WMJ_2023_04_final

Official Journal of The World Medical Association, Inc. Nr. 4, December 2023
vol. 69
Contents
Editorial   3
Valedictory Speech by the WMA President, Dr. Osahon Enabulele 4
Inaugural Address by the WMA President, Dr. Lujain Alqodmani 9
The 224th Council Session: A Glimpse into Global Medical Governance 12
WMA Declaration of Washington on Biological Weapons 16
WMA Declaration on the Ethical Use of Medical Technology   18
WMA Statement in Times of Armed Conflict and Other Situations of Violence 19
WMA Statement on Forced or Coerced Sterilisation 21
WMA Statement on Human Health as a Primary Policy Focus for Governments Worldwide 22
WMA Statement on International Medical Meetings 22
WMA Statement on Medical Ethics During Public Health Emergencies 23
WMA Statement on Natural Variations of Human Sexuality 25
WMA Statement on Primary Health Care 27
WMA Statement on Electronic Cigarettes and Other Electronic Nicotine Delivery Systems 29
WMA Resolution Condemning the Violence Against Physicians in Nepal   30
WMA Resolution for an Immediate Ceasefire in Sudan and the Protection of Health Care 31
WMA Resolution in Support of the Medical Associations in Latin America and the Caribbean 31
WMA Resolution on Acknowledgement and Condemnation of the Human Rights
Violations Against the Uyghurs and Other Minorities in China   32
WMA Resolution on Anti-LGBTQ Legislation in Uganda 33
WMA Resolution on Human Rights Demonstrations in Iran 34
WMA Resolution on Medical Workforce 34
Update on the Revision of the WMA Declaration of Helsinki 37
Interview with the WMA President 38
A Few Words about WMA Associate Membership 42
Forming a Transdisciplinary Research Network to Address Diseases and their Syndemics 44
The Road to the Antimicrobial Resistance High-Level Meeting 2024 51
Advocating for Change: Junior Doctors’ Role in Global Antimicrobial Resistance Initiatives  56
WMA Members Contribute Insight on Global Efforts to Combat Antimicrobial Resistance 58
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
Over the past 12 months, our global medical community has
successfully led numerous robust clinical and public health
initiatives and contributed to timely research collaborations,
which have reinforced community stakeholder engagement with
decision-makersandthepublic.Thesemilestoneshavebeenwidely
recognised across the World Medical Association (WMA) and
other professional medical societies, resulting in the preparation
and revision of declarations (e.g.biological weapons,ethical use of
medical technology), statements (e.g. e-cigarettes, primary health
care), press releases (e.g. physicians’ rights), and resolutions (e.g.
human rights,workplace violence).Notably,these judicious efforts
underscore the need for multidisciplinary collaborations to closely
examine complex global challenges, driven by identifying disease
or toxic hotspots and vulnerable populations, fostering networks
and communicating with relevant stakeholders,and implementing
ethical interventions to protect population health. For example,
the WMA Resolution on Collaboration between Human
and Veterinary Medicine highlights the One Health concept
and describes ongoing collaborations with the World Health
Professions Alliance and the World Veterinary Association.
Recently, WMA members have participated in several global
meetings – including the UN General Assembly (UNGA78)
(5-19 September), Group on Earth Observations (GEO)
Ministerial Summit (6-10 November), and UN Climate
Change Conference (Conference of the Parties, COP28) (30
November–12 December) – which aimed to raise awareness
of urgent global health challenges (like climate change) and
reestablish solidarity to reaching the ambitious targets of the 2030
Agenda for Sustainable Development. Simultaneously, national
medical associations (NMAs) have coordinated activities related
to three global events – One Health Day (3 November), World
Antimicrobial Resistance (AMR) Awareness Week (18-24
November),and World AIDS Day (1 December) – which offered
a platform to share research findings and clinical updates,identify
existing challenges, expand collaborative networks, and ensure
best practices and interventions to mitigate risk to population
health. Notably, these WMA and NMA contributions can
leverage clinical expertise to advance science, streamline health
service delivery, support national health objectives, and ultimately
strengthen global health security.
With special recognition to the Rwanda Medical Association,the
74th WMA General Assembly was held in Kigali, Rwanda, from
4-7 October 2023. At the event, WMA members contributed
to important discussions on WMA statements and resolutions,
learned from invited speakers on global health security topics,
and connected with other NMAs and WMA members. Now, we
eagerly await the 226th WMA Council Session, which will be
held in Seoul, Korea, from 18-20 April 2024.
We are honoured to share this issue of the World Medical Journal,
which presents the opportune adoption of WMA declarations,
statements,and resolutions on topics,ranging from promoting the
ethical use of medical technology to condemning violence against
physicians, at the 224th WMA Council Session. In this issue,
Ms. Magda Mihaila summarised the event proceedings, and Dr.
Osahon Enabulele and Dr. Lujain Alqodmani offered energising
speeches on WMA milestones. In an interview, Dr. Alqodmani
expressed her viewpoints on global challenges within the medical
community, shared upcoming WMA activities, and described the
UN Decade of Action on Nutrition (2016-2025).The American
Medical Association provided an update on the revision of the
WMA Declaration of Helsinki.Dr.Jacques de Haller encouraged
WMA members to join the WMA Associate Membership. Dr.
Dennis Pérez Chacón and colleagues highlighted the inaugural
meeting of the Transdisciplinary Research Network that aims to
address diseases and their syndemics.
To support the World AMR Awareness Week 2023,three articles
were specifically focused on global efforts to combat AMR. First,
Dr. Pablo Estrella Porter, Dr. Caline Mattar, and Dr. Helena
Chapman described the emerging threat of AMR and the
upcoming 2024 UN High-Level Meeting on AMR. Second, Dr.
Pablo Estrella Porter stressed the important role of junior doctors
in the development and implementation of AMR initiatives.
Finally, WMA members representