, as part
of an interdisciplinary discussion within the scope of the WMA
Declaration of Helsinki Revision, in Munich, Germany, from 14-
15 May 2024.Also,WMA members representing seven countries
shared practical policies and activities that support immunisation
efforts related to World Immunisation Week 2024. Together, we
can collaborate on key local and national initiatives that strengthen
clinical guidelines and policies and ultimately population health
across the globe.
We look forward to continued networking at the 226th WMA
Council Session in Seoul!
Helena Chapman, MD, MPH, PhD
Editor in Chief of the World Medical Journal
editor-in-chief@wma.net
4
For this interview, Dr. Rafael
Laguens, the President of the World
VeterinaryAssociation(WVA),shares
his perspectives on his global health
leadership, the future of veterinary
medicine, existing challenges in
veterinary medical education, and
key priorities for WVA and World
Medical Association (WMA)
members, with Dr. Helena Chapman,
the WMJ Editor in Chief.
Please share two quotes and
describe how these quotes reflect
your journey as WVA president
(2022-2024).
The seventh Secretary-General of
the United Nations, Kofi Annan
said, “More than ever before in human
history, we share a common destiny. We
can master it only if we face it together.”
Although we can perceive the
differences that exist in our world, the
veterinary profession offers a unique
perspective to global health. The
work of the WVA allows us to better
understand the veterinary medicine
profession across all continents,
appreciate social, economic, political,
religious, and cultural diversity, and
recognise the persisting inequalities
within and among countries.
Together with clinical and public
health expertise, veterinary medicine
professionals worldwide share
common principles that are essential
to promoting animal health and
welfare, environmental health, food
safety, and of course, public health.
Professor Peter Doherty, the first
person with a veterinary degree to be
awarded a Nobel Prize in Physiology
or Medicine in 1996, stated, “The
need to deal with pathogens has driven
the evolution of the vertebrate immune
system, so it should not be surprising that
experiments with infectious agents have
often illuminated key elements of the
underlying mechanisms.” By reviewing
the history of human and animal
medicine, we can clearly observe
their close connections and synergies
in clinical diagnostics, surgical and
pharmaceutical management, and
prevention strategies. As we ensure
that high-quality medical care is
provided to different species, we
recognise the importance of the
interconnectedness between humans,
animals, and the surrounding
environment in protecting public
health. A rational and orderly
exchange of information and
experiences between all fields of
human and animal medicine is crucial
for optimal health of our global
society. This Nobel Prize, which was
shared between Professor Doherty
and Dr. Rolf Zinkernagel (Swiss
physician), illustrates this essential
interface between human and animal
medicine (Photo 1).
Over the past year, what do you
consider to be your most important
leadership achievements as WVA
president (2022-2024)?
Over the past year, I have been
honored to lead WVA efforts to
strengthen official relationships with
different international organisations,
such as the World Health
Organization (WHO), the Food
and Agriculture Organization of the
United Nations (FAO), the United
Nations Environment. Programme
(UNEP),and the World Organisation
Rafael Laguens
Interview with the President of the World Veterinary Association
Interview with the President of the World Veterinary Association
Photo 1. Dr. Rafel Laguens with Professor Peter Doherty (right), recipient of the Nobel Prize in Physiology or Medicine in
1996. Credit: Rafael Laguens
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5
for Animal Health (WOAH).
One noteworthy collaboration was
formalised between the WVA and the
WOAH, which aimed to “advocate
for better integration of veterinary
services in One Health projects and
initiatives at all levels, including legal
frameworks to reduce the risk of, and
prevent future pandemics.” A second
important achievement included the
active participation of the WVA in
the Antimicrobial Resistance Multi-
Stakeholder Partnership Platform,
which developed an urgent global
vision, narrative, and targets to
combat antimicrobial resistance and
mobilize all relevant stakeholders.
This platform includes governments,
civil society, private sector, financial
institutions, donors and researchers,
who work across the human, animal,
plant, and environmental health
sectors.
Finally, I have had numerous
opportunities to connect with medical
and veterinary medicine professionals
as well as help coordinate and
contribute to scientific events,
including the WVA and WVA
national member association
conferences. Overall, I greatly
appreciate the opportunities to
collaborate with WMA leadership,
staff, and members, such as
sharing experiences regarding
the management of both global
associations and participating in
discussions of common interest,
such as issues of ethics and bioethics
or actions to tackle antimicrobial
resistance.
How do you envision the future of
veterinary medicine?
Looking into the future, I envision
that veterinary medicine will gain
more attention in terms of care for
companion animals and biodiversity
conservation. As people are
increasingly seeking medical attention
for their companion animals, this
demand will drive changes in
academic curricula, training, and
clinical practice. Likewise, since
citizens aim to keep all animals (pets,
livestock, wildlife) in optimal health
and well-being, more opportunities
will be opened for veterinary practice
related to implementing evidence-
based guidance to protect animal
welfare. Also, with the effects of
climate change due to natural
and anthropogenic phenomena,
initiatives to protect biodiversity and
surrounding ecosystems will become
a significant priority in veterinary
medicine.
Aside from the coronavirus disease
2019 (COVID-19) pandemic, how
would you describe the anticipated
challenges in veterinary medical
education over the next decade
across the globe?
As the world experienced the
COVID-19 pandemic and the
post-pandemic world, human and
veterinary medicine professionals
should be vigilant for emerging risks
that affect the delicate balance of
the surrounding ecosystem. Some
of these challenges include priority
zoonotic diseases such as rabies, avian
influenza, and viral haemorrhagic
fevers (e.g. Ebola), to cross-cutting
issues including antimicrobial
resistance, food safety, climate change,
and weak healthcare infrastructure.
To address these challenges,veterinary
medicine professionals can lead
efforts to prevent potential pathogen
spillover by improving education on
pandemic prevention, preparedness,
and response, as well as integrating
surveillance that links human, animal,
and environmental health.
Using a multisectoral and
multidisciplinary approach, we can
increase awareness and understanding
of antimicrobial resistance through
effective education and training
in human health, animal health,
and agricultural production.
Simultaneously, we can support
concrete actions that substantially
advance progress in containing,
combatting, and ultimately reversing
antimicrobial resistance. Together,
as we can promote a healthy planet
as a prerequisite for the health of
people and animals, future veterinary
medicine professionals will be
prepared to face the triple planetary
Interview with the President of the World Veterinary Association
BACK TO CONTENTS
Photo 2. Rafael Laguens speaking during the 10th Chinese Veterinary Medical Association Conference in August 2023.
Credit: CVMA
6
Interview with the President of the World Veterinary Association
crisis of climate change, biodiversity
loss, and pollution.
As WVA president, what are the
three key priorities that WVA and
WMA members should address in
the next five years?
Over the next five years, I firmly
believe that WVA and WMA
members can achieve all established
organisational goals and collaborate
on joint initiatives.First,members can
continue strengthening professional
relationships by better understanding
the scientific expertise and technical
training that each profession offers
to global discourse. Second, both
associations can collectively organise
global conferences, such as the World
One Health Congress (https://
globalohc.org/), in selected host
countries. Finally, leaders can appoint
experts from each association who
can collaborate on joint working
groups on topics of mutual interest
for human and veterinary medicine
communities.
Rafael Laguens, DVM
President, World Veterinary Association
Soria, Spain
rlaguens@gmail.com
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7
The World Medical Association
(WMA) has recently published the
International Code of Medical Ethics
(https://www.wma.net/policies-post/
wma-international-code-of-medical-
ethics/), to serve as a set of ethical
principles applicable to members of
the medical profession across the globe
[1]. This code outlines and clarifies
the professional responsibilities
of physicians concerning their
patients, fellow clinicians and health
professionals,theirownwell-being,and
the broader society. Concerning the
matter of a physician’s conscientious
objection, this code states that “…
on some issues there are profound moral
dilemmas concerning which physicians
and patients may hold deeply considered
but conflicting conscientious beliefs.
The physician has an ethical obligation
to minimize disruption to patient
care. Physician conscientious objection
to provision of any lawful medical
interventions may only be exercised if
the individual patient is not harmed or
discriminated against and if the patient’s
health is not endangered” [1].
The issue with this section of the code
is that the perception of discrimination
can be subjective. Refusing to
perform a legal abortion is frequently
criticised as “discrimination” in
mainstream bioethics, by the medical
establishment, in politically
progressive legislation, and in
progressive cultural and legal advocacy.
Moreover, in international pro-
abortion advocacy, the terms “harm”or
“endangered health” are often broadly
construed to include non-physical
consequences such as emotional
distress, financial outcomes, and
impacts on patient self-esteem. On
the flip side, in countries where genital
mutilation practices are legalised,
doctors who decline to perform
these procedures may be viewed as
contradicting the offerings of the
healthcare system to the population.
Therefore, the provision on medical
conscience within the WMA employs
neutral language to undermine the
right of doctors to abstain from
involvement in highly debated
and occasionally life-threatening
procedures, such as abortion or
euthanasia, that conflict with their
moral convictions. Furthermore, the
code mandates physicians to actively
resist laws and ethical guidelines
that permit doctors to refrain from
participating in interventions that
contradict their consciences. The code
states that “the physician should follow,
protect, and promote the ethical principles
of this Code. The physician should help
prevent national or international ethical,
legal, organizational, or regulatory
requirements that undermine any of the
duties set forth in this Code” [1].
The matter of conscientious objection
in medicine has evolved into an
international controversy. If the
WMA code is enforced or legally
adopted, it is likely to force pro-life
practitioners and those who uphold
traditional Hippocratic Oath beliefs
to limit their professional practice.
It appears that we encounter two
distinct perspectives on understanding
the purpose of medicine that have
different viewpoints regarding
conscientious objection. First, the
service-provider model of medicine
asserts that the primary goal of
medicine is to offer a service,
specifically healthcare, with a crucial
emphasis on respecting patient
autonomy. Consequently, physicians
are obligated to provide this service
even when their personal values
conflict with those of the patient.
Second, a goal-directed approach
identifies medicine as a pursuit aimed
at the goods of health and healing,
taking into account the values of both
patients and physicians. This model
understands that the phenomenon
of conscientious objection requires
embracing preexisting concepts
of professional discretion and the
development of virtue in clinical
practice. These two models give rise
to inquiries about the nature and
purpose of medicine. What prompts
a shift in the conception of medicine’s
purposes in recent years? Why does
the Hippocratic Oath, after being in
effect for thousands of years, appear
to lose its validity in certain medical
contexts?
Jaime Hernandez-Ojeda
Two Models of Approaching the Goals of Medicine: The Dilemma
that Sparks Different Perspectives in Conscientious Objection
Different Perspectives in Conscientious Objection
BACK TO CONTENTS
Pablo Requena
8
The Service-Provider Model in
Medicine
The service-provider model postulates
that medicine is transactional,
primarily revolving around delivering
a service, namely healthcare [2].
Citizens possess an inherent
entitlement to healthcare access,
encompassing rights to sexual and
reproductive healthcare, the right to
end one’s life, among others. In this
perspective, medicine is likened to
other service provisions in society,
like driving a cab or offering cleaning
services. It advocates that consumer
preferences should dictate the types
of services and how they are delivered.
Clinicians, in this view, are tasked
with delivering medical services as
requested by patients, and a doctor’s
ethical duties are centred on fulfilling
this role.
According to this model, the primary
purpose of the medical profession is to
addressthehealthneedsofsociety.This
forms the foundation of its structure,
the government support it receives,
and the underlying licensing processes
[3]. Indeed, the effectiveness of
medicine as a profession should be
assessed by its success in fulfilling
this essential role. It is important to
acknowledge that medicine is, indeed,
a profession. It involves a structured
body of technical knowledge dedicated
to serving the public interest.
Physicians undergo extensive training
to acquire a thorough understanding
of the medical art and to deliver
safe and effective care to patients.
Upon licensure and induction into
the profession, doctors profess to
prioritise patients’ health and well-
being. They commit to setting aside
personal interests and assume the
role of advocates for their patients.
This detachment and commitment
to patients encapsulate the essence of
medical professionalism [4].
Medicine is often regarded as an
essential service, distinguishing
it from other consumer services
such as gardening or tattoo artistry.
The average person might not be
significantly impacted if they cannot
hire a gardener or get a tattoo, but
inadequate access to medical care can
profoundly affect many individuals.
The medical profession exists to fulfill
a fundamental societal need, and the
well-being of the population suffers
when medical practitioners fail to
fulfill this crucial role, as it is
emphasised by some WMA policies
[1].
Because medicine is considered an
essential service, its success should be
assessed by the comprehensiveness
and quality of healthcare coverage in
the community. The effectiveness of
medicine is determined by its ability to
offer a comprehensive range of medical
interventions to patients in a timely
and convenient manner. Medical
professionals hold a monopoly over
medical care, and if they fall short in
fulfilling their role, they undermine
the very purpose of medicine and fail
to act in the public interest.
Physicians are often argued to assume
the role of public servants, particularly
when serving as employees of the state.
In such cases, it is contended that they
should provide healthcare in alignment
with the standards and values set by
the state. It is suggested that doctors
should refrain from incorporating
their personal values into healthcare
practices and instead offer services
authorised by relevant state authorities.
Failure to provide appropriate state-
sanctioned professional services could
be viewed as a form of disrespect
towards the profession’s clients and
may run counter to the principles of
political neutrality endorsed in liberal
ideals [5].For instance,a gynaecologist
refusing to perform elective abortions
might be seen as taking a morally
paternalistic stance toward their
patients, thereby undermining the
ethos of liberal tolerance in medicine.
An implication of this perspective is
that physicians should separate their
personal views from their interactions
with patients. Patients should be
entitled to all safe and legal medical
services, and a doctor’s privately held
moral beliefs should not hinder the
availability of medical procedures.
Physicians are free to hold personal
beliefs in their private lives, but in
their professional role, they must
provide interventions as prescribed by
the medical profession.The healthcare
system, in turn, should strive to ensure
thewidespreadavailabilityofhealthcare
services. Efforts should be directed at
minimising barriers to patient access,
whether these are financial, logistical
or stem from a physician’s personal
moral reservations about safe and legal
medical procedures. Patients should
have timely and convenient access to
healthcare services [6].
Professional discretion does not
encompass contentious value-
based questions in medicine, such
as the availability of services like
abortion, euthanasia or emergency
contraceptives. In matters of value,
doctors should align their practice with
the values of the state,relevant medical
authorities, and preferences of their
patients.Any other approach would be
inconsistent with one’s responsibility
as a public servant and an advocate for
the interests of their patients [7].
The service-provider model promotes
an ethical framework in medicine
that prioritises compliance over the
virtue and character of clinicians. It
erodes traditional concepts of medical
professionalism and substitutes them
withanorientationtowardgovernment
and market influences in medical
practice. Particularly, this model
creates a conflict between the exercise
Different Perspectives in Conscientious Objection
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9
of conscience and the foundational
norms of the medical profession. The
criteria established by professional
associations are given almost absolute
significance, relegating conscience to
the domain of one’s private beliefs.
This scenario diminishes the perceived
relevance of conscience in the exercise
of effective clinical judgment. In fact,
the moral perspectives of individual
practitioners are cast as suspicious
and potentially detrimental to patient
well-being.This poses a challenge in a
profession characterised by numerous
ethically complex situations and the
imperative for practitioners to cultivate
a capacity for sound moral decisions.
The service-provider model sharply
contrasts with a more traditional
approach to medicine and healthcare.
The former lacks an inherent
orientation toward human goods
such as health and the alleviation
of suffering. Instead, its focus is on
delivering a diverse array of services,
some of which may relate to health,
but many are unrelated to therapeutic
health aspects. In contemporary
medical practice, patients commonly
request interventions that are not
strictly aimed at promoting health
and healing. For example, euthanasia
involves actively ending a patient’s life,
contrary to the traditional medico-
ethical principle that doctors should,
above all, refrain from causing harm.
However, in jurisdictions where
legalised, euthanasia is labeled as
medical assistance in dying and
voluntary assisted dying. Some
theorists argue that it is an integral
part of basic healthcare. This example
serves as an illustration of why one
might approach with skepticism a
“rigid” definition of medicine solely
focused on the goods of health and the
relief of suffering.
A Goal-Directed Model of Medicine
The goal-directed model conceives
medicine as a practice that is directed
towards certain goods,in particular the
goods of health and healing. It asserts
that the exercise of conscience is crucial
in determining how these objectives
apply to individual situations.
Instead of relegating conscience to
the domain of personal beliefs, this
model acknowledges the moral nature
of medical pursuits and identifies
conscience as an indispensable aspect
of the moral psychology of virtuous
medical professionals. A virtuous
clinician is adept at discerning and
pursuing the medical and human
good amidst the complexity of
contemporary medical practice. A
well-developed conscience endows
practitioners with a heightened
sensitivity to recognise the goods of
health and healing. This sensitivity
is achieved by considering relevant
clinical and moral aspects, applicable
laws and professional guidelines,
patient wishes and preferences, and
one’s own accumulated wisdom as an
experienced medical practitioner [8].
Asserting that medicine is oriented
toward the goods of health and
healing does not imply solely doctors
should serve these goods, but it also
emphasizes that comprehending
medicine necessitates keeping these
goods in focus. Doctors are engaged
in the critical tasks of preserving
lives and addressing illness and
injuries; the role of doctors becomes
meaningful when centred on their
therapeutic actions.Medicine becomes
incomprehensible if we disregard its
fundamental orientation toward life
and health.This assertion goes beyond
describing doctors’ actions; it delves
into the philosophical claim about
the essence of medicine as a social
practice, asserting that it is defined
by these inherent goods. Medicine is
teleological, functioning as a practice
defined by the goods it seeks. It is a
cohesive and intricate form of socially
established cooperative human activity,
complete with its own internal goods
and standards of excellence [9].
Medicine is a coordinated human
effort directed toward the goods of
health and healing, and it possesses
virtues that arise from these goods.
This model dismisses the notion
that medicine is exclusively focused
on service provision, the respect for
patients’ rights and well-being, and/
or the advocacy of patient preferences.
This is not to imply that the model
neglects patients’ rights and welfare;
these remain crucial factors that
should guide healthcare practitioners’
decision-making.However,this model
envisions patients’ rights and welfare
within the framework of the medical
good. The extent and boundaries
of patients’ rights and welfare are
contingent upon what one considers
to be essential for health and healing
[3]. It would be illogical for a doctor
to comply with a patient’s request for
a service that blatantly contradicts the
principles of health and healing. For
instance, a patient with xenomelia
might seek a clinician’s assistance in
amputating a perfectly healthy limb.
Nevertheless, it would be inconsistent
with the objectives of medicine for
the doctor to support the patient in
this request, regardless of the patient’s
strong desire to remove a healthy limb.
This same scenario happens in cases
of genital mutilation, which is also
against human rights.
Advocates of a goal-directed model
of medicine highlight the crucial
importance of fostering virtue and
character in medical practitioners [8].
This stands in contrast to other models
that prioritise duties at the expense
of virtues.Virtues, seen as habits
of excellence, enable practitioners
to actualize the goods inherent in
medicine. These medical virtues
encompass qualities such as reliability,
collegiality, composure, personability,
good judgment, and transparency. To
be recognised not just as competent but
as a paragon of professional excellence,
a clinician must embody at least some,
Different Perspectives in Conscientious Objection
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10
if not all, of these virtues. Additionally,
virtues explicitly associated with
the exercise of conscience, such as
integrity, fidelity to one’s professional
calling, and habits of moral reflection,
should be considered. To be truly
dedicated to their profession and to
exhibit a commitment to continuous
improvement, clinicians must cultivate
the moral awareness and fidelity
integral to the exercise of conscience.
This model argues that the medical
field benefits from cultivating
virtuous medical practitioners.
These practitioners would possess a
robust ability for moral discernment,
reflection, and reasoned decision-
making, coupled with a profound
sense of vocation in their approach
to their work. Exploring avenues to
support doctors in acquiring these
virtues, which are considered essential
for providing excellent medical care,
is crucial. A facet of cultivating virtue
involves internalising moral beliefs
and commitments, shaping them into
the guiding principles for morally
meaningful actions, and serving as
a source of moral motivation and
direction for the individual. These
internalised beliefs and commitments
undoubtedly form an integral
aspect of one’s character. Healthcare
professionals are required to internalise
a conception of what defines good
medical practice and, drawing from
their personal experiences and
guidance from peers, develop the
ability to discern the medical good in
specific circumstances. Importantly,
they must construct their own moral
and technical rationality, enabling
them to accurately determine how
the medical good should be realised
in particular situations within clinical
practice. A physician should aspire
to develop virtues and enhance
their ability for clinical judgment to
effectively navigate the diverse clinical
scenarios encountered in the practice
of medicine,while holding the latitude
to exercise their judgment.
As physicians need a certain level of
professional autonomy to develop the
essential virtues of medical practice, it
is important to safeguard and preserve
the discretionary space for physicians.
This space allows individual clinicians
to exercise both technical and moral
discernment, enabling them to decide
whether a specific intervention or
practice contributes to the well-being
of patients or poses potential harm. It
is impossible for medical associations
or health authorities to oversee
medical practice in such a manner
that professional discretion becomes
irrelevant.Medicine is tangible,subject
to variation, and influenced by specific
contexts, while patients are unique
individuals rather than uniform cases.
Consequently, the informed judgment
of individual practitioners becomes
an essential element of providing
effective healthcare. The significance
of a physician’s discretionary space lies
in its connection to virtue, character,
and the development of a professional
identity. Without the freedom to
act, physicians cannot cultivate
the character and virtues essential
for realising the intrinsic goods of
the medical profession. Virtue is
inseparable from agency, particularly
in medicine, where expertise is gained
through experiential decision-making
in clinical settings. Deprived of the
opportunity to exercise their capacities
for moral and technical discernment
and action, physicians would struggle
to acquire the qualities necessary for
excellence in medical practice.
Inthegoal-directedmodelofmedicine,
conscientious objections arise when
a physician holds a dissenting
perspective on the nature of medical
goods. Many conscientious objections
involve the physician’s exercise
of moral and technical judgment
regarding the appropriate realisation
of the medical good in a specific
situation. This type of disagreement
does not revolve only around religious
or personal values; instead, it centers
on how we should conceptualize
the goods of medicine in particular
scenarios and the most effective means
of achieving these goods. This type of
conscientious objector believes that a
specific medical practice, either in a
general sense or within certain specific
situations, does not contribute to the
promotion of health and well-being.
Consideringthis,itisessentialtoafford
physicians the flexibility to practice in
alignment with their well-thought-out
judgments, just as we generally allow
them in clinical practice to align their
approach with their best clinical and
moral insights.
Reflections and Conclusion
The goal-directed model of medicine
has been ingrained in medical practice
since the Hippocratic Oath gained
prominence in the Western world
during the third century BC. This
historical oath marks the earliest
articulation of medical ethics, laying
the foundation for enduring principles
that retain paramount significance
today, such as medical confidentiality
and non-maleficence. However, as
medicine progressed in modern times,
this model faced challenges stemming
from the abuse of medical paternalism,
where the patient’s perspective was
often marginalised in favor of the
doctor’s values.
In response to this, the service-
provider model emerged, seeking to
underscore the patient’s dignity and
the importance of respecting their
opinions in medical decision-making.
Simultaneously, modern bioethics
took shape, initially formulated
around four principles outlined by
Beauchamp and Childress (1979):
respect for autonomy, nonmaleficence,
beneficence, and justice [10]. In
situations where these principles
conflict, the paramount factor guiding
decision-making is the respect for the
patient’s autonomy. However, it is
crucial to acknowledge that a patient’s
Different Perspectives in Conscientious Objection
BACK TO CONTENTS
11
autonomy, though essential, is not
absolute, and physicians play an active
role in clinical decisions.
While the emphasis on respecting
patient autonomy is commendable,
it is imperative to recognise that
physicians also possess their own
autonomy. Physicians are not mere
service providers, but actively engage
in ethical decision-making. Although
patient autonomy is crucial for
informed decision-making, it alone
is insufficient for ethical reflection
guiding individuals in making sound
decisions.
Medical ethics steadfastly advocates
for respecting patient autonomy,partly
in response to historical physician
paternalism and an increasing
awareness of the need to acknowledge
human dignity in medical practice.
Despite the emphasis on patient
autonomy, some have mistakenly
granted it an independence that may
not always align with the patient’s best
interests.While patient consent is vital,
decision-making should not singularly
prioritise the patient’s desires. Medical
science, rooted in preserving a
patient’s life and alleviating suffering
associated with illness, necessitates a
collaborative and respectful exchange
of perspectives between physicians and
patients.
The engagement of conscience plays
a crucial role in achieving proficient
clinical judgment. It is essential
not to view the moral viewpoints
of individual practitioners with
suspicion or as potentially harmful to
patient well-being.This is particularly
pertinent in a profession marked
by numerous ethically complex
situations, where practitioners are
required to develop the ability to
make sound moral decisions. A
doctor should aim to cultivate virtues
and improve their capacity for clinical
judgment to adeptly handle the
varied clinical situations encountered
in medical practice. This entails
granting physicians the flexibility to
apply their judgment.Deprived of the
liberty to act, physicians are unable
to foster the character and virtues
necessary for realising the intrinsic
goods of the medical profession.
Since the establishment of
fundamental medical principles by
the Hippocratic Oath in the Western
world, a clear indication has emerged
regarding the approach needed to
preserve and cure while avoiding
harm to human life, even in its early
stages. This definition has exerted
a profound influence on the ethical
stance of the medical profession for
centuries. Medicine, with its unique
perspective on the importance of
human life, warrants reflection on
its purposes in the context of current
bioethics, as encapsulated in the title
of Galen’s work: “The best doctor is also
a philosopher.”
References

1. Parsa-Parsi RW. The internation-
al code of medical ethics of the
World Medical Association.JAMA.
2022;328(20):2018-21.
2. Curlin FA, Tollefsen CO. Con-
science and the way of medicine.
Perspect Biol Med.2019;62:560-75.
3. Sulmasy DP. Tolerance, profession-
al judgment, and the discretionary
space of the physician. Camb Q
Healthc Ethics.2017;26:18-31.
4. Stahl RY, Emanuel EJ. Physicians,
not conscripts – conscientious ob-
jection in health care. N Engl J
Med.2017;376:1380-5.
5. LaFollette E, LaFollette H. Private
conscience, public acts. J Med Eth-
ics.2007;33:249-54.
6. Stahl RY, Emanuel EJ. Conscien-
tious objection in health care. N
Engl J Med.2017;377:97-8.
7. Savulescu J, Schuklenk U. Doctors
have no right to refuse medical as-
sistance in dying,abortion or contra-
ception.Bioethics.2017;31:162-70.
8. Pellegrino ED,Thomasma DC.The
virtues in medical practice. New
York:Oxford University Press;1993.
9. MacIntyre AC.After virtue: a study
in moral theory, 2nd ed. Notre
Dame: University of Notre Dame
Press; 1984.
10. Beauchamp TL, Childress JF. Prin-
ciples of biomedical ethics. New
York:Oxford University Press;1979.
Authors
Jaime Hernandez-Ojeda,
MD, PhD, STB
School of Theology,
Department of Moral Theology,
Pontifical University of the
Holy Cross, Rome, Italy
jaheroj@gmail.com
Pablo Requena, MD, STD
School of Theology,
Department of Moral Theology,
Pontifical University of the Holy Cross,
Pontifical Academy for Life,
Clinical Ethics Commission,
Bambino Gesù Pediatric Hospital
Rome, Italy
requena@pusc.it
Different Perspectives in Conscientious Objection
BACK TO CONTENTS
12
Quality of Care as a Priority of the
WHO European Region’s Policy
Agenda
Quality of care is recognised as a
critical objective of health systems,
essential for achieving long-term
health goals. The World Health
Organization (WHO) defines
quality of care as the degree to which
health services for individuals and
populations increase the likelihood
of desired health outcomes and
are consistent with evidence-
based professional knowledge [1].
Additionally, the WHO emphasises
other elements such as efficiency,
equity, timeliness, and accessibility as
vital for fully realising the benefits of
quality care [2].
The term “permacrisis” is increasingly
used to describe the convergence
of multiple crises straining health
systems, such as the pressing effects
of the coronavirus disease 2019
(COVID-19) pandemic, wars and
conflict settings, and the escalating
health-related consequences of
climate change. The pandemic has
exposed pre-existing vulnerabilities
in health systems while also
spotlighting innovative solutions that
could enhance healthcare delivery
in the post-COVID-19 era [3-6].
Additionally, health systems and
social care sectors are contending
with exhausted frontline staff,
depleted budgets, and a backlog of
patients awaiting treatment. While
the full legacy of this prolonged
stress is not yet fully understood, it
is clear that the situation demands
more than short-term fixes. Effective
responses require governance
foresight, characterised by creativity,
innovation, and collaboration across
all sectors and partners [7].
To drive positive transformation
and achieve universal health
coverage (UHC), it is imperative to
establish quality of care as a systemic
organising principle. This principle
should apply not only to individual
healthcare services, but also to entire
health systems, fostering a beneficial
intersection between individual needs
and societal demands [8]. In other
words, it reflects the need to integrate
clinical sciences and public health.
Recognising the critical importance
of quality of care and patient safety for
health policy agendas and ethical care
provision, the European Programme
of Work, 2020–2025 – “United
Action for Better Health in Europe”
(EPW), is dedicated to supporting
countries towards the implementation
of evidence-informed policies and
practices.This initiative aims to ensure
that individuals receive safe, effective,
timely, equitable, and people-centred
care [9].
The WHO Office on Quality of
Care and Patient Safety, in Athens,
Greece
To enhance collaboration and learning
among countries and partners, and
to foster an innovative approach in
improving quality of care and patient
safety within the European Region,
the WHO Regional Office for
Europe established the WHO Office
on Quality of Care and Patient Safety,
in Athens, Greece, in April 2021.
This unit is dedicated to providing
technical support, policy advice, and
capacity building to countries, which
can encompass the entire spectrum
of healthcare quality improvement,
ranging from healthcare delivery,
healthcare workforce development,
and the integration of new health
technologies.
Operating with a visionary approach,
quality of care is envisioned as a
catalyst for transformative changes
in the global healthcare landscape.
This vision transcends individual
healthcare organisations, aiming
to reshape national health systems
and the global healthcare sector at
large. The Office’s work includes
Strengthening Health Systems’ Quality in the World
Health Organization European Region
Strengthening Health Systems’ Quality in the WHO European Region
Christos Triantafyllou
Válter R. Fonseca
João Breda
BACK TO CONTENTS
13
providing technical support for
the development of strategies and
frameworks to enhance quality of care,
scaling up effective interventions, and
facilitating the exchange of best
practices and new ideas across
borders. It plays a critical role in
innovation and knowledge sharing
in quality of care and patient
safety, as well as in comprehensive
policy analysis, thereby shaping
policies that prioritise these areas.
Building networks and alliances and
emphasising stakeholder engagement,
are also significant parts of its mission,
fostering a collaborative environment
for continuous improvement in
healthcare quality and safety.
One of the breakthrough activities
was the launch of the First WHO
Autumn School on Quality of Care
and Patient Safety, which was held
in Lisbon, Portugal, from 23-27
October 2023 [10]. This event was
hosted by the WHO Office on
Quality of Care and Patient Safety,
in a joint venture with the WHO
Collaborating Center for Education,
Research, and Evaluation of Safety
and Quality Healthcare at the
NOVA National School of Public
Health, in Lisbon, Portugal. National
representatives from the WHO
European Region, key health system
decision-makers, and global experts
in quality of care and patient safety
were brought together in this course.
The program provided an in-depth
exploration of the latest advancements
in healthcare quality and patient safety
for high level decision- and policy-
makers, showcasing pioneering case
studies and insights from global
leading experts. Through keynote
lectures, plenary sessions, workshops,
case studies, and networking
opportunities, participants gained
insights into critical healthcare quality
and patient safety practices from
acrosstheEuropeanregion.Thecourse
aimed to equip participants with
the knowledge and skills necessary
to effectively optimise healthcare
systems, improve patient outcomes,
reduce waste, build resilience, and
emphasize the importance of a
well-prepared healthcare workforce
capable of delivering high-quality
care in challenging circumstances.
The Need for a New Vision for
Quality of Care
While many efforts are underway
to strengthen quality of care and
patient safety at the national level,
data collected from the WHO
European Region Member States
highlighted that reporting of the
quality of care dimensions remains
highly heterogeneous across the
European region. Data fragmentation
and knowledge gaps have a profound
impact on the decision-making
process and health outcomes.
Therefore, the adoption of agreed-
upon metrics and a common vision
for quality of care at the regional
level underpins a data-driven
transformation of healthcare systems.
The need for a new vision for
quality of care is underscored by the
evolving challenges in healthcare
systems worldwide. UHC aims to
provide high-quality care without
financial hardship, but achieving
this requires more than just access to
services. Notably, the services must
be effective and of high quality to
improve health outcomes. The rapid
pace of technological advancement
and innovation in healthcare, the
growing shortages in the healthcare
workforce, and pressing issues like
climate change and cybersecurity
are reshaping healthcare current
demands.
Quality of care should, therefore,
adapt and guide these innovations,
focusing on effectiveness, safety, and
people-centredness, alongside with
access, equity, and efficiency. This
reshape involves embracing patient
engagement, leveraging digital health
and new technologies,and integrating
new care models and business
approaches to ensure comprehensive
and effective healthcare delivery
[8,11,12].
The current situation highlights a
need for comprehensive policies
that integrate modern healthcare
approaches, focusing on patient
safety, effectiveness, and accessibility.
Moving forward, it is crucial to foster
collaboration among Member States,
support and promote technological
advancements, and prioritise patient-
centred care. By adopting a unified
vision for quality improvement, the
European Region can overcome
existing challenges and pave the way
towards a healthier future for all its
citizens.
Disclaimer
The authors affiliated with the World
Health Organization (WHO) are
alone responsible for the views
expressed in this publication, and
they do not necessarily represent the
decisions or policies of the WHO.
References
1. World Health Organization,
Regional Office for Europe,
European Observatory on Health
Systems and Policies, Busse R,
Klazinga N, Panteli D, Quentin
W. Improving healthcare quality in
Europe: characteristics, effec-
tiveness and implementation of
different strategies. Copenhagen:
WHO Regional Office for
Europe; 2019. Available from:
h t t p s : / / i r i s . w h o. i n t / h a n –
dle/10665/327356
2. World Health Organization.
Handbook for national quality
policy and strategy: a practical ap-
BACK TO CONTENTS
Strengthening Health Systems’ Quality in the WHO European Region
14
proach for developing policy and
strategy to improve quality of care.
Geneva: WHO; 2018. Available
from: https://www.who.int/publi-
cations/i/item/9789241565561
3. Bourgeault IL, Maier CB, Di-
eleman M, Ball J, MacKenzie A,
Nancarrow S, et al. The COV-
ID-19 pandemic presents an
opportunity to develop more sus-
tainable health workforces. Hum
Resour Health. 2020;18(1):83.
4. Paschoalotto MAC, Lazzari EA,
Rocha R, Massuda A, Castro
MC. Health systems resilience:
is it time to revisit resilience af-
ter COVID-19? Soc Sci Med.
2023;320:115716.
5. Ramalingam B, Prabhu J. Innova-
tion, development and COVID-19:
challenges, opportunities and ways
forward. OECD. 2020;1-14.
6. Palanica A, Fossat Y. COVID-19
has inspired global healthcare in-
novation. Can J Public Health.
2020;111(5):645-8.
7. Maccaro A, Audia C, Stokes K,
Masud H, Sekalala S, Pecchia L, et
al. Pandemic preparedness: a scop-
ing review of best and worst prac-
tices from COVID-19. Healthcare
(Basel). 2023;11(18):2572.
8. Larsson S, Clawson J, Howard
R. Value-based health care at an
inflection point: a global agenda
for the next decade. NEJM Cata-
lyst Innovations in Care Delivery.
2023;4(1).
9. World Health Organization.
The European Programme of
Work, 2020–2025: United Ac-
tion for Better Health. Copenha-
gen: WHO Regional Office for
Europe; 2021. Available from:
https://www.who.int/europe/
publications/i/item/WHO-EU-
RO-2021-1919-41670-56993
10. World Health Organization.
First WHO autumn school on
quality of care and patient safety
[Internet].2023[cited2024Jan29].
Available from: https://www.who.
int/europe/news-room/events/
item/2023/10/23/default-calen-
dar/first-who-autumn-school-on-
quality-of-care-and-patient-safety
11. World Health Organiza-
tion. Health care accreditation and
quality of care: exploring the role
of accreditation and external eval-
uation of health care facilities and
organizations. Geneva: WHO;
2022. Available from: https://
www.who.int/publications/i/
item/9789240055230
12. Papanicolas I, Rajan D,
Karanikolos M, Soucat A,
Figueras J, eds. Health system
performance assessment: a frame-
work for policy analysis. Ge-
neva: WHO; 2022. Available
from: https://www.who.int/news/
item/23-05-2022-9789240042476
Authors
Christos Triantafyllou,
RN, MSCE, PhD(c)
Project Officer Quality of Care,
WHO Office on Quality of
Care and Patient Safety,
WHO Regional Office for Europe
Athens, Greece
triantafyllouc@who.int
Válter R. Fonseca, MD, PhD
Technical Officer Health Systems &
Quality of Care, WHO Office on
Quality of Care and Patient Safety,
WHO Regional Office for Europe
Athens, Greece
fonsecav@who.int
João Breda, MPH, PhD, MBA
Head, WHO Office on Quality
of Care and Patient Safety,
WHO Regional Office for Europe
Athens, Greece
rodriguesdasilvabred@who.int
BACK TO CONTENTS
Strengthening Health Systems’ Quality in the WHO European Region
15
Emerging alongside the coronavirus
disease 2019 (COVID-19) pandemic,
we have seen the rapid circulation
of misinformation, often called an
infodemic. According to the World
Health Organization (WHO), “an
infodemic is too much information
including false or misleading
information in digital and physical
environments during a disease outbreak
[and] it causes confusion and risk-taking
behaviours that can harm health” [1].
In the context of the COVID-19
pandemic, the infodemic has resulted
in frequent observations of the
disregard of recommended policies
to contain virus transmission as
well as vaccine hesitancy (including
opposing vaccination). In this
article, I will briefly present the
philosophical reasoning regarding
phenomena such as an infodemic.
This reasoning suggests that
misinformation, fake news, and
related phenomena do not
simply appear, but rather they are
manufactured and implemented into
discourse. I will shortly highlight
some of the most important
discussion points that suggest a
better strategy to tackle the deliberate
spread of misinformation, as
compared to past approaches.
As argued elsewhere [2], spreading
misinformation is especially
successful in a specified epistemic
structure. However, what is an
epistemic structure? An epistemic
structure is the social surroundings
in which knowledge is produced
and shared. While we all live in
somewhat limited structures, there
are important differences regarding
these limitations. Chris Thi Nguyen
introduced a helpful distinction
between epistemic bubbles and echo
chambers [3]. While often used
synonymously, Nguyen argues that
while we all live in bubbles, most do
not live in echo chambers.
Furthermore, while living in the
former is not harmful, epistemically,
living in the latter is. For example, our
hobbies and interests form bubbles. If
I am interested in 19th-century novels
and opera, I might not be informed
about contemporary literature and
music. Moreover, as my friends share
my interests, I am most likely in an
epistemic bubble regarding music
and literature. Someone might easily
pop this bubble and introduce me to
Taylor Swift and Zadie Smith, and I
may start to listen to contemporary
music and read contemporary
literature. How come?
Nguyen defines epistemic bubbles as
follows: “Loosely, an epistemic bubble
is a social epistemic structure in which
some relevant voices have been excluded
through omission. Epistemic bubbles can
formwithoutillintent,throughordinary
social selection processes and community
formation” [3]. Being an academic in
central Europe, it is not unlikely that
I will be surrounded by people who
listen to one genre of music rather
than the other genre. I simply did not
become acutely aware of other genres.
However, that was not because I was
kept away from them intentionally;
it just happened to be so. An echo
chamber works entirely differently:
“An echo chamber, on the other hand,
is a social epistemic structure in which
other relevant voices have been actively
discredited. […] Echo chambers work by
systematically isolating their members
from all outside epistemic sources […].
In epistemic bubbles, other voices are
merely not heard; in echo chambers, other
voices are actively undermined” [3].
If other voices are actively
undermined, the general openness
described in the cases of epistemic
bubbles is not a given anymore. What
makes them chambers and not mere
bubbles is that any new information
can only strengthen members’ beliefs.
Nguyen calls this the disagreement-
reinforcement mechanism: “Members
can be brought to hold a set of beliefs
such that the existence and expression of
contrary beliefs reinforces the original set
of beliefs and the discrediting story” [3].
One can quickly see how this helps
the manufacturers of misinformation:
they cannot be falsified. That also
offers an argumentative advantage in
situations where knowledge is limited:
they knew from the beginning.
Unlike scientists, physicians, and
policymakers who must adapt to
new information, those who spread
misinformation must bend the facts
in a catchy yet convincing way so
that those who initially believed a
false story are difficult to persuade.
Complicating this pattern, as they
listen to radio programs, watch
television shows, and conduct
internet searches, they often look
for information that concurs with
their already established beliefs [4].
Hence, they capture some true beliefs
but an inability to perceive and react
to information contradicting those
beliefs [5].
Daniel Lucas
Bioethicists in Public Health: A Chance
to Counter Misinformation?
Bioethicists in Public Health: A Chance to Counter Misinformation?
BACK TO CONTENTS
16
Minimising the effects of echo
chambers will most likely be
successful before they are
implemented, since echo chambers
function like closed communities.
Once you are a “community member”,
it is difficult to exit the community.
To combat this challenge, we should
support adopting new strategies to
strengthen public health and science
communication.
As a hopeful note, we understand
that those who believe in and
spread misinformation are not
necessarily anti-science, but rather
that they believe that they have
the relevant scientific knowledge.
Moreover, as studies suggest [6],
they are partly right: people with
anti-consensus views in some cases
are better informed than those with
consensus views. Nevertheless, at
the same time, they overestimate
their level of knowledge and general
understanding of the topic.Regarding
COVID-19 vaccination, Light et al.
(2022) found that “[a]s opposition to
getting a COVID-19 vaccine increases,
both general and COVID-specific
objective knowledge decreases, and
subjective knowledge of how a
COVID-19 vaccine would work
increases” [6]. Here, objective
knowledge describes a consensus
among scientists in the field, while
subjective knowledge is the belief
of laypersons that they share this
consensus. If people object to the
COVID-19 vaccination, then they
are a) likely to know less about how
these vaccinations work and b) more
likely to be overconfident regarding
their knowledge [6].
Notably, it shows that believing and
spreading misinformation is not
(necessarily) connected to an anti-
scientific worldview; it is more likely
a pro-scientific worldview with a deep
misunderstanding of what scientific
knowledge is. However, there is a
definite need for scientific expertise
and, therefore, for experts. Those
who function as experts in these echo
chambers are what Lily Tappe and
I call pseudo-experts [2]. We define
pseudo-experts as people who “claim
knowledge they do not have and gain
importance by having contrary opinions
to mainstream research, and are seen as
insiders of the academic community” [2].
Most of these pseudo-experts hold
academic degrees (including the
majority with doctoral degrees) and
have or have had academic positions,
and their academic background
can but must not be connected
to their area of expertise. As one
example, Sucharit Bhakdi, former
professor of microbiology, who
retired in 2012, claimed (among
other things) that there would only
be one COVID-19 wave. Because
his predictions were incorrect, he did
not only lose his scientific credibility,
but also his standing within the anti-
consensus community. As another
example, Stefan Homburg, former
professor of finances, claimed that
non-pharmaceutical interventions
were ineffective, and that excess
deaths were due to the vaccination
campaigns. He often links studies
with weak epidemiological designs
and opinion pieces (including use
of journals flagged as predatory) to
support his claims, knowing that
his many followers on X (formerly
known as Twitter) cannot verify the
scientific validity.
One might wonder why people
like Homburg are so successful.
My hunch would be that these
individuals function as experts, have
an answer to every claim, and ride
on the articulated fear and worry of
the general public. While experts (if
sincere) stick to their area of expertise,
pseudo-experts can claim any area of
expertise as their own. This should
be considered if we want science
communication, especially regarding
public health policies,to be successful.
In summary, I argued that
misinformation is most likely to
be successful in closed epistemic
structures like echo chambers. These
structures are built in a way that
keeps its members from receiving
any information that does not concur
with their already established beliefs.
Furthermore, pseudo-experts take
over the role of actual experts in these
echo chambers, since topic matter
experts are needed to discuss complex
scientific topics, albeit the general
understanding that people seek
knowledge within their communities.
How do bioethicists contribute to
this situation? A bioethicist functions
as someone who is not an expert in
any respective field (e.g. virology),
but rather as a meta-expert who
knows better than others about
what is occurring in the respective
fields. Four elements accompany the
understanding of a bioethicist’s role in
tackling the spread of misinformation
during a pandemic or similar public
health crisis.
First, bioethicists can be less easily
pressured to share a personal opinion
on a scientific or social issue. As
they are not experts themselves,
they can only explain what the
scientific evidence has reported to
date, including what topics need
further research. Bioethicists (on a
professional level) usually do not have
a standpoint in the discussion, which
often challenges staging a scientific
debate that would otherwise suggest
disagreement on a higher level than
observed.
Second, as meta-experts, their
perspective is not from one individual
field, and it is less likely that some
specific areas will be emphasised over
other areas. For example, expertise on
transmission pathways from German
virologists and epidemiologists was
widely shared across media platforms,
and although warranted, this public
Bioethicists in Public Health: A Chance to Counter Misinformation?
BACK TO CONTENTS
17
debate omitted the discussion of
mental health and other related topics.
Third, bioethicists are usually
better trained in inter- or even
transdisciplinary research as well
as understanding and translating
different scientific languages. These
skills help facilitate diverse discussions
between scientists, share expertise
with policymakers, and strengthen
science communication within the
wider community.
Fourth,sincebioethicistshaveaclearer
understanding of hidden normative
premises behind some policies,
they can more clearly communicate
the rationale behind some policy
decisions than other experts in
specified fields. As with regard to
the transdisciplinary research, this is
helpful when facing policy makers
and serving as communicators to
the general public. But they should
ensure that they do not become the
voice of the policy or administrative
authorities.
Although my suggestions provide an
additional perspective to the general
discussion, they do not solve all the
problems, and limitations remain to
be discussed. As John Evans pointed
out more than 15 years ago [7], the
expertise that bioethicists can offer
is not the same expertise that experts
in specified areas can provide to the
public. His principal argument is that
there is no common morality in the
way that there is common ground in
specified areas of the sciences. I want
to tackle this objection in two ways.
First, I do not claim that bioethicists
are similar to other scientific experts
(e.g. virologists), but rather meta-
experts (or experts on expertise).
Second, Evans’s view on the common
ground in the sciences seems
somewhat naïve. There is room for
disagreementinthesciences,especially
when evidence is challenging to find
ornotyetavailable.Deliberationabout
morality might work differently
than an expert dissent in a specified
area, but dissent is a common
phenomenon in any specified area.
Bioethicists should consider their
position, distinguish their role as a
bioethicist and a citizen, and be aware
of their limits [8]. Through these
reflections, they can offer a holistic
perspective on a range of scientific
issues, without falling into the
pseudo-expert category.
References
1. World Health Organization.Info-
demic [Internet]. n.d. [cited 2024
Jan 20]. Available from: https://
www.who.int/health-topics/info-
demic
2. Tappe L, Lucas D. Of sheeple
and people: echo chambers, pseu-
do-experts and the corona crisis.
Disputatio. 2022;11(20):119-31.
3. Nguyen CT. Echo chambers and
epistemic bubbles. Episteme.
2018;17(2):141-61.
4. Levy N. Do your own research!
Synthese. 2022;200(356):1-19.
5. Santos BRG. Echo chambers, ig-
norance and domination. Social
Epistemology. 2020;35(2);109-19.
6. Light N, Fernbach PM, Rabb
N, Geana MV, Sloman SA.
Knowledge overconfidence is
associated with anti-consensus
views on controversial scientific
issues. Science Advances.
2022;8(29):1-10.
7. Evans JH. Between technocracy
and democratic legitimation: a
proposed compromise position for
common morality public bioeth-
ics. Journal of Medicine and Phi-
losophy. 2006;31(3):213-34.
8. Düwell M. Bioethics: methods,
theories, domains. Oxfordshire:
Routledge; 2014.
Daniel Lucas
PhD candidate,
Professorship of Practical Philosophy,
ETH Zürich
Zürich, Switzerland
daniel.lucas@gess.ethz.ch
Bioethicists in Public Health: A Chance to Counter Misinformation?
BACK TO CONTENTS
18
The Sixth Assessment Report of the
Intergovernmental Panel on Climate
Change (IPCC),which was published
in 2023, outlined the concerns and
the impact of climate change on the
global population and noted that
human activities have been largely
responsible for global warming since
1750 [1]. Scientists confirmed that
2023 was the hottest year on record,
claiming that the Earth’s global
average surface temperature was more
than 2°C higher than pre-industrial
levels. Subsequently, an estimated 200
million people could be displaced by
climate change, including frequent
extreme weather conditions, fires,
and droughts, and an urgent call
must tackle climate change to avert
irreversible damage [2]. Also, the
Global Risks Report 2024 highlighted
that environmental risks make up
half of the top 10 risks over the next
decade, with the top four risks being
extreme weather events, critical
change to Earth systems, biodiversity
loss and ecosystem collapse, and
shortage of natural resources [3].
With the loss of two million lives
over the last 50 years, and economic
losses running into trillions of dollars,
there is concern around the impact
of climate change – now, referred to
as the climate crisis – seeking urgent
redress.
Current debates have focused on
the practical measures imposed by
respective governments for its citizens
to mitigate the effects of climate
change. Some individuals have taken
personal action to reduce their own
contributions to their ecological
footprint beyond what is imposed
by their respective governments. The
Hamburg Climate Futures Outlook
2023 paints a pessimistic outlook
of achieving deep decarbonisation
by 2050, given that the current
drivers, corporate responses, and
consumption patterns undermine
global decarbonisation efforts [4].
The matter appears to include the
ambivalent attitudes of individuals,
companies,and governments.Despite
societal debates on the urgent need to
address climate change, there is little
appetite to rein in global consumption
in pursuit of continued growth.
Although current measures will be
insufficient to tackle the impacts of
climate change, one aspect missing
from public discourse has been our
moral obligation to care for the
planet. As available data portray that
greenhouse gas emissions are highest
in China, Germany, India, Ireland,
the United Kingdom (UK), and the
United States [5], two questions
remain: “who” is the most to blame
for climate change, and “who”
should pay for the damage? A global
approach is essential to address these
climate concerns, including detecting
inequalities between countries,
but this in itself is unlikely to help
minimise the damage inflicted on
the planet that will impact all global
citizens.
Nevertheless, I acknowledge that
individual states have obligations and
responsibilities to take the necessary
measures to safeguard citizens’
interests, especially vulnerable
communities. For example, the UK
Government adopted their Climate
Change Strategy 2021-2024, which
focussed on five strategic pillars
toward achieving net zero by 2050
[6]. To successfully implement
the strategy, the government must
engage with its citizens, and citizens
should understand the nature and
scale of the problem with a focus on
their moral responsibility. Currently,
society is divided on the scale of the
problem, given how climate impacts
are reported. Furthermore, the advent
of social media platforms continues
to significantly influence public
perception related to the real-time
risks of climate impacts.
Recently, authors have argued that
small-scale individual actions in
a large world are inconsequential
and would make little difference
in safeguarding the planet [7].
Many citizens have adopted this
approach to divest themselves of any
individual or collective responsibility
in addressing this urgent matter [8].
However, if we support individuals
in taking their obligations seriously,
then we need to openly identify and
discuss these moral obligations. As
such,public discussions must focus on
the scientific data that demonstrate
climate damage as well as identify the
expectations at an individual level.
The failure to anchor the discussion
within individual moral obligations
means that some individuals may turn
a blind eye to the irreversible planet
damage. For example, individuals
who are not directly affected by
extreme weather may feel that they
owe no moral obligation to society, as
they may remain unconvinced about
the alarmist nature of climate action,
despite the scientific evidence [9]. In
contrast, those individuals who are
directly affected may tell a different
Chantal Patel
Our Moral Obligations vis a vis Climate Change
Our Moral Obligations vis a vis Climate Change
BACK TO CONTENTS
19
tale of the striking climate impacts on
their health and well-being. Hence,
by positioning the climate debate
around the harms that it has already
inflicted via the moral lens, individual
states and global organisations
may support collective activities.
By understanding the scale of the
problem, depoliticising the concerns,
and moving away from a capitalist
stance, we can clarify our individual
and collective responsibilities for
climate action.
In the current narrative on climate
change, there is a tendency to shy
away from discussing the individual’s
role in managing climate matters and
focus on framing the government’s
responsibility at the local, regional,
national or global level. For example,
the government acts by imposing
various measures, such as recycling
and timely legislation, to minimise
carbon emissions. Hence, a focus
on our individual moral obligations
might assist in shifting our individual
stance to becoming more active in
supporting current decarbonisation
efforts.
As one example, we can reflect upon
the tobacco cessation campaigns
and assess how we can adapt any
techniques to climate change. Over
the past decades, we have witnessed
that sustained public health
campaigns with clear messaging on
tobacco cessation has led to a global
decline in tobacco use. The World
Health Organization reported that
150 countries have successfully
reduced tobacco use, including a
notable 35% decline in tobacco use in
Brazil [10]. However, did this focus
on one’s moral obligation motivate
individuals to take personal action
to support tobacco cessation efforts?
One longitudinal study examined
this question in a sample of tobacco
smokers, and authors suggested that
moralisation predicted an increase
in the perceived personal risk among
some smokers [11].
In this current discourse on climate
change and relevant actions, defining
moral obligations and responsibilities
is a necessity and should serve as
a central theme, in efforts to avert
catastrophic and irreversible damage
to the planet. Further debate should
include whether we accept the moral
obligations and responsibilities as
evidence for framing climate damage
via a moral lens. I contend that as
a global society, urgent actions are
needed, and we have nothing to lose
by adopting a moral approach to
tackling climate change.Without this
personal and political commitment,
the costs of irresponsibility will
become prohibitive to all current
citizens and future generations [12].
References
1. Intergovernmental Panel on Cli-
mate Change. AR6 Synthesis
Report: Climate Change 2023.
Geneva: IPCC; 2023. Available
from: https://www.ipcc.ch/re-
port/six
2. Cripps E. What climate justice
means and why we should care.
London: Bloomsbury Continu-
um; 2022.
3. World Economic Forum. Global
Risks report 2024, 19th ed. Ge-
neva; World Economic Forum;
2024. Available from: https://
www.weforum.org/publications/
global-risks-report-2024
4. Engels A, Marotzke J, Gonçalves
Gresse E, López-Rivera A,
Pagnone A, Wilkens J (eds).
Hamburg Climate Futures Out-
look 2023. The plausibility of
a 1.5°C limit to global warm-
ing – social drivers and physical
processes. Hamburg: Cluster
of Excellence Climate, Climat-
ic Change, and Society; 2023.
Available from: https://www.
cliccs.uni-hamburg.de/publi-
cations/hamburg-climate-fu-
tures-outlook.html
5. Crownhart C. These three charts
show who is most to blame for cli-
mate change [Internet]. 2022 [cit-
ed 2024 Feb 15]. Available from:
https://www.technologyreview.
com/2022/11/18/1063443/re-
sponsible-climate-change-charts/
6. UK Export Finance. Climate
Change Strategy 2021-2024.
London: UK Export Finance;
2021. Available from: https://
www.gov.uk/government/public-
tions/uk-export-finance-climate
7. Sinnott-Armstrong W. It’s not
my fault: global warming and
individual moral obligations. In:
Sinnott-Armstrong W, Howarth
RB, eds. Climate ethics: essential
readings. Amsterdam: Elsevier;
2005:285-307.
8. Grossman MR. Climate change
and the law. Am J Comp Law.
2010;58:223-55.
9. Banks M. Individual responsi-
bility for climate change. The
Southern Journal of Philosophy.
2013;51(1):42-66.
Our Moral Obligations vis a vis Climate Change
BACK TO CONTENTS
20
10. World Health Organisation. To-
bacco use declines despite tobacco
industry efforts to jeopardise pro-
gress [Internet]. 2024 [cited 2024
Feb 15]. Available from: https://
www.who.int/news/item/16-01-
2024-tobacco-use-declines-de-
spite-tobacco-industry-efforts-
to-jeopardize-progress
11. Helweg-Larsen M. Does mor-
alization motivate smokers to
quit? A longitudinal study of
representative samples of smok-
ers in the United States and
Denmark. Nicotine Tob Res.
2014;16(10):1379-86.
12. Knowles JH. The responsibili-
ty of the individual. Daedalus.
Winter 1977;106(1):57-80.
Chantal Patel, LLB, MA in
Healthcare Law and Ethics
Associate Professor in Law and Ethics,
Faculty of Medicine, Life Sciences
and Health and Social Care,
Swansea University
Swansea, Wales, United Kingdom
t.m.c.patel@swansea.ac.uk
Our Moral Obligations vis a vis Climate Change
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21
In the digital age, the relationship
between people and digital media has
become stronger aligned, observed by
theincreasedsocialmediaparticipation
of healthcare professionals. As a
result, e-professionalism, which
encompasses attitudes and behaviours
that reflect traditional paradigms of
professionalism among healthcare
professionals, has emerged as a new
phenomenon relevant for all health
professions [1]. One important
type of social media includes social
networking sites, which are defined as
websites and applications that allow
users to create, share, and comment on
content, as well as serve as platforms
for social networking. The number
of social media users is growing
exponentially across the world, as
active internet users increased from
8% in 2005 to 56.8% (4.8 billion
people) in 2023 [2].Additional reports
demonstrated that Facebook had 3.3
billion users, Instagram had 2 billion
users,andTwitterhad556millionusers
in 2023, of which Croatia accounted
for 2.4 million Facebook users and 1.5
million Instagram users [3].
The development of digital media
affects all aspects of society as a
whole and has created a new way of
communication culture. Instead of
exclusively focused on exchanging
information, it enables social
interactions between individuals who
may or may not know each other.The
relative ease and simplicity with which
users can create, post, share, tag or
comment on content, simultaneously
allow users to have a higher level of
participation and expressiveness in the
digital world. However, one frequently
overlooked fact is that every activity
on digital media (including internet
searches) leaves a digital footprint that
cannot be erased. Thanks to services
such as “The Wayback Machine”,even
a deleted website remains preserved
forever or users of digital media are
subject to the “perfect recall of silicon
memory” [4]. Notably, our social
media posts – illustrating “where we
have been”and“what we have posted”–
can represent a false digital perception
of ourselves (“what we seem like”)
and has been particularly highlighted
among healthcare professions.
SMePROF Project
Funded by the Croatian Science
Foundation, the Dangers and Benefits
of Social Networks: E-professionalism
of Healthcare Professionals
(SMePROF) project was conducted
in Zagreb, Croatia, from May 2018
to November 2023. Dr. Tea Vukušić
Rukavina (University of Zagreb
School of Medicine) served as the
leading researcher, along with other
team members who were experts
from the University of Zagreb School
of Dental Medicine (Dr. Joško
Viskić), University of Zagreb School
of Medicine (Dr. Danko Relić, Dr.
Marko Marelić, Dr. Lovela Machala
Poplašen), and the Croatian Catholic
University (Dr.Kristijan Sedak).In the
project implementation, Dr. Marjeta
Majer also participated and provided
support for the qualitative research.
Since e-professionalism requires
an interdisciplinary team, the
SMePROF team included doctors
of medicine from various specialties
(psychiatry, family medicine, school
and adolescent medicine), doctors of
dental medicine (specialists in fixed
prosthodontics and orthodontics), and
researchers from the social sciences
(information-communication experts
and sociologists). The objectives were
to: 1) analyse the frequency and habits
of the use of social networks among
healthcare professionals (e.g. students,
professors,andhealthcareprofessionals
in medicine, dentistry, nursing); 2)
determine whether and how the
content posted on social networks
affects professionalism competence;
3) examine the dangers and benefits
of healthcare professionals using social
networks; and 4) explore how safety
and professionalism can be improved
in daily professional tasks.
Part 1. Defining E-professionalism
among Medical/Dental Students
and Faculty. From 2018-2022, the
researchers conducted a cross-sectional
study and documental analysis to
examine how students and teachers
at the University of Zagreb Schools
of Medicine and Dental Medicine
perceive the potential opportunities
and challenges in using social media
Tea Vukušić Rukavina
E-professionalism of Healthcare Professionals:
An Ongoing Challenge
E-professionalism of Healthcare Professionals
Marko Marelić
BACK TO CONTENTS
22
for professional purposes. After
reviewing the scientific literature on
the dangers and benefits of social
networks, the team developed a survey
instrument to collect these study
variables for analysis [5-7]. They also
conducted a documental analysis of
Facebook profile content of students
and teachers. Study findings showed
that e-professionalism is widely
understood, and that medical and
dental healthcare professionals use
social media differently. For example,
dental professionals were more
desensitised to visual representations
of patients and more prone to patient
interactions on social media, leading
to an increased risk of exhibiting
unprofessional behaviour.
Part 2. E-professionalism of Medical
and Dental Healthcare Professionals
in Croatia. From 2021-2022, the
researchers collaborated with the
Croatian Medical Chamber and
the Croatian Chamber of Dental
Medicine to expand the data collection
to administer the survey and conduct
focus groups with a sample of medical
and dental healthcare professionals as
well as perform a documental analysis
of the content of their Facebook
profiles. First, the team used a survey-
specific questionnaire (“SMePROF
Project Survey Questionnaire on
Social Media Usage,Attitudes,Ethical
Values and E-professional Behaviour
of Doctors of Medicine and Doctors
of Dental Medicine”), which was
derived from the project focusing on
medical and dental students entitled,
“Dangers and Benefits of Social
Networks: E-professionalism of
HealthcareProfessionals–SMePROF”
[6,8,9].This questionnaire used in the
study on MDs/DMDs was composed
of eight instruments that measured:
1) sociodemographic characteristics
and habits of social networking
sites (SNS) usage; 2) knowledge of
SNSs; 3) reasons for SNS usage; 4)
impression management on SNSs;
5) security on SNSs; 6) attitudes
toward professionalism; 7) attitudes
toward e-professionalism; and 8)
perceptions of e-professional content
on SNSs. The instrument, which was
used to measure the perception of
e-professional content on SNSs, was
first developed by White et al. [10],
and aimed to measure the perceptions
of e-professional content on SNSs
among medical and dental healthcare
professionals, and after validation,
incorporated 17 variables [11].
Second, using the scientific literature
and trained expertise, the team
prepared an interview guide for
focus groups with selected medical
and dental healthcare professionals
and participants from the general
population.Theinterviewguide,which
was developed based on the previous
research and face validity among
interdisciplinary researchers from the
SMePROF team, aimed to investigate
their social media use habits, attitudes
towards e-professionalism, and
perceptions of unprofessional posts
encountered. Finally, the analysis of
Facebook profile content of medical
and dental healthcare professionals
was completed using a novel
SMePROF rubric for assessment of
unprofessional Facebook content [7],
with an improved rubric and criteria
to minimise subjective interpretation.
Study findings demonstrated that
although both professions were
careful in their online interactions,
the general Croatian population had
a narrower perception regarding the
professionalism of social media posts
on profiles of medical and dental
healthcare professionals.
Part 3. Effectiveness of Published
Guidelines that Promote
E-professionalism. In collaboration
with the Croatian Medical Chamber
and the Croatian Chamber of
Dental Medicine, the researchers
incorporated empirical and expert
findings of the SMePROF project
into the development of guidelines for
the promotion of e-professionalism
using social networks of medical and
dental doctors, which were published
in October 2020 [12,13]. In 2023,
the researchers administered surveys
to determine whether medical and
dental students in other Croatian
cities modified their attitudes and
perceptions of e-professionalism
before and after the publication of
the guidelines. Although researchers
are currently analysing the survey
results,they successfully developed and
validated a series of new measurement
instruments enabling the assessment of
e-professionalism within and between
individual healthcare professions
[7,9,11]. Study findings, including
the validated instruments, have been
shared with the scientific community
through reputable scientific journals.
Challenges and Future Directions in
Researching E-professionalism
Innovation was vital to tackle the
intricate and ever-evolving realm of
social networks research. Exploring
social networks from the standpoint of
social media users often felt daunting
and challenging. During our five-year
project, we encountered the shutdown
of old platforms (Google+) as well as
the emergence of new social networks
(TikTok), which required constant
and dynamic adaptation of research
methodology. We also observed social
movements (#medbikini) that resulted
in rapid changes in the interpretation
of scientific findings, which we
could only overcome by introducing
novel approaches for controlling and
assessing gender bias using qualitative
designs [7,14-16].
Throughout the SMePROF project,
researchers have recognised the rapid
evolution of social media and have
acquired knowledge and insight
into the strategies for managing
E-professionalism of Healthcare Professionals
BACK TO CONTENTS
23
and assessing the novel concept of
e-professionalism. However, one
question remains: Recognising the
global nature of social media, how
has e-professionalism changed
over time or across cultures? Using
other interpretive lenses (e.g. social
sciences), rather than only healthcare
professions, next research initiatives
can explore the economic, legal,
communication, and sociological
perspectives of e-professionalism in
order to help fill additional gaps in
practice.
References
1. Cain J, Romanelli F. E-profes-
sionalism: a new paradigm for
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macy Teaching and Learning.
2009;1(2):66-70.
2. Global Digital Insights. Digi-
tal around the world [Internet].
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3. Global Digital Insights. Dig-
ital 2023: Croatia [Internet].
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tal Insights. 2023 [cited 2024
Feb 14]. Available from: https://
datareportal.com/reports/digi-
tal-2023-croatia
4. Thompson C. Your outboard
brain knows all [Internet].Wired.
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able from: https://www.wired.
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5. Vukušić Rukavina T, Viskić J,
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ward e-professionalism among
medicine and dental medicine
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7. Vukušić Rukavina T, Machala
Poplašen L, Majer M, Relić D,
Viskić J, Marelić M. Defining
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21]. Available from: https://mef.
unizg.hr/znanost/istrazivanje/
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jekt-hrzz-smeprof/
9. Marelić M, Viskić J, Poplašen
LM, Relić D, Jokić D, Rukavina
TV. Development and validation
of scale for measuring attitudes
towards e-professionalism among
medical and dental students:
SMePROF-S scale. BMC Medi-
cal Education. 2021;21(1):445.
10. White J, Kirwan P, Lai K,Walton
J, Ross S. ‘Have you seen what is
on Facebook?’ The use of social
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Open. 2013;3:e003013
11. Viskić J, Marelić M, Machala
Poplašen L, Vukušić Rukavina T.
Differences between doctors of
medicine and dental medicine in
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12. Relić D, Vukušić Rukavina T,
Marelić M, Machala Poplašen L,
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za poticanje razvoja e-profesion-
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voja-e-profesionalizma-tije-
kom-studija-medicine-i-den-
talne-medicine.pdf
13. Relić D,Luetić K,Pezo H,Mare-
lić M,Machala Poplašen L,Viskić
J, et al. Smjernice za korištenje
društvenih mreža te poticanje
razvoja e-profesionalizma dok-
tora medicine i doktora dentalne
medicine [Internet]. Medicinski
fakultet Sveučilišta u Zagrebu.
2023 [cited 2024 Feb12]. Croa-
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unizg.hr/app/uploads/2023/10/
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voja-e-profesionalizma-dok-
tora-medicine-i-doktora-den-
talne-medicine.pdf
14. Hardouin S, Cheng TW, Mitch-
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15. Kaur W. ‘Too pretty to be a doc-
tor’: female physicians, #MedBi-
kini, and who determines what’s
“professional” [Internet]. ELLE.
2020 [cited 2024 Feb12]. Avail-
able from: https://www.elle.com/
beauty/a33796252/women-doc-
tors-medbikini-sexism/
E-professionalism of Healthcare Professionals
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24
16. Laughney C. What you need to
know about the infamous #Med-
Bikini study [Internet]. Medium.
2020 [cited 2024 Feb 22]. Avail-
able from: https://medium.com/
beingwell/what-you-need-to-
know-about-the-infamous-med-
bikini-study-1d814e1ebe44
Authors
Tea Vukušić Rukavina, MD, PhD
Andrija Štampar School of Public
Health, School of Medicine,
University of Zagreb,
Zagreb, Croatia
tvukusic@snz.hr
Marko Marelić, PhD
Andrija Štampar School of Public
Health, School of Medicine,
University of Zagreb,
Zagreb, Croatia
marko.marelic@snz.hr
E-professionalism of Healthcare Professionals
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25
Public health misinformation and
disinformation have emerged as
pervasive and insidious threats,
undermining efforts to protect
and promote public health on a
global scale. Their roots are deeply
intertwined with the broader societal
trends, technological advancements,
and geopolitical dynamics. In an age
marked by the rapid proliferation of
digital platforms and social media,
false narratives can spread quickly
and widely, reaching millions of
individuals within seconds [1].
As a critical care physician who
has been on the frontlines of
the coronavirus disease 2019
(COVID-19) pandemic since its
beginning in the United States, I
have witnessed the quick propagation
of COVID-related disinformation.
At the start of the pandemic, we were
fighting the deadly virus, but as the
pandemic evolved, we also had to
combat the infodemic that resulted in
patients choosing ineffective or even
harmful strategies over recommended
life-saving treatments. False public
health statements were made by
political leaders, technology moguls,
and other people with no medical
or public health training. Sadly,
members of our own medical
community have contributed
significantly to the rapid spread
of untrue statements that call for
the dismantling of national and
international regulatory bodies, with
messaging that ultimately confuses
the public [2].
The consequences of public health
disinformation are far-reaching and
profound, as they can contribute
to vaccine hesitancy, decreased
adherence to public health guidelines,
and exacerbated health disparities.
Moreover, they can fuel social unrest,
political polarisation, and erosion
of trust in democratic institutions.
Recognising the urgent need to
address this multifaceted challenge,
organisations, governments, and
communities around the world have
attempted to mobilise efforts to
combat public health misinformation
and disinformation in their countries.
However, the global success of these
individual and collective efforts
has been variable, underscoring the
particular importance of sharing
successful strategies globally.
Highlights from the Panel
Discussion
As we navigate the complex landscape
of public health misinformation
and disinformation, it is essential to
engage in open dialogue, share best
practices, and work collaboratively
worldwide. In an attempt to raise
awareness within the global medical
community about the dangers
of disinformation, the Associate
Members of the World Medical
Association(WMA)convenedapanel
discussion entitled, “Disinformation
in Healthcare: How to Respond,”
in February 2024. Four panellists –
Ms. Katie Owens, Dr. Siddhartha
Datta, Dr. Natalia Pasternak, and
Dr. Osahon Enabulele – described
their experiences with public
health disinformation, reflected on
strategies that were effective and
ineffective in combating public
health disinformation, and explored
potential opportunities to address
public health disinformation.
Ms. Katie Owens, who serves as the
Information and Communication
Officer at the European Commission’s
Directorate General for Health and
Food Safety, defined misinformation
and disinformation and delineated
the distinction between both terms
by emphasising the deceptive
intent or motives for political or
financial gain. She contextualised
the historical background to public
health disinformation, particularly
regarding vaccine hesitancy, and
noted an escalation of conspiracies
facilitated by technological
advancements. Ms. Owens
outlined actions undertaken by the
European Commission during the
COVID-19 pandemic, including the
implementation of tools to monitor,
analyse, and counter disinformation.
These measures included an action
plan on disinformation, including
a rapid alert system, a COVID-19
disinformation monitoring program,
the European Democracy Action
Plan, and a strengthened code of
practice in collaboration with fact-
checkers and academic researchers.
Regarding misinformation,
she highlighted the efficacy of
pre-bunking over debunking,
emphasising the importance of
preemptive communication strategies,
identifying knowledge gaps, and
optimising channels for science
communication. She underscored the
significance of ongoing monitoring
Natalia Solenkova
Navigating the Public Health Information Space:
Responding to Disinformation with Global
Expert Insights and Potential Strategies
Responding to Disinformation with Global Expert Insights and Potential Strategies
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26
and analysis, particularly concerning
disinformation spread across
traditional and social media channels.
Dr. Siddhartha Datta, who acts
as Regional Advisor for the
Vaccine-preventable Diseases
and Immunisation program of
the Division of Country Health
Programs at the World Health
Organization (WHO)’s Regional
Office for Europe, described
malformation as factual information
taken out of context to mislead, harm
or manipulate and acknowledged
the rapid dissemination of false
information in the contemporary
era compared to previous years.
Dr. Datta centred his presentation
on vaccination as one primary
component of healthy behaviours
and underscored the multifactorial
nature of caregivers’ decisions
regarding vaccination. As he
delineated various factors influencing
vaccination decisions, including
individual concerns about side effects
and vaccine safety, family dynamics,
community vaccination patterns, and
healthcare system accessibility, he
stressed the importance of instilling
confidence in health professionals
through tailored communication
strategies, active listening, and
individualised advice. He highlighted
the training modules aimed at
equipping health professionals to
address vaccine hesitancy effectively
and advocated for integrating vaccine
literacy into broader health education
curricula, including the role of game-
based learning in shaping future
decision-makers.
Dr. Natalia Pasternak, who is
a Brazilian science writer and
communicator, professor of science
communication and policy at the
Colombia University’s School of
International and Public Affairs,
president of the Instituto Questão
de Ciência in Brazil, and member
of the Committee for Skeptical
Inquiry in the United States,
shared her experiences as a science
communicator across various media
platforms as well as promoted
the importance of adapting
communication styles to different
audience groups. She underscored
the necessity of teaching scientific
principles and critical thinking
to diverse stakeholders, including
health professionals, policymakers,
journalists, and politicians. Dr.
Pasternak emphasised the need
for comprehensive training for
health professionals to address
patient concerns and conspiracy
theories effectively. Drawing from
her experiences testifying about
COVID-19 vaccines in the Brazilian
legislature, she highlighted the
nuances of scientific communication
to policymakers and stressed the
critical role of transparency in public
health measures, particularly in
fostering trust among the general
public, legislators, regulatory bodies,
and policymakers.
Dr. Osahon Enabulele, who serves as
the WMA Immediate Past President,
Past President of the Nigerian
Medical Association, Coordinator
of the Coalition of African Medical
Associations, Past President of
the Commonwealth Medical
Association, Director General of the
Dr. Osahon Enabulele Foundation,
and Director-General of the
Initiative for Citizens Health and
Good Leadership Development,
articulated the causes of
misinformation and disinformation
as pathological (societal resistance to
science, deliberate acts of conspiracy
theories), public distrust of science
(Kano drug trial), structural issues
(low health literacy, cultural,
traditional, and religious beliefs,
poor communication), politics
(interference, unscientific claims
by politicians), media (knowledge
deficit), and disempowered
communities (poor living, poor
education, unengaged communities,
unclear benefits, no role models). He
proposed a multi-faceted approach
to address these underlying factors,
such as developing legal and policy
frameworks (addressing resistance
of societies and deliberate acts of
conspiracy theorists), establishing
timely actions against the public
distrust of science (community
involvement in research, real-time
information about disinformation
outcomes, effective ethics
committees), building collaborative
networks (media collaboration,
fact checks), promoting structural
actions (training health professionals,
improving public health awareness,
supporting advocacy and effective
evidence-based responses to false
claims), supporting political actions
(limitation of political interference,
exemplary leadership by politicians),
and empowering communities
(community engagement, recognition
of role models). He stressed that the
expression of an individual’s rights
should not impinge on citizens’rights,
well-being, and health.
Conclusion
In summary, the insights shared by
our esteemed panellists underscore
the critical importance of combating
disinformation for safeguarding
public health on a global scale. An
effective approach against public
health disinformation necessitates
a comprehensive and multi-faceted
strategy that incorporates measures
that can improve information space
and address other contributing
factors.
First, working with information
space requires addressing the ways
information is being produced,
disseminated, and received, which
would include addressing content,
information sources, dissemination
channels, media and social media
platforms and their algorithms,
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27
regulatory and policy frameworks,
and science and communication
literacy. However, focusing on the
information space alone will not be
effective without addressing other
contributing factors that determine
health decisions in different global
communities, including the ways
health information is received in
these communities. Therefore,
the second set of measures should
target socioeconomic disparities,
psychological biases, cultural and
religious beliefs, historical and
cultural context, political interference,
economic interests, and trust in
institutions, which will allow the
development of strategies tailored
to the needs and characteristics
of different global communities
and groups of patients. Forming
interdisciplinary collaborations across
sectors and borders is essential to
protect the integrity of public health
information and safeguard the health
and well-being of individuals and
communities worldwide.
References
1. Rodrigues F, Newell R, Babu GR,
Chatterjee T, Sandhu NK, Gupta
L. The social media infodemic of
health-related misinformation and
technical solutions. Health Policy
Technol. 2024:100846.
2. Smith R, Chen K, Winner
D, Friedhoff S, Wardle C. A
systematic review of COVID-19
misinformation interventions:
lessons learned. Health Aff
(Millwood). 2023;42(12):1738-46.
Natalia Solenkova, MD, PhD, MLS
Intensivist
Miami, Florida, United States
solenkova@gmail.com
Responding to Disinformation with Global Expert Insights and Potential Strategies
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28
As one key public health strategy,
vaccines boost natural immune
responses that protect against
invading pathogens, preventing
between 3.5 and 5 million annual
deaths globally [1]. The history
of vaccine development, starting
with the smallpox vaccine in 1796,
has highlighted how the scientific
method was used to guide the trial-
and-error period related to vaccine
safety and efficacy. Vaccines, which
protect against more than 20 grave
diseases, are a testament to scientific
advancements, which help reduce
health expenditure (alleviating
financial struggles that can lead to
poverty), minimise antibiotic use
by protecting microbial diversity,
and control pathogen growth and
transmission especially with the
effects of climate change [2].
Notable vaccination progress was
halted during the coronavirus disease
2019 (COVID-19) pandemic, due to
hospital surges in health care services,
disruptions in vaccination programs,
observed socioeconomic disparities
across communities, and public
fear to seek routine medical care at
hospitals. Likewise, the reemergence
of cholera and measles outbreaks has
been linked to weak health system
infrastructure, inadequate vaccination
coverage, demographic growth and
urbanisation, and climatic factors. In
2022, 44 countries reported cholera
cases (compared to 35 countries in
2021), and 37 countries experienced
significant malaria outbreaks
(compared to 22 countries in 2021)
[3,4]. As measles cases and deaths
had increased by 18% and 43% in
2022, respectively, expanded coverage
for vaccine-preventable diseases is
needed to reverse these trends [3,4].
The World Health Organization
(WHO), however, has recently
reported significant progress in
expanding global vaccination
coverage. Health leaders shared that
that there are 14.3 million zero-dose
children, or the number of children
missing any vaccinations, when
compared to 18.1 million in 2021
[5]. Also, reports showed that 84% of
children had received the third dose
of diphtheria, tetanus, and pertussis
vaccines (compared to 81% in 2021),
83% of children were administered
the first dose of measles vaccines
(compared to 81% in 2021), and 21%
of female children had acquired the
first dose of human papillomavirus
(HPV) vaccines (compared to 16% in
2021) [5].
In August 2020, the WHO adopted
the Immunisation Agenda 2030 at
the World Health Assembly, as an
ambitious strategy to sustain political
commitment to universal health
coverage, including vaccination
coverage [6,7]. Building upon the
Global Vaccine Action Plan (2011-
2020) and eradication efforts related
WMA Members Contribute Insight on Global Vaccination Efforts
WMA Members Contribute Insight on Global Vaccination Efforts
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Credit:
rangizzz
/
shutterstock.com
29
to polio and measles, this strategy
promises to uphold objectives to
expand vaccination coverage through
four elements – operational planning,
ownership and accountability design,
monitoring and evaluation approach,
and communications and advocacy
strategy [7]. In short, WHO leaders
have expressed their goal: “A world
where everyone, everywhere, at every
age, fully benefits from vaccines for good
health and well-being” [7].
Furthermore, immunisations and
optimal health outcomes are directly
and indirectly linked to at least 14
of the 17 Sustainable Development
Goals (SDGs) of the 2030 UN
Agenda for Sustainable Development
[2,6,8]. For example, vaccines can
help improve work productivity and
economic sustainability, which can
support economic growth (SDG 8)
and reduce poverty (SDG 1). They
can protect against pathogens and
other enteric diseases, which can
ensure clean water and sanitation
(SDG 6) and reduce hunger (SDG
2). By conserving microbial diversity
and reducing the use of antimicrobial
agents, they can protect the marine
and terrestrial ecosystems (SDG 14
and SDG 15) and the planet (SDG
13) [2]. In turn, equitable access to
vaccines can reduce inequalities (SDG
10), promote quality education (SDG
4),and support gender equality (SDG
5), collective action and partnerships
(SDG 17), peace and justice (SDG
16), and sustainable urban and rural
communities (SDG 11) [2,8]. These
connections showcase the importance
of the One Health approach (human-
animal-environmental nexus) to
better understand these direct and
indirect connections between one
public health approach (vaccines
and immunisations) and the desired
outcome (optimal population health).
Notably, 2024 marks the 50th
anniversary of the Expanded
Programme on Immunisation (EPI),
which was launched by the WHO
in 1974, to promote the coverage
of childhood immunisations [9].
The list initiated with six vaccines
(Bacillus Calmette-Guérin,
diphtheria, pertussis, tetanus, polio,
measles), and today includes seven
additional vaccines (Haemophilus
influenzae type B, Hepatitis B,
rubella, pneumococcal disease,
rotavirus, HPV, COVID-19 for
adults), for a total of 13 vaccines
[9]. Key milestones include the
eradication of smallpox in 1980, as
well as the elimination of polio by
99%, due to key partnerships with
the WHO, U.S. Centers for Disease
Control and Prevention, United
Nations International Children’s
Emergency Fund (UNICEF), Rotary
International, Bill and Melinda Gates
Foundation, and Gavi the Vaccine
Alliance. As the rapid spread of
misinformation and disinformation
was acutely observed during the
COVID-19 pandemic, global leaders
should prepare comprehensive
communication strategies for future
public health initiatives.
World Immunisation Week, which
is held annually from April 24-30
(https://www.who.int/campaigns/
world-immunization-week/2024),
provides an opportunity to promote
joint public action to safeguard the
population (including children) from
vaccine-preventable diseases. Global
health leaders recognise that the One
Health approach offers a holistic view
that can foster robust collaborations
between scientific disciplines and
sectors, which can support infection
control practices and antimicrobial
stewardship across human, animal,
and agricultural sectors as well
as equitable vaccine delivery and
coverage across communities.
In this article, physicians from
seven countries – Brazil, Bulgaria,
Myanmar, Nigeria, Philippines,
Trinidad and Tobago, and Turkey –
shared insightful contributions about
local and national efforts to promote
immunisations through community
activities and relevant policies across
their national health systems.
Brazil
The Brazilian National Immunisation
Program (Programa Nacional
de Imunizações, PNI), one of
the greatest achievements of the
Brazilian public health system, was
established in 1973 and celebrated its
50th anniversary in 2023 [10]. This
program has helped promote and
maintain high immunisation coverage
for vaccine-preventable diseases
and has successfully eradicated
smallpox, measles, rubella, congenital
rubella syndrome, poliomyelitis, and
neonatal tetanus [11]. However,
Brazilian health leaders continue
to face significant challenges with
expanding immunisation coverage to
its 209 million residents, especially
with marginalised communities
widely spread across the country and
spread of vaccine hesitancy due to
misinformation [12]. They continue
to support robust efforts to improve
national surveillance, prevention, and
control for pneumonia, diphtheria,
whooping cough, and diarrheal
diseases (https://www.gov.br/saude/
pt-br/vacinacao).
In recent years, successful
immunisation campaigns have led to
a reduction in the overall perceived
risk about eradicated diseases, leading
to a drop in national vaccination
rates [13]. The Brazilian Ministry of
Health has proposed several initiatives
to reverse this trend and build public
trust in vaccines, including training of
health professionals, investing in the
cold chain,improving the information
system and dose registration,
supporting vaccine industry
production, and combating the
infodemic. In 2023, the Government
of Brazil established the National
Vaccination Movement (Movimento
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30
Nacional Pela Vacinação), which
incorporated the Health with Science
platform to combat misinformation
about vaccine adherence, enhanced
vaccine dose registration into the
National Health Data Network
(Rede Nacional de Dados em Saúde,
RNDS), and ensured political
commitment (estimated US $30
million) to support vaccination
approaches for local decision-making
activities [14].
The World Immunisation Week
offers a global platform for health
leaders to leverage their expertise
and work directly with community
members, where they can help
exchange successful practices
and initiatives for expanded
immunisation coverage. Over the
past two years, Brazilian leaders have
specifically supported community
actions and massive communication
campaigns involving renowned
celebrities and musicians, which have
subsequently halted the declining
national vaccination rates with
the first signs of recovery in 2023.
Recognising these accomplishments,
the Brazilian Medical Association
(AMB) continues to collaborate
with its affiliated medical societies,
where they can reinforce the
successful implementation of Brazil’s
vaccination strategies and promote
PNI’s immunisation initiatives across
the Americas region.
Bulgaria
The Bulgarian Medical Association
has continued to raise awareness
about vaccinations as the most
effective public health intervention
and reassure society about their
safety, efficacy, and beneficence.
According to the Bulgarian National
Immunisation calendar (https://
vaccine-schedule.ecdc.europa.eu/
Scheduler/ByCountry), the average
national (mandatory) vaccination
coverage in 2023 was 92%, compared
to the desired 95% coverage (e.g.
diphtheria, measles, mumps,
pertussis, poliomyelitis, rubella,
tetanus, tuberculosis) (https://www.
mh.government.bg/bg/informaciya-
za-grazhdani/imunizacii/). With
relatively high levels of immunisation
coverage, vaccine-preventable
diseases are rare; however, society at
large may not fully appreciate the real
benefit of such immunisations [15].
Dr. Gergana Nikolova (Bulgarian
Medical Association’s Management
Board) reflected upon this hesitancy
as “fear” (e.g. why fears of the vaccine
were greater than fears of cancer)
and found that the infodemic
campaigns had spilled over from
COVID-19 vaccines to the National
Immunisation calendar of mandatory
vaccines [16]. Also, Dr. Nikolay
Branzalov (Bulgarian Medical
Association’s Vice-Chairperson)
regularly consults with vaccine-
hesitant parents in his primary
practice, where he actively schedules
appointments with patients who
have upcoming immunisations and
collaboratively discusses the scientific
evidence on vaccines’ benefits and
harms. Notably, nearly 100% of
his patients are vaccinated with
mandatory immunisations.
As a top priority, health leaders of the
Bulgarian Ministry of Health have
led efforts to adopt several national
programs that support the National
Immunisation calendar, where
mandatory preventive immunisations
and revaccinations are administered
free of charge (recommended
vaccines for a nominal fee) by general
practitioners or regional health
inspectors at acquired ages (https://
www.mh.government.bg/en/). First,
the national program for seasonal
flu and pneumococcal vaccinations
(2023-2026) provides free vaccines in
individuals over age 65, with the goal
of achieving 35% coverage against
seasonal flu,and 15% coverage against
pneumococcal infections by 2026.
Notably, the percentage of vaccinated
individuals has increased from 7.8%
in 2019, 11.4% in 2020, and 13.2% in
2021.Second,thenationalprogramfor
primary prevention of cervical cancer
(2021-2024) offers free vaccines
against HPV for girls of ages 10-13.
Although HPV vaccinations were
initially well accepted, due to targeted
anti-vaxxer campaigns, coverage
has declined from 4% in 2019, 2%
in 2020-2021, and 1% in 2022. The
newly established HPV Coalition,
bringing together physicians and
public figures, calls for expanding the
programmatic scope to boys of ages
10-12. Third, the national program
for the prevention of rotavirus
gastroenteritis (2022-2025) has
led to reduced hospitalisations and
emergency room visits (by 85-95%),
with approximately 40% of newborns
vaccinated against rotavirus [17].
Health leaders of the Bulgarian
Medical Association continue to
streamline their efforts to support
local and national vaccination
campaigns that help build public
trust in vaccine efficacy and safety,
leading to increased adherence to
the recommended vaccinations of
the National Immunisation calendar.
They collaborate with partner
institutions and stakeholders such as
UNICEF and patient organisations
to host regular informational events
and campaigns on vaccine safety,
distribute institutional- or state-
sponsored surveys (e.g. Bulgarian
Ministry of Health), and support
team discussions that help interpret
scientific data on vaccine safety.
Finally, members recognise that these
essential collaborations can emphasise
howevidence-basedscientificfindings
guide the development of national
immunisation guidelines, help
combat the spread of misinformation
and disinformation in society, and
ultimately reduce vaccine-preventable
diseases for Bulgarian citizens.
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31
Myanmar
The Myanmar health system has
reported two priorities related to
immunisations – restoring and
maintaining routine immunisations
and delivering vaccinations across
the country (including marginalised
communities) – recognised as a
fundamental human right and
essential public health measure that
promotes community well-being [18].
In 2022,10 million Myanmar citizens
lacked access to basic healthcare
vaccines and 300,000 children missed
their regular immunisations, as a
result of blocked clinic and vaccine
access by the Myanmar military and
security forces [18]. The coup d’état’s
systematic and widespread use of
tactics against innocent civilians and
health professionals, has increased
risk of physical and emotional harm
(including severe injury and death),
and the UN and other international
organisations have reported these acts
as crimes against humanity [19,20].
Global attention should be placed on
the underreported atrocities against
civilians by the Myanmar’s military
junta, including the purposeful
manipulation of vaccination access
and distribution as well as denial of
essential health care services, which
ultimately hinders global health
security [21].
Days prior to the military takeover
on 1 February 2023, the International
Monetary Fund (IMF) provided
US $372 million to Naypyidaw
authorities for COVID-19
vaccination efforts. However, the
military junta failed to submit any
procurement reports for transparency
in these financial transactions.
Subsequently, millions of dollars
for the COVID-19 vaccination
fund were reported missing, and
the military junta accounted for US
$350 million in COVID-19 funding
[22]. Furthermore, Dr. Htar Htar
Lin, the former leader of Myanmar’s
COVID-19 immunisation campaign,
together with her husband, seven-
year-old son, and family dog, were
escorted into military custody in
June 2021. Her alleged crime was
her attempt to return US $94,580 to
the UN, as to reduce risk of military
seizure of these funds [23].
There is desperate need of UN and
international community respond
to the issue in Myanmar with the
same urgency that they responded
to the crisis in Ukraine and Israel.
Moving forward, UN organisations
and the global community must
ensure the implementation of the
UN Security Council Resolution
2286 (Protection of Civilians in
Armed Conflict), which strongly
condemns attacks on health care
personnel in conflict situations
and supports that all necessary
measures are taken to improve
health care protection and access
in Myanmar [24]. Leading health
and humanitarian agencies, like the
UN, World Medical Association
(WMA), International Court of
Justice (ICJ), and International
Criminal Court (ICC), can reinforce
that responsible committees regularly
document cases of manipulated
vaccination aid in Myanmar, critically
analyse each case, and share public
reports. Furthermore, collaborations
with community stakeholders can
foster engagement opportunities
with appropriate parties to ensure
immunisation supplies and establish
secure corridors for delivery. For
example, by connecting with ethnic
health care groups in liberated regions,
leaders can provide immunisations
via access points in China, Thailand,
India, and Bangladesh. Specific to
Asia, the UN can expand networks
with the Association of Southeast
Asian Nations (ASEAN) (https://
asean.org/), with 10 member states
(Indonesia, Malaysia, Philippines,
Singapore, Thailand, Brunei,
Vietnam, Lao PDR, Myanmar,
Cambodia), to support immunisation
efforts in Myanmar. As a global
community, we are reminded
that preventable diseases have no
boundaries,andtimelyactioniscrucial
to mitigate risk to our neighbouring
countries’ health.
Nigeria
Nigerian leaders, serving a country of
an estimated 195 million residents,
are challenged to achieve universal
immunisation coverage for children
acrossthenation,especiallyascoverage
has continued to decline from 81.5%
in the early 1990s, 30% in 1996, to
12.9% in 2003 [25]. According to the
WHO, an estimated 868,000 annual
deaths occur in children under five
years of age in Nigeria, primarily due
to vaccine-preventable diseases [26].
To address this burden, community
health professionals travel across the
country, by terrain vehicles and boats,
to reach marginalised populations,
including nomadic groups, seasonal
migrants, and fishing and agricultural
settlements [27]. They often use
mainstream and social media to
promote health messaging to help
strengthen trust in vaccine adherence
and dispel myths [28].
Established in 1978, the National
Programme on Immunisation
in Nigeria (or EPI) supports the
prevention of vaccine-preventable
diseases among children and adults.
In 2023, the HPV vaccine was
introduced into the immunisation
schedule,as cervical cancer is the third
most common form of cancer and
the second most common cause of
cancer mortality (about 8,000 annual
deaths) in Nigerian women [29].
Although the National Programme
on Immunisation has enthusiastically
reported the eradication of endemic
polio in 2020, it continues to
encounter challenges toward
the adherence to recommended
(gratuitous) immunisations across
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32
the 36 states in the country [30].
Health leaders have openly discussed
approaches to combat vaccine
hesitancy, as a result of perceived
insecurity (e.g. community health
professionals cannot conduct home
visits to administer vaccines due to
security issues like armed robbery
and kidnapping), cultural beliefs
(e.g. vaccines will cause stunted
growth in children), and the spread
of misinformation and myths (e.g.
vaccinations for population control or
sterility) [25].
Over the past decade, the Nigerian
federal and state governments
have periodically used innovative
jingles and skits on mainstream
media to increase awareness of the
safety and efficacy of recommended
vaccinations. Leaders also organised
these educational campaigns (in the
local dialect) at religious places of
worship and town hall meetings,
as religious and traditional leaders
are highly respected in Nigerian
communities and can help demystify
any public concern or erroneous
beliefs toward vaccinations. Also,
Nigerian medical professional
associations (Medical Women’s
Association of Nigeria, MWAN;
Nigerian Medical Association,NMA;
Paediatric Association of Nigeria,
PAN) and non-governmental
organisations actively promote
immunisations through concurrent
community health programmes (e.g.
nutrition, sanitation and hygiene,
breastfeeding, family planning) that
help build public trust of vaccinations.
By forming collaborations between
local organisations, community
stakeholders, and international health
institutions (e.g. WHO, UNICEF),
African health professionals can help
lead advocacy efforts to enhance
national immunisation coverage in
health facilities across urban and rural
settings.
Philippines
Vaccination efforts in the Philippines,
a country of approximately 118
million residents,have been integral to
the country’s public health initiatives
that protect population health.
Since the 1990s, the Philippines has
faced challenges in achieving a 95%
mandatory vaccination coverage
rate for children [31]. Globally, the
Philippines ranked fifth for having
18 million zero-dose children and
seventh for the number of children
without measles vaccinations
in 2021 [32]. Recognising this
challenge, the Philippines health
system reinforced vaccination efforts,
including polio vaccines to 11 million
children, leading to the successful
end to a polio outbreak in June
2021. As health leaders celebrate
this achievement, they understand
the need to continually reinforce
vaccination adherence, as 1.5 million
Filipino children remain unprotected
(unvaccinated or incomplete
vaccination scheme) from the
poliovirus, and many communities
have an increased risk of poliomyelitis.
In 2022, the UNICEF Philippines
marked World Polio Day by raising
awareness of the importance of the
polio vaccine and highlighting that
1 million children across the country
had not received any of the four doses
of the polio vaccine [33].
In 2022, the WHO and UNICEF
published a joint news release report
that revealed a significant and
sustained global decrease in childhood
vaccinations, noted as the largest
decline over the past three decades
[34]. In the Philippines, although the
COVID-19 pandemic significantly
impacted health care service
delivery, including immunisation
programs, health leaders successfully
administered COVID-19 vaccines
with an unprecedented highest daily
number of 229,769 vaccination doses
administered on 20 May 2021 [31].
The Philippines, along with other
middle-incomecountries,experienced
a high number of children missing
one or more doses of diphtheria,
tetanus, and pertussis routine
immunisations in 2021, recognised as
a measure of immunisation coverage
within and between countries. After
reaching a peak of 87% in 2014, the
country’s immunisation coverage
among children steadily dropped to
68% in 2019 and then 62.9% in 2022.
In addition to reestablishing efforts
to ensure that more children are
protected from vaccine-preventable
diseases, there is an urgent need to
shift to “vaccination programs for all
ages and all groups” [35].
In November 2023, the
Pharmaceutical and Healthcare
Association of the Philippines
(PHAP) and member Pfizer
Philippines in collaboration with
the Philippine Press Institute (PPI),
and in strategic partnership with
the Philippine Medical Association
(PMA), the Philippine Foundation
for Vaccination (PFV), and the
Philippine Alliance for Patient
Organizations (PAPO), conducted
the “Injecting Hope” seminar-
workshop for journalists and patient
groups, to support “The Big Catch-
Up” and acknowledge the essential
role of media in providing reliable
public health information [36].
Furthermore, the PMA proposed
strategies to enhance trust in
life-course immunisation (LCI),
including the annual National
Vaccination Days, synchronised
digital individual immunisation
records, national digital
immunisation cards, vaccination
records as a requirement for school
admission, vaccine history included
in annual physical examinations
for employment, and infectious
disease lectures in K-12 school
curricula. These efforts aimed to
help increase public awareness,
support vaccination activities, and
WMA Members Contribute Insight on Global Vaccination Efforts
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33
assist health professionals as they
monitor patient reactions and report
adverse effects to the Department of
Health. The PMA, working with the
Department of Health,remains at the
forefront of advocating for increased
trust and adherence to recommended
vaccinations, among families and
communities [37].
Trinidad and Tobago
As a country in the Caribbean and by
extension the Region of the Americas,
Trinidad and Tobago (T&T) has
recognised Vaccination Week in the
Americas (VWA) since 2002.It aligns
with World Immunisation Week
that standardised the observance of
Immunisation Week globally in 2012.
This week is significant to medical
practitioners in T&T as it heightens
awareness and educational efforts on
the historical timelines and benefits
of immunisation for our residents.
For VWA 2023, the Honourable
Terrence Deyalsingh, the Minister of
Health T&T, reminded citizens that
the history of vaccinations in curbing
the effects of fatal infectious diseases
is well established [38]. For example,
T&T has been polio-free since 1972,
had the last recorded case of measles
in 1991, and had no cases of rubella
and yellow fever since 1997 [38].
Immunisation services are provided
at no charge to T&T citizens and
residents through the EPI.
This EPI, a joint effort of the WHO,
Pan American Health Organization
(PAHO) and the Ministry of Health
of T&T, was established in the 1970s.
It adheres to the philosophy that
every child should be immunised
against vaccine-preventable diseases,
and its vision is to identify and
completely immunise all infants,
children, pregnant women, and men
as early as possible, in accordance
with a national immunisation
schedule (https://health.gov.tt/
services/immunization). Vaccines are
made available through the EPI Unit,
and country-wide immunisation is
embedded in the services provided
throughmorethan100primaryhealth
care access points. The Ministry of
Health’s Immunisation Manual for
Health Professionals describes the
Public Health (Nursery Schools and
Public Schools Immunisation) Act,
Chapter 28:03 of 1973,which requires
immunisations against poliomyelitis,
diphtheria, tetanus, measles, and
yellow fever for school entry.
In recent years, the historically
high immunisation coverage in
the Caribbean has been declining,
and T&T is no exception. The
COVID-19 pandemic has worsened
the immunisation trends, leaving
gaps in human, financial, and
material resources within countries’
immunisation programs [39]. At a
country level, efforts are being made
to improve immunisation coverage,
especially within the 0-5 year age
group. For example, primary care
facilities in strategic locations have
been opened outside of regular
hours to encourage parents to bring
their infants and young children for
wellness checks and immunisations.
Community outreach initiatives have
incorporated educational campaigns
that emphasise the benefits of
vaccines.
The Trinidad and Tobago Medical
Association (T&TMA) stands on
its motto, ‘Teach, Treat, Mentor and
Advocate’, which is upheld in its
approach to current and emerging
public health concerns or emergencies,
including immunisations. When the
Association was asked to assist with
the national COVID-19 vaccination
campaign, it supported vaccinations
to more than 70,000 persons. The
Association encourages global health
professionals to be mindful of and
support local immunisation programs
so that all countries can achieve their
immunisation goals. A resilient and
robust immunisation system keeps
our population safe from preventable
infections and subsequent morbidity
or mortality.
Turkey
Although data illustrating national
vaccination coverage across 81
Turkish provinces are unavailable
from the Ministry of Health, the
WHO has reported at least 95%
coverage for the third dose of
diphtheria-tetanus-pertussis vaccines
in 69 provinces, first dose of measles
vaccines in 40 provinces, and second
dose of measles vaccines in 43
provinces [40]. With these
achievements, Turkish leaders
recognise that the irregular migratory
routes from some countries, like
Afghanistan, have most likely
contributed to the ongoing measles
epidemic in the nation (with 4,547
reported cases, as of October 2023)
since December 2022 (https://data.
euro.who.int/CISID/) [41,42].
Hence, Turkish health leaders are
concerned about safeguarding
population health through upholding
the national vaccination guidelines.
Although the WHO has set the
target of 90% coverage of HPV
vaccinations to support efforts to
eliminate cervical cancer by 2030, the
Turkish Ministry of Health has not
included this vaccine in its National
Vaccination Schedule (NVS) [43]. As
the lower socioeconomic levels bear
a higher burden of cervical cancer
morbidity and mortality, one primary
concern is that HPV vaccinations
are inaccessible to a large percentage
of the populace, especially as one
HPV vaccination costs US $76.80
(when the minimum wage is US
$561.62). Considering the financial
burden, one rotavirus vaccination
costs US $57.51 and has not yet
been included in the NVS. Hence,
socioeconomic inequalities for
vaccine coverage remain significant in
WMA Members Contribute Insight on Global Vaccination Efforts
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34
Turkey, especially across eastern and
southeastern Anatolia [44,45]
The continued spread of
misinformation related to adverse
events following immunisations
aligns with growing vaccine hesitancy
across the world. According to the
Institute for Health Metrics and
Evaluation, a multi-nation survey
(with 496,868 responses) examined
perceived vaccine safety and efficacy,
of which Turkish respondents
believed that vaccines were safe
(43.0%), sometimes safe (32.6%), and
unsafe (24.4%), as well as effective
(47.2%), sometimes effective (31.0%),
and not effective (21.9%) [46].
Furthermore, according to Turkey
Health Report 2020, individuals
without vaccinations (zero-dose)
were 2.8% and 2.2% of children
between 12-23 month of age in
2003 and 2018, respectively [44].
With limited national and regional
data, including the gaps noted
between administered surveys, it is
important to fully understand the
impact of national emergencies (e.g.
COVID-19 pandemic, earthquakes
affecting 11 million people) that have
collectively led to a weakened health
care infrastructure.
As the Turkish Ministry of Health
does not widely share health
surveillance data with the public,
health leaders cannot effectively
develop evidence-based policies.
To build public trust related to the
benefits of vaccination, the Turkish
Medical Association’s Immunisation
Working Group founded the
Coalition for Immunisation to
support immunisation advocacy [47].
Moving forward,the Turkish Medical
Association can support the Turkish
Ministry of Health, helping leaders
strengthen political commitment to
implementing WHO’s immunisation
targets and sustainable immunisation
services related to vaccine-preventable
diseases.
Conclusion
The World Immunisation Week
2024 presents a global platform to
recognise ongoing immunisation
efforts across all countries as well as
address barriers toward achieving
projected global and national
vaccination rates. Collectively, global
leaders can identify gaps in their
national vaccination coverage, share
lessons learned from their vaccination
campaigns, and take prompt action to
implement the Immunisation Agenda
2030 framework across their national
health systems. Since immunisations
and optimal health outcomes overlap
with the SDGs, global leaders can
simultaneously align overarching
goals with plans to expand vaccination
coverage and hence strengthen
national primary care health systems.
Notably, WMA members hold
strategic leadership roles, where they
can actively leverage their expertise
and help guide the implementation
of these four operational elements
of the Immunisation Agenda 2030
framework across national health
systems. This collective article offers
an overview of community initiatives
and relevant polities that highlights
achievements, states encountered
challenges, and advocates for timely
community action to ensure equitable
access to vaccines for expanded
coverage for all ages. These valuable
collaborations demonstrate strong
health leadership across the African,
Americas, European, South-East
Asian, and Western Pacific regions,
while ensuring political commitment
for expanded vaccination coverage
to promote optimal health outcomes
and strengthen global health security.
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Authors
Sandi Arthur, B. Med Sci,
M.B.B.S, DM Family Medicine
Public Relations Officer & 5th
Vice President (2024),
Trinidad and Tobago
Medical Association
Port of Spain, Trinidad and Tobago
Maia Blackman, M.B.B.S.,
MSc Sports Medicine
Council Member (2024), Trinidad
and Tobago Medical Association
Port of Spain, Trinidad and Tobago
Dabota Yvonne Buowari, MBBS
Department of Accident
and Emergency,
University of Port Harcourt
Teaching Hospital
Port Harcourt, Nigeria
Maria Minerva P. Calimag,
MD, MSc, PhD
Department of Pharmacology
and Clinical Epidemiology,
Faculty of Medicine and Surgery,
University of Santo Tomas
Manila, Philippines
Helena Chapman, MD, MPH, PhD
Milken Institute School
of Public Health,
George Washington University
Washington DC, United States
Maymona J. Choudry,
RN, MD, MPH
Department of General Surgery,
Vicente Sotto Memorial Medical Center
Cebu City, Philippines
Muzaffer Eskiocak, MD
Immunisation Working Group,
Turkish Medical Association
Department of Public Health, Faculty
of Medicine, SANKO University
Gaziantep, Turkey
Elisaveta Geretto, PhD
International Relations,
Bulgarian Medical Association
Sofia, Bulgaria
Renato de Ávila Kfouri, MD
Infectious disease pediatrician
Member, Technical Advisory
Board, National Immunisation
Program of Brazil (PNI)
Member Director, Network of
Immunisation Programs of the
Americas (RNA), Pan American
Health Organization (PAHO)
São Paulo, Brazil
Wunna Tun, MBBS, MD
Fellow, Medical Education,
JDN Secretary
Yangon, Myanmar
WMA Members Contribute Insight on Global Vaccination Efforts
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38
A representative delegation from the
World Medical Association (WMA)
attended the 28th Conference of
the Parties (COP28) to the United
Nations Framework Convention
on Climate Change (UNFCCC).
The conference was presided over by
Dr. Sultan Ahmed Al Jaber of the
United Arab Emirates (UAE) and
heldattheExpo2020CenterinDubai
from 30 November to 12 December
2023. The WMA delegation,
led by Dr. Lujain Alqodmani and
Dr. Ankush Bansal, consisted of
seven delegates from Austria, India,
Kuwait, the United Kingdom,
and the United States (Photo 1).
The WMA delegation worked closely
with the World Health Organization
(WHO), the Global Climate and
Health Alliance (GCHA), and other
non-governmental organisations
(NGOs), universities, and professions
in the greater healthcare community.
Their activities included daily
policy meetings among healthcare
professionals, researchers,
and trainees coordinated
by the GCHA across
multiple topic areas of
interest to healthcare
professionals. The
conference topic areas
included Loss and
Damage Fund (including
the Santiago Network
and Warsaw International
Mechanism), Global
Stocktake, Global Goal
on Adaptation, Just
Transition, Mitigation
Work Program, Long-
term Finance, Articles
(6.2 on Bilateral Trading,
6.4 on Carbon Markets,
6.8 on Non-market Approaches),
Gender and Climate, National
Adaptation Plans, Agenda for
Climate Empowerment (ACE),
World Medical Association’s Participation at COP28 Dubai
WMA’s Participation at COP28 in Dubai
Ankush K. Bansal
Lujain Alqodmani
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Muha Hassan
Johanna Schauer-Berg
Suryakanta Acharya
Mahesh Prasad Bhatt
Photo 1. The WMA delegation (Week 1) included Dr. Johanna Schauer-Berg,
Dr. Lujain Alqodmani, Dr. Ankush Bansal, and Dr. Muha Hassan (left to
right). Credit: WMA
39
Agriculture and Food Security,
Capacity Building, and Green
Climate Fund.
Health Day
The WMA delegates agreed that the
most notable development of COP28
was the initiation of the first themed
Health Day on 3 December 2023.
At the event opening, Dr. Tedros
Ghebreyesus, the WHO Director
General, emphasised that health is
the human face of climate change
and that the health workforce, as one
of the largest workforces worldwide,
have an important role to speak up for
a cleaner, healthier future.
TheHonourableDr.TerranceMichael
Drew, who serves as both the Prime
Minister and Minister of Health
of St. Kitts and Nevis, captured the
audience with his passionate speech.
As an active physician himself, he
highlighted the poignant reality that
nations, particularly small-island
developing states (SIDS), contribute
little to greenhouse gas emissions yet
bear a disproportionate burden of
health impacts due to climate change.
Additionally, he described the severe
disruptions to medical infrastructure
caused by extreme weather events,
including tropical storms and
hurricanes.
Ministerial High-Level Meeting
on Health
The second notable development
during COP28 was the first
Ministerial High-Level Meeting
on health at a COP. Dr. Lujain
Alqodmani, WMA President and
the only invited speaker representing
an NGO, gave an inspiring call to
action to the more than 49 Ministers
of Health and representatives to over
25 additional Ministries of Health
present at the meeting (Photo 2).
COP28 Health Declaration
Prior to the meeting, the WMA
endorsed an international declaration
calling on nations to apply the health
perspective when supporting rapid,
sustainable, equitable action on
climate change [1]. By the close of
COP28, approximately 143 nations
had signed this declaration, which
had increased to 146 nations by 1
February 2024 (Photo 3).
COP28 Food Systems Declaration
The COP28 UAE Declaration on
Sustainable Agriculture, Resilient
Food Systems, and Climate Action was
generated at COP28 and signed by
158 nations [2]. The tenets of this
declaration emphasise the urgency to
address food security and nutrition
with an equity lens, “in the face of
mounting hunger, malnutrition, and
economic stresses.”
Fossil Fuel Phase-out
Despite a GCHA co-sponsored
effort and analysis showing over
46 million healthcare professionals
worldwide standing for a fossil-fuel
phase-out, the consensus was for
transition with the goal of net zero
(not phase out) by 2050.This net zero
language included carbon capture and
storage for so-called “hard to abate”
sectors. The agreement also used gas
as a “transition”fuel, no agreement on
phase-out of coal, and no action on
limiting fossil fuel subsidies.
Photo 2. WMA president Dr. Lujain Alqodmani delivered a powerful speech at the High-Level Ministerial Meeting.
Credit: WMA
Photo 3. The WMA delegation (Week 1) included Dr.
Johanna Schauer-Berg, Dr. Ankush Bansal, and Dr. Muha
Hassan, with Dr. Maria Naira (WHO Director of the
Department of Public Health and Environment), after
the launch of the new Declaration on Climate and Health.
Credit: WMA
WMA’s Participation at COP28 in Dubai
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40
Loss and Damage
The COP28 started with a significant
early win on climate change.The Loss
and Damage (L&D) Fund, which
was launched on Day 1, intended
to compensate climate-vulnerable
nations. About US $700 million
were pledged by the UAE, Germany,
Japan, the European Union, the
United Kingdom, and the United
States. Although this is a small
amount needed for this pledge, it
nevertheless illustrates a start.
An additional US $1 billion was
pledged by a total of 41 non-state
actors on finance and implementation
on climate and health, including
The Global Fund, The Rockefeller
Foundation, Green Climate
Fund, Bloomberg Philanthropies,
Wellcome Trust, and Asian
Development Bank.
Finally, the Santiago Network,
the technical branch of L&D
negotiations operationalised during
COP28, will be hosted by the United
Nations Office for Disaster Risk
Reduction (UNDRR) and the United
Nations Office for Project Services
(UNOPS), with support from the
Pacific Development Bank.
Global Stocktake
The Global Stocktake (GST), a type
of accountability report on meeting
the metrics and deadlines of the
Paris Agreement, was discussed in
detail for the first time at a COP.
The agreement on GST incorporated
language on fossil fuels (see the Fossil
Fuels Phase-out section), including
tripling renewable energy by 2030,
doubling energy efficiency, reducing
methane emissions, greening the
transportation sector, stopping
deforestation, and reforming the
financial sector.
Global Goal on Adaptation
Althoughhealthisaprimetargetinthe
Global Goal on Adaptation (GGA)
agreement, there was no agreement
on indicators and targets or finance.
For healthcare, the importance of the
GGA is resilience against climate-
change health impacts, developing
climate-resilient health systems, and
reducing morbidity and mortality
from climate-change health impacts.
This topic will likely be discussed at
the Intersessional in June 2024.
Party Meetings
The WMA delegation met with
several national party delegations
during weeks 1 and 2 of COP28
(Photos 4-5).
Week 1
Dr. Muha Hassan met with
representatives from the Somali
delegation. First, Dr. Ali Haji Aden
(Minister of Health, Somalia)
pointed out the significant disruption
to health services and financial loss
that Somalia faces due to periods of
extreme weather events, fluctuating
from floods to droughts. He also
shared the need to focus efforts
towards adaptation and building
climate resilient systems. Second,
Mr. Hareed (National Ozone Unit
Coordinator, Somalia Ministry of
Environment) underscored Somalia’s
commitment to the Global Cooling
Pledge as an initiative that binds
countries to reduce their cooling-
related emissions by at least 68% by
2050. Additionally, he highlighted a
concerted effort to enhance research
capacity within hospitals, aiming to
collect vital data on the health impacts
of climate change.
Dr. Johanna Schauer-Berg met
with Dr. Stela Drucioc (Republic of
Moldova) to discuss the public health
benefits of implementing reporting
on co-benefits, especially air pollution
at a national level. Then, Dr. Ruperta
Lichtenecker (Director, Austrian
Competence Center for Climate and
Health) shared her experiences as
lead author for the Austrian strategy
for climate neutral health care.
Dr. Ankush Bansal met with Dr.
John Balbus (Director, U.S. Office of
Climate Change & Health Equity)
and Admiral (Dr.) Rachel Levine
(Assistant Secretary of Health, U.S.
Department of Health & Human
WMA’s Participation at COP28 in Dubai
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Photo 4. Dr. Mohammed Mohamud Derow and Dr. Ali
Haji Aden (Minister of Health, Somalia) with Dr. Muha
Hassan and Dr. Johanna Schauer-Berg (left to right).
Credit: WMA
Photo 5. Dr. Muha Hassan and Dr. Johanna Schauer-Berg
engaged in an extensive discussion on health aspects of the
negotiations with Mr. Matthias Knopper and Mrs. Ilonka
Horvat, representatives of the Austrian delegation. Credit:
WMA
41
Services, HHS) (Photos 6-7). They
keenly understood that climate
change is fundamentally a public
health issue. Since June 2022, they
have worked on health system
resiliency and decarbonisation in
the entire government health sector
and have shared best practices with
the private health sector through
the White House-HHS climate
sector pledge. The goal is 50% GHG
reduction by 2030 and net-zero by
2050, and thus far, 130 organisations
and900hospitalshavesignedontothis
pledge. They gave examples of three
large health systems in the United
States that have significantly reduced
carbon emissions and cut energy
expenses. These efforts are now
expanding globally through the
President’s Emergency Plan
for Adaptation and Resilience
(PREPARE) initiative, which
includes features of the landmark
United States legislation known as
the Inflation Reduction Act (IRA).
Additionally, the United States is
working with the United Kingdom
National Health Service (NHS)
on supply procurement to establish
global standards to reduce carbon
emissions. Although the United
States supported these efforts,without
commenting on L&D, leaders signed
both the climate change and food
systems declarations. Dr. Balbus’
key messages were that physicians
are the front-line in climate change
advocacy, which needs to be a priority
of physicians to their policymakers.
He also urged further research and
publication on the health effects
of climate change on individuals
and communities so that he and his
counterparts could use evidence to
effect change when engaging with
policymakers.
Week 2
Dr.Mahesh Bhatt and Dr.Suryakanta
Acharya had met official delegations
of several South Asian countries
including India to know their
perspectives on Climate Change and
Health.
Indian officials had spoken at length
about making a fine balance of
adaptation and mitigation strategies
to enable developing countries to
buy time for strict mitigation norms
(Photo 8). India had not signed
the Health Declaration because of
disagreements related to points on
strict mitigation norms.
The Sri Lanka delegation spoke
about the derailment of ‘Health and
Climate Change’ programs because
of economic meltdown due to the
unstable political situation (Photo
9). They had reiterated greater roles
of UN and other intergovernmental
agencies, NGOs, and civil societies
to help Health and Climate Change
programs back on track.
Bangladesh officials mentioned
several initiatives on renewable energy
transitions to reduce dependency on
fossil fuel. They are more focused
on adaptation strategies like climate
resilient agriculture to ensure food
security and climate resilient health
systems to lessen damage from global
climate change.
The Azerbaijan delegation fully
supported the adaptation and
WMA’s Participation at COP28 in Dubai
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Photo 6. Dr. Ankush Bansal with Admiral (Dr.) Rachel
Levine (Assistant Secretary of Health, U.S. Department of
Health & Human Services). Credit: WMA
Photo 7. Dr. Ankush Bansal and Menna Zayed (pharmacy
student from Egypt) with Dr. John Balbus (Director, U.S.
Office of Climate Change & Health Equity).
Credit: WMA
Photo 8. Dr. Mahesh Bhatt and Dr. Suryakanta Acharya
with Mr. Shard Sapra (Climate Change Scientist, Minis-
try of Environment, India). Credit: WMA
Photo 9. Dr. Mahesh Bhatt and Dr. Suryakanta Acharya
with members of the Sri Lankan delegation. Credit: WMA
42
mitigation strategies to combat
climate change, and notably, COP29
was later confirmed that it will be
held in Baku, Azerbaijan, from 11 to
22 November 2024 (Photo 10).
Analysis of Health Presence at
COP28
Led by Dr. Alqodmani, the WMA
delegation spearheaded an effort on
the presence of health delegates at
WMA. Our analysis determined
that 2.4% of the 81,039 delegates
at COP28 represented the health
sector, including 50 health ministers
participating in Health Day activities.
Presentations and Panels by WMA
Delegates
At this COP, the WMA delegation
was quite active in side events as
presenters or panellists.
Dr. Bansal first presented at the
Education Center in the Green
Zone on 3 December 2023, as part
of a panel hosted by YOUNGO and
entitled,Prescribing Change: Shaping a
Climate-Ready Healthcare Future.
He then served as a panellist on
a session hosted by both Harvard
University’s Tseng-Hsi (T.H.)
Chan School of Public Health and
François-Xavier Bagnoud (FXB)
Center for Health & Human Rights,
entitled, Linking Agendas on Climate
Change & Health at the UNFCCC
and World Health Assembly, at the
WHO Pavilion on 12 December
2023 [3]. Dr. Bansal discussed WMA
policies on climate change and health,
the WMA work at COP, and World
Health Assembly (WHA), and how
the WMA advocates for synergy and
action among the WMA, UNFCCC,
and WHA. Dr. Bansal also presented
a summary of the health issues from
climate change and some of the results
from COP28 to the Kenyan Medical
Association by virtual meeting on 15
December 2023, upon the request
of the Chair of the Kenya Medical
Association’s Planetary Health
Committee.
Dr.Hassan was invited to deliver a talk
on how digital health technologies
contribute to climate change
mitigation efforts and development of
climate resilient technologies in the
healthcare sector, as part of Digital
Health and Youth session hosted by
YOUNGO at the Climate Live
pavilion.
On 6 December 2023, Dr. Schauer-
Berg served as panellist for the
Linking Agendas of the UNFCCC and
the World Health Assembly in Latin
America and the Caribbean session.
The panel was kindly hosted at the
Guatemala Pavilion, on behalf of
the Independent Alliance of Latin
America and the Caribbean (AILAC)
and facilitated by the Harvard T.H.
Chan School of Public Health and
the Inter-American Institute for
Global Change Research (Photo 11).
Dr. Schauer-Berg highlighted
WMA’s advocacy action on climate
and health as well as the unique
position of physicians who are
clinical experts, directly connect with
their patients and communities, and
are keenly aware of their patients’
vulnerabilities. She emphasised that
physicians should therefore have a
seat on the global platform, especially
on the creation and implementation
of climate change preparedness plans,
emergency planning, and response
on local, national, and international
levels to achieve health in all policies.
WMA’s Participation at COP28 in Dubai
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Photo 10. Dr. Mahesh Bhatt and Dr. Suryakanta Acharya with members of the Azerbaijani delegation. Credit: WMA
Photo 11. Dr. Johanna Schauer-Berg (WMA) and fellow
panellists Dr. Maria Guevara (Médecins Sans Frontières),
Dr. Milena Sergeeva (Global Climate and Health Alli-
ance), Dr. Marco Vinicio Ochoa (Vice Minister, Natural
Resources and Climate, Guatemala), Dr. Andrea Hurtado
Epstein (Health Care Without Harm), and the session’s
facilitators Dr. Elizabeth Willets (Harvard T.H. Chan
School of Public Health) and Dr. Anna Stewart-Ibarra
(Inter-American Institute for Global Change Research) at
COP28 (left to right). Credit: WMA
43
Collaboration with Global Health
Community
The WMA delegation has
collaborated with physicians, nurses,
pharmacists, academics, students, and
scientists in the climate and health
space from around the world through
the GCHA and daily policy meetings.
The WMA delegation contributed to
these meetings, based on monitoring
of negotiation meetings, party
outreach, and analysis of health
presence at COP28 (Photo 12).
Future Direction and Strategy at
Subsequent COP Meetings
TheWMA delegation andWorkgroup
on Environment were disappointed
that their side event proposal at
the WHO Pavilion on health
system resiliency was not accepted.
Nevertheless, the delegation actively
participated in panels for side events
and attended numerous meetings,
high-level events, and monitored
topic negotiations. Additionally, the
delegation networked with other
academic, professional, and advocacy
organisations focused on health and
participated in daily policy meetings
through the GCHA.
In preparation for COP29 in Baku,
Azerbaijan, and COP30 in Belem,
Brazil, the WMA Workgroup on
Environment will discuss and plan for
side event proposals, pre-planning of
targeted party meetings towards the
goals and policies of the WMA with
respect to climate change and health,
and participation at the UNFCCC
intersessional and the WHA. It is
also recommended that interested
individuals representing national
medical associations should consider
participating as delegates at future
COP meetings.
A report will be presented at the
226th Council Session in Seoul,
Republic of Korea.
“The climate crisis is a health
crisis and a human rights crisis”
– David R. Boyd, U.N. Special Rapporteur
on Human Rights and the Environment
“Medicine is a social science,
and politics is nothing else
but medicine on a large scale.
Medicine, as a social science,
as the science of human beings,
has the obligation to point
out problems and to attempt
their theoretical solution.
The politician, the practical
anthropologist, must find the
means for their actual solution.
Physicians are the natural
attorneys of the poor, and social
problems fall to a large extent
within their jurisdiction.”
– Rudolf Virchow
Photo 12. Dr. Ankush Bansal, Dr. Johanna Schauer-Berg, and Dr. Muha Hassan with health professionals, as part of the Global Climate and Health Alliance (GCHA) at COP28. Credit:
WMA
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WMA’s Participation at COP28 in Dubai
44
References
1. World Health Organization.
COP28 UAE Declaration on
climate and health [Internet].
2023 [cited 2024 Feb 15]. Avail-
able from: https://www.who.int/
publications/m/item/cop28-uae-
declaration-on-climate-and-
health”https://www.who.int/
publications/m/item/cop28-uae-
declaration-on-climate-and-health
2. Conference of Parties (COP28).
COP28 UAE Declaration on Sus-
tainable Agriculture,Resilient Food
Systems, and Climate [Internet].
2023 [cited 2024 Feb 15]. Availa-
ble from: https://www.cop28.com/
en/food-and-agriculture”https://
www.cop28.com/en/food-and-ag-
riculture
3. World Health Organization.
COP28 Health Pavilion [Internet].
2023 [cited 2024 Feb 15].Available
from: https://www.who.int/news-
room/events/detail/2023/11/30/
default-calendar/cop28-health-pa-
vilion
Authors
Ankush K. Bansal,
MD, FACP, FACPM, SFHM,
DipABLM, MCFLC
Chair, Workgroup on Environment,
World Medical Association
WMA Delegation Co-Chair for COP28
Voluntary Clinical Assistant
Professor of Medicine, Herbert
Wertheim College of Medicine,
Florida International University
Loxahatchee, Florida, United States
dr.akb1@gmail.com
Lujain Alqodmani,
BMSc, MBBS, MIHMEP
President, World Medical Association
WMA Delegation Co-Chair for COP28
Director of Global Action and
Project Portfolio, EAT
Kuwait City, Kuwait
lujainalq@gmail.com
Muha Hassan, MBChB, BSc
Associate Member,
World Medical Association
Internal Medicine Trainee,
National Health Service
Coventry, United Kingdom
muha.hassan@outlook.com
Johanna Schauer-Berg, MD, MPH
Member, Workgroup on
Environment & Associate Member,
World Medical Association
Research Associate,
Institute of General Practice,
Family and Preventive Medicine
Salzburg, Austria
j.schauer-berg@posteo.de
Suryakanta Acharya, MD
Associate Member,
World Medical Association
Clinical Oncologist,
Assam Cancer Care Foundation
Lakhimpur, India
suryaoncology@gmail.com
Mahesh Prasad Bhatt, MD
Associate Member,
World Medical Association
CEO, MMBSHS Trust
Dehradun, Uttarakhand, India
mpmbhatt@gmail.com
WMA’s Participation at COP28 in Dubai
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45
As the global community recognises
the burden of emerging and
reemerging disease risks, especially of
zoonotic origin, health professionals
continue to leverage their clinical
knowledge and skills in patient care,
community health and education,
laboratory diagnostics, and policy
activities. Their leadership role is
crucial to identify innovative
approaches that can support health
service delivery (including times
of hospital surges), prevention
and control efforts for infectious
disease outbreaks, and accurate
health messaging to the public,
which was well demonstrated
during the coronavirus disease 2019
(COVID-19) pandemic.Even placing
their own health at risk at times, their
critical contributions to health service
delivery cannot be overlooked. The
emergence of the COVID-19
pandemic marked a wake-up call for
the global community to strengthen
health system preparedness and
support global health workforce
training [1]. However, it also raised
another issue on how national leaders
holistically define and conceptualise
“health security”, especially how it
relates to health system resilience,
multi sectoral collaborations, and
global partnerships [2].
The Global Health Security
Agenda (GHSA) (https://
globalhealthsecurityagenda.org/),
comprised of more than 70 nations,
non-governmental organisations,
and private companies, was formed
in February 2014, to promote the
International Health Regulations
(2005), which were adopted at the
58th World Health Assembly
(WHA) in 2005 and then
implemented at the 59th WHA
(Resolution WHA59.2) in 2006 [3,4].
These regulations help reinforce
infectious disease preparedness,
surveillance, and response efforts
related to cholera, plague, and yellow
fever [5]. The International Health
Regulations were originally adopted
in 1969, focusing on six infectious
diseases (cholera, plague, relapsing
fever, smallpox, typhus, yellow fever),
and subsequently amended to remove
smallpox (due to its eradication
efforts) in 1981. However, the global
community has observed multiple
outbreaks since 2014 – such as
Ebola in West Africa (2014-2016),
Middle East Respiratory Syndrome
in the Republic of Korea (2015),
Zika in the Americas (2015-2016)
– and more recently, the COVID-19
pandemic. GHSA leaders developed
nine GHSA Action Packages to
operate as working groups that
promote technical regional and
global collaborations to address
established objectives,on the topics of
antimicrobial resistance, biosecurity
and biosafety, immunisation,
laboratory systems,legal preparedness,
surveillance, sustainable financing for
preparedness,workforce development,
and zoonotic disease [6].
Strengthening Global Health Security Dialogue at the
74th WMA General Assembly in Kigali, Rwanda
Damas Dukundane
Helena Chapman
John Baptist Nkuranga
David Ntirushwa
Emmanuel Rudakemwa
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Strengthening Global Health Security Dialogue at the 74th WMA General Assembly
46
The GHSA’s mandate was renewed
until 2024, based on consensus from
the 2015 Seoul Declaration and
2017 Kampala Declaration, and for
a third time until 2028, based on
the 2022 New Seoul Declaration
[7]. The GHSA 2024 Framework
serves to guide leaders in achieving
the established goals (2019-2024),
as they prioritise sustainable
national and global collaborations
to improve health system resilience
(including health service delivery)
to combat emerging health threats
[8]. Embraced by the World Health
Organization (WHO) and countries
like Rwanda, health systems can
surveillance, resource preparation
and mobilisation, and prevention and
response measures that strengthen
capacity, reduce health expenditure
and related financial burden, and
permit continued essential health
service delivery in parallel to the
concurrent health priorities (e.g.
non-communicable diseases) or
emergencies (e.g. pandemic response,
natural disasters).
As part of the 74th World Medical
Association (WMA) General
Assembly, the Rwanda Medical
Association (RMA) Organising
Committee coordinated the Global
Health Security scientific session on
5 October 2023 in Kigali, Rwanda.
This session aimed to raise awareness
and elicit discussion on the current
state of global health security across
nations, existing knowledge and
practice gaps that hinder reinforcing
security efforts, and innovative
solutions to help prepare countries
to mitigate risk of emerging and
reemerging One Health (human-
animal-environmental nexus) risks
[9]. The Opening Session provided
an opportunity to learn about high-
level efforts to improve global health
security from esteemed leaders from
the Rwanda Ministry of Health and
WHO Office in Rwanda (Photo
1). Then, experts offered their
insight and perspectives related to
enhancing global health security
in three scientific sessions, entitled,
Leaving No One Behind: Together
to Fulfill the Global Health Security
Mandate (Session 1), Walking towards
Sustainable Global Networking Era in
Fighting Emerging Pandemics (Session
2), and Sustainable Global Health
Security: The Role of Multinationals
and Biotechnology Firms (Session
3). Finally, the RMA Scientific
Committee moderated a high-level
discussion on the role of national
medical associations in delivering
on the GHSA 2024 Framework and
concluded with a session summary
and recommendations for the
collective WMA call to action.
Opening Session
As part of the Opening Session,
Dr. John Baptist Nkuranga (RMA
President-Elect, currently RMA
President) welcomed the WMA
members to the WMA 74th General
Assembly and introduced the invited
speakers to offer their perspectives
related to national and global health
security (Photo 2). First, Dr. Osahon
Enabulele (WMA President,
currently WMA Past President)
and Dr. David Ntirushwa (RMA
President, currently RMA Immediate
Past President) provided welcome
remarks to health leaders representing
more than 60 countries. They
reminded the audience of the team
consensus to select the Global Health
Security theme for this scientific
session, due to the urgent need to
discuss the observed achievements,
challenges, and lessons learned by
countries during the COVID-19
response efforts. Dr. Ntirushwa noted
that the diverse representation of
WMA countries at this event offered
a valuable opportunity for networking
and sharing knowledge and
experiences related to global health
security, emphasising that collective
responsibility lies beyond one nation.
Dr. Yvan Butera (State Minister,
Ministry of Health of Rwanda)
shared a novel perspective on how
the redesign of health systems can
help nations improve health security,
including the GHSA 2024 Framework
and targets of the Sustainable
Development Goals (SDGs). He
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Strengthening Global Health Security Dialogue at the 74th WMA General Assembly
Photo 1. Leaders from the World Medical Association, Rwanda Medical Association, Rwanda Ministry of Health, and
World Health Organization Office in Rwanda. Credit: WMA
47
commented that ensuring political
commitment to invest in specialised
health services can prioritise
prevention and population health
[10]. In a recent interview for the
2023 TIME100 Africa Summit, he
emphasised a similar sentiment that
“The wellbeing of people is central to the
wellbeing of a country” [11].
Dr. Brian Chirombo (WHO
Representative to Rwanda) provided
the keynote presentation, defining
health priorities and illustrating
health system achievements over the
past decade, including lessons learned
during the COVID-19 pandemic.He
commented on how Rwanda’s health
leaders have developed multi-sectoral
partnershipswithinlocalcommunities
as well as across the nation and
region. He agreed that the GHSA
2024 Framework can guide national
health systems to combat emerging
health risks to population health.
As he joined the WHO Office in
Rwanda in 2021,after leaving his post
in South Africa, he enthusiastically
shared his commitment to his new
leadership position: “As a secretariat
to the Ministry of Health, it is our
mandate to accompany the Government
in its journey towards achieving a
stronger health care system which can
meet the growing demand for quality
health care and the changing health
needs of the population” [12].
Session 1: Leaving No One Behind:
TogethertoFulfiltheGlobalHealth
Security Mandate
“The true measure of a society’s
progress is how it responds to
health emergencies and ensures the
health and safety of its citizens”
– Dr.Tedros Adhnom Ghebreyesus,
WHO Director-General
In the first session, panellists
provided diverse perspectives on the
value of incorporating stakeholders
at the community, national, and
regional levels into the global health
dialogue, in order to fulfil the GHSA
mandate (Photo 3). Dr. Kayitesi
Kayitenkore (RMA Inaugural
President) moderated the session,
reiterating the importance of the
global commitment to “leave no one
behind” and the “endeavour to reach
the furthest behind first” toward
achieving the targets of the 2030
Agenda for Sustainable Development.
He reminded participants that as the
world continues to recover from
the direct and indirect effects
of the COVID-19 pandemic,
coupled with climate change, it
is important to identify the most
vulnerable populations (e.g. extreme
poverty, marginalised) who are
disproportionately affected.
Dr. Nathalie Umutoni (Director
of Operation, Center for Impact,
Innovation and Capacity Building
for Health Information Systems
and Nutrition, CIICHIN SEEK-
IN) addressed the role of research in
anticipating, preventing, and timely
responding to global health threats.
She commented that epidemiological
research using geospatial data can
offer real-time maps to decision-
makers, helping communities and
countries identify the location of
harmful exposures or risks and assess
the progress of targeted interventions
in a proactive (vs reactive) manner.
She highlighted the challenges of
limited research capacity in some
low- and middle-income countries,
especially noting limited available
funding, few specialised research
training programs, weak regulatory
systems, and disconnected links
between research, policies, and action.
Ms. Bunmi Femi-Oyekan (Cluster
Regulatory Lead,Sub-Saharan Africa
of Pfizer’s International Regulatory
SciencesandPolicies)highlightedthat
the role of medical regulatory systems
(e.g. national regulatory agencies) is
key to maintaining well-functioning
health systems with the oversight
of laws, rules, and policies to ensure
that pharmaceutical products (e.g.
medicines,vaccines) are safe,effective,
and fulfil quality specifications.
She emphasised that universal
access to quality pharmaceutical
products, guaranteed through strong
national and international regulatory
mechanisms, can help mitigate the
impact of infectious disease outbreaks
on population health. With multiple
challenges – such as fragmented
regulatory systems, absent or
ineffective frameworks where good
reliance practices are poorly utilised,
gaps in digital infrastructure, and
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Strengthening Global Health Security Dialogue at the 74th WMA General Assembly
Photo 2. Panellists of the Opening Session of the Scientific Program with WMA participants. Credit: WMA
48
lengthy bureaucratic processes – the
African Medicines Agency (https://
www.nepad.org/microsite/african-
medicines-agency-ama) is working
to accelerate access through the
adoption of regulatory best practices,
harmonisation of regulatory standards
on a continental level, alignment with
international standards and practices,
and capacity building across the
initiatives.
Ms. Maggie Rarieya (Global
Partnerships Director, African
Medical and Research Foundation,
AMREF Health Africa) recognised
the key role of the prepared health
workforce in supporting epidemic
and pandemic preparedness and
capabilities at the national and global
levels. These frontline defenders
represent the backbone of global
health security, crucial in efforts to
improve national capacity to predict,
prevent, detect, and effectively
respond to infectious diseases and
other emerging threats. Specific
tasks include surveillance and early
detection, effective management
of vaccination and immunisation
programs, infection prevention and
control, contact tracing quarantine
measures, risk communication, and
public education, which serve as
cornerstones to resilient and strong
health systems that ensure better
preparedness for future global health
threats.
Session 2: Walking towards
Sustainable Global Networking Era
in Fighting Emerging Pandemics
“To raise new questions, new
possibilities, to regard old problems
from a new angle, requires
creative imagination and marks
real advance in science”
– Albert Einstein
In the second session, panellists
shared their unique experiences and
perspectives in medical, veterinary,
and Earth sciences related to applying
innovative approaches and expanding
global networks to promptly combat
emerging health risks affecting
global communities (Photo 4). Dr.
Eustache Penniecook (Founding
Dean, Adventist University of
Central Africa’s School of Medicine)
moderated the session, requesting
that WMA members reflect upon the
cutting-edge technologies ranging
from vaccine production to research
sharing as well as tailor their analyses
to how leveraging expertise across
disciplines can revolutionise scientific
inquiry and discovery and ultimately
enhance national and global health
security.
Dr. Helena Chapman (Earth Action
Program, U.S. National Aeronautics
and Space Administration and Booz
Allen Hamilton) described the One
Health concept and One Health Joint
Plan of Action (2022-2026), which
builds upon the Resolution WHA74.7
(Strengthening WHO preparedness
for and response to health emergencies),
to help refine how nations can
prevent, predict, detect, and respond
to emerging and re-emerging health
threats related to the human-animal-
environment nexus [13,14]. She
commented that the implementation
of this action plan should be guided by
cooperation and shared responsibility,
multisectoral action and partnership,
gender equality, and inclusiveness
and equality. By highlighting two
urgent health challenges – harnessing
new technologies and building
public trust – she illustrated concrete
examples of how health professionals
can incorporate Earth observation
data into public health surveillance
to develop operational tools to
identify disease or hazard hotspots
and mitigate risk of exposure (e.g.
cholera or malaria disease forecasting,
air quality monitoring) [15]. She
encouraged WMA members to
leverage their expertise and join
communities of practice – like the
Group on Earth Observations (GEO)
Health Community of Practice
(https://www.geohealthcop.org/) –
where they can form multidisciplinary
partnerships, enhance community
engagement, and support capacity
training on cross-cutting scientific
topics.
Professor Musso Munyeme (School
of Veterinary Medicine, University
of Zambia) stressed that as the
majority of novel emerging infectious
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Strengthening Global Health Security Dialogue at the 74th WMA General Assembly
Photo 3. Panellists of Session 1 of the Scientific Program. Credit: WMA
49
diseases are of zoonotic origin with
anthropological drivers (e.g. land use
changes due to rapid urbanisation,
agriculture intensification,
international travel,trade),controlling
future pandemics will require
multisectoral and multidisciplinary
collaborations to streamline a robust
response. As he highlighted the
recent formation of the Quadripartite
organisations – WHO, Food and
Agriculture Organization of the
United Nations (FAO), United
Nations Environment Programme
(UNEP), World Organisation for
Animal Health (WOAH) – to
incorporate the One Health approach
into global policies, noting the need
to balance the diversity of stakeholder
and sector representation in global
health collaborations [16]. As
Chair of the PREZODE Steering
Committee, he described the aim to
prevent zoonotic pandemic outbreaks
by ensuring sustainability of solutions
based on One Health principles
through five pillars – understanding
zoonotic risks and activities, co-
designing solutions to reduce
zoonotic risks, strengthening early
warning systems to detect zoonotic
risks, forming a prototype of a global
information system for surveillance
and early detection, and engaging
stakeholders in One Health networks
and policies (https://prezode.org/).
Professor Sir Ian Gilmore (President,
British Medical Association)
underscored the reality of how the
COVID-19 pandemic left substantial
direct impacts on mental health as
well as the indirect harm (collateral
damage). As pandemic-related
social isolation, fear of infection, and
financial insecurity contributed to
increased levels of anxiety, depression,
and stress in society, simultaneous
disruption of substance use treatment
services hindered coping mechanisms.
With the 40% increase of the global
burden of alcohol use disorders since
1990, he reported that there was a
US $3.3 billion increase in alcohol
sales (27% increase between 2019-
2022) in Australia.He concluded that
evidence-based policy interventions
should limit the negative impact of
excessive alcohol consumption within
society,to prioritise mental health and
well-being across global communities,
especially among vulnerable and
disadvantaged communities that
experience health inequalities and
increased risk of addiction.
Session 3: Sustainable Global
Health Security: The Role of
Multinationals and Biotechnology
Firms
“We have made important progress,
but we still have a long path to
travel to improve the way that
multilateral organizations work
together to support countries. We
must listen to what countries tell
us and act upon their guidance.”
– Dr.Tedros Adhanom Ghebreyesus,
WHO Director-General
In the third session, panellists offered
concrete examples of national and
international health initiatives that
help identify research gaps and
facilitate the development of relevant
policies and timely partnerships
(Photo 5). Dr. Faustin Ntirenganya
(Associate Professor of Surgery,
University of Rwanda’s College
of Medicine and Health Sciences;
Director, NIHR Research Hub on
GlobalSurgeryinRwanda)moderated
the session, demonstrating that goal-
oriented and focused partnerships
have improved the research capacity
in surgical disciplines across Rwanda.
Ms. Fatima Abba (Pandemic
Preparedness and Response
Advocacy, Bill & Gates Foundation)
commented on the Gates
Foundation’s financial commitment
early on in the COVID-19 pandemic
– US $5 million by January 2020, US
$100 million by February 2020, and
US $250 million by April 2020 – for
a total of more than US $2 billion
by January 2022. She underscored
emerging threats (including chemical,
biological or nuclear hazards), and
how climate change, urbanisation,
deforestation, and heightened travel
and trade could exacerbate these risks
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Strengthening Global Health Security Dialogue at the 74th WMA General Assembly
Photo 4. Panellists of Session 2 of the Scientific Program. Credit: WMA
50
and contribute to the rapid spread
of novel pathogens. She opened
a call for collaboration on three
key priority areas: 1) accelerating
outbreak detection up to the minute;
2) developing new diagnostic,
treatments, and vaccine technologies
which can take years even decades;
and 3) advancing equitable access.
Dr. Emile Rwamairabo (Professor of
Urology, Vice President of Rwanda
Agency for Accreditation and Quality
Healthcare) presented how ensuring
healthcare quality and safety during
pandemics is challenging, often
leading to compromises in established
protocols. As the COVID-19
pandemic exemplified the critical
need to maintain essential health
services,hecommentedthatRwanda’s
response showcased a multifaceted
approach, where leaders implemented
robust testing and contact tracing
alongside the continuous delivery of
routine healthcare services. Notably,
Rwanda health authorities and
community leaders implemented
Operation Save the Neighbor, a home-
based care system designed to alleviate
the burden of the hospital surge and
prioritise the protection of health
professionals in their frontline role
through medical (including personal
protection equipment) supplies,
training, and mental health support.
Looking forward, he commented
that building resilient health systems
requires the evaluation of systemic
limitations, including infrastructure,
workforce training, and international
collaborations, as well as community
engagement, technological
integration, and adaptable healthcare
policies for future pandemic
preparedness.
Dr. Otmar Kloiber (WMA Secretary
General) presented an overview
of the consensus framework for
the ethical collaborations between
patients’ organisations, healthcare
professionals and the pharmaceutical
industry, which was adopted in
2014 [17]. He shared four guiding
principles – prioritising patients,
supporting ethical research and
innovation, ensuring independence
and ethical conduct, and promoting
transparency and accountability
– as a consensus between five
organisations (WMA; International
Federation of Pharmaceutical
Manufacturers and Associations,
IFPMA; International Association
of Patients Associations, IAPO;
International Council of Nurses,
ICH; International Pharmaceutical
Federation, FIP). After he shared the
underlying WMA policies (WMA
Declaration of Helsinki in 2013 and
WMA Statement concerning the
Relationships between Physicians and
Commercial Enterprises in 2009),
he encouraged national medical
associations to adapt this consensus
framework for their own policy and
cooperation models [18,19].
Recommendations
Led by the RMA Organising
Committee, the scientific session
offered an open platform to showcase
high-quality presentations by global
experts that presented diverse
perspectives of national and global
health security. Each themed session
illustrated how WMA members and
other global physicians can streamline
their efforts to identify emerging risks
to public health, explore innovative
approaches to mitigate harmful
risks, and ultimately reinforce global
health security across nations. The
team captured key summary points
after each themed session and
identified four salient themes where
the global medical community can
take immediate measures to support
global health security.
First, the medical community can
lead efforts to strengthen global
collaborations that advocate for
increased engagement among nations,
international organisations, and
health institutions, to enhance the
collective preparedness and response
actions. One fundamental step
should integrate knowledge sharing,
joint research applications, and
coordinated health system efforts to
combat emerging pandemics. Second,
the adoption of a comprehensive One
Health approach and alignment of
national plans with the One Health
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Strengthening Global Health Security Dialogue at the 74th WMA General Assembly
Photo 5. Panellists of Session 3 of the Scientific Program. Credit: WMA
51
Joint Plan of Action (2022-2026), will
be essential to simultaneously address
emerging health threats affecting
the delicate balance of humans,
animals, and the environment. By
embracing cross-cutting scientific
tools and technologies, including
remote sensing and geospatial data
applications, health professionals
can contribute their expertise to the
development of operational tools
that can provide real-time risk maps
of hotspots of harmful exposures or
pathogens to improve health decision-
making activities across communities.
Third, by ensuring sustainable
pandemic preparedness, the global
community can encourage the
development and adoption of
sustainable approaches that prepare
leaders to manage endemic and
epidemic scenarios as well as recognise
the potential collateral impacts within
society. It will be crucial to promote
long-term planning, resource
allocation, and response mechanisms,
while ensuring ethical collaborations
and adherence to high-quality safety
standards for patient care during
health crises. Finally, investments in
epidemic intelligence, preparedness,
and response, coupled with
public-private sector engagement
(including biotechnology firms
and philanthropic organisations),
can expand professional networks
between health and business sectors
that leverage expertise and foster
innovation across complex challenges
affecting the health and safety of
global communities.
Conclusion
As the RMA Organising Committee
successfully hosted the 74th WMA
General Assembly, it demonstrated
that African medical associations are
critical players in contributing their
scientific expertise and expanding
regional networks and partnerships
toward reshaping a responsive global
health systems (Photo 6). Notably,
the leadership team represented the
African Francophone region, with
knowledge of national and regional
health priorities (including strengths
and limitations), and engaged with
key clinicians, scientists, researchers,
and policy-makers to support
evidence-based policy interventions.
The agenda focused on addressing
key elements that affect global health
security, including the inclusion
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Strengthening Global Health Security Dialogue at the 74th WMA General Assembly
Photo 6. Delegates of the 74th WMA General Assembly in Kigali, Rwanda. Credit: WMA
52
of all stakeholders to achieve the
GHSA mandate, global networking
to combat emerging health risks, and
the participatory role of multinational
organisations and biotechnology
firms. By strengthening global
collaborations, promoting a
comprehensive One Health approach,
ensuring sustainable pandemic
preparedness, and investing in
epidemic intelligence, preparedness,
and response, our global community
can be one step ahead of the next
pandemic.
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Acknowledgments
The authors appreciate the dedicated
efforts of the Rwanda Medical
Association’s Organising Committee
to coordinate a comprehensive
scientific session focused on global
health security. They also express
their gratitude and appreciation
to national and global institutions,
which were represented by
exceptional speakers and
moderators who facilitated the
collective dialogue of this scientific
event, including the Ministry of
Health Rwanda, World Health
Organization (WHO), Rwanda
Biomedical Center (RBC),
National Aeronautics and Space
Administration (NASA), Bill &
Melinda Gates Foundation, Centre
for Impact, Innovation and Capacity
building for Health Information
Systems and Nutrition (CIICHIN
SEEK-IN), African Medical and
Research Foundation (AMREF
Health Africa), World Medical
Association (WMA), Rwanda
Medical Association (RMA),
British Medical Association (BMA),
University of Rwanda, University
of Global Health Equity, Adventist
University of Central Africa,
University of Zambia, and Rwanda
Agency for Accreditation and Quality
Healthcare.
Authors
Damas Dukundane, MD
Head of Department of Internal
Medicine, King Faisal Hospital
President, Rwanda
College of Physicians
Organising Committee, 74th
WMA General Assembly
Kigali, Rwanda
damas.dukundane@kfhkigali.com
Helena Chapman, MD, MPH, PhD
Earth Action Program, Earth
Science Division, NASA Headquarters
Washington, DC
& Booz Allen Hamilton
McLean, Virginia
United States
helena.chapman@nasa.gov
John Baptist Nkuranga, MD, MMASc
Senior Consultant, Pediatrician/
Neonatologist, King Faisal Hospital
Senior Lecturer, University of Rwanda
President, Rwanda Medical Association
nkuranga.baptist@gmail.com
David Ntirushwa, MD
Senior Consultant, Obstetrics &
Gynecology, University Teaching
Hospital of Kigali (CHUK)
Immediate Past President,
Rwanda Medical Association
Kigali, Rwanda
dagrain002@gmail.com
Prof. Emmanuel Rudakemwa, MD
Chief Consultant Radiologist,
Rwanda Military Hospital
Organising Committee & Lead, Global
Health Security Scientific Committee,
74th WMA General Assembly
Kigali, Rwanda
erudakemwa@gmail.com
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Strengthening Global Health Security Dialogue at the 74th WMA General Assembly
54
Dear Colleagues,
On behalf of the Organising Committee, we cordially
invite all World Medical Association (WMA) members
and relevant guests to attend the Research with Vulnerable
People conference at the State Chamber of Physicians of
Bavaria (Mühlbauerstrasse 16,81677) in Munich,Germany,
from 14-15 May 2024.
Co-organisedbytheGermanNationalAcademyofSciences
(Leopoldina) and the German Medical Association
(GMA),in collaboration with the WMA and the American
Medical Association (AMA), and with kind support from
the State Chamber of Physicians of Bavaria, this targeted
interdisciplinary discussion will gather leading experts on
the ethics of research involving human subjects to explore
and analyse the concept of vulnerability in different research
settings.
Comprehensive Program
The meeting, which will be held in-person and in English,
aims to contribute valuable input from multiple experts
in medical ethics to the ongoing revision of the WMA,
Declaration of Helsinki (https://www.wma.net/what-we-
do/medical-ethics/declaration-of-helsinki/). Specifically,
the discussion will focus on the comprehensive review of
vulnerable groups, including children, the elderly, pregnant
people, and people with disabilities, in this landmark
document.
For this scientific event, the following speakers will share
their insight for collective analysis and discussion:
Samia Hurst, Director of the Institute for Ethics, History,
and the Humanities, University of Geneva, Switzerland
Pierre Mermet-Bouvier, Senior Manager of eCOA,ICON,
France
Rieke van der Graaf, Department of Global Public Health
& Bioethics, UMC Utrecht, Netherlands
Florencia Luna, Principal Researcher at the Facultad
Latinoamericana de Ciencias Sociales (FLACSO) and
Consejo Nacional de Investigaciones Científicas y Técnicas
(CONICET), Argentina
Hilary Marston, Chief Medical Officer of the Food and
Drug Administration (FDA), United States
Olaf Witt, University Hospital Heidelberg, Germany
Adam C. Berger, Director of the Division of Clinical and
Healthcare Research Policy, National Institutes of Health
(NIH), United States
Alex John London, Director of the Center for Ethics and
Policy, Carnegie Mellon University, United States
Jack Resneck,MD,Chair of WMA Declaration of Helsinki
Workgroup, AMA immediate past president
Urban Wiesing, MD, PhD, Chair of Leopoldina
Workgroup on vulnerable groups
Mohammed Ghaly, Professor of Islam and Biomedical
Ethics at the Research Center for Islamic Legislation &
Ethics (CILE) at the College of Islamic Studies, Qatar
Registration Information
We encourage all WMA members and relevant guests
to register for this in-person event (in English) by using
the following link (https://www.leopoldina.org/en/form/
registration-conference-research-with-vulnerable-people/).
Registration is free of charge and includes two lunches, two
dinners, and a tour of Munich.
Please mark your calendar for 14-15 March 2024, and join
us in Munich for this important discussion on the ethics of
research involving vulnerable populations.
German Medical Association
Berlin, Germany
international@baek.de
Research with Vulnerable People: A Targeted
Interdisciplinary Discussion within the Scope of
the WMA Declaration of Helsinki Revision
Research with Vulnerable People Conference
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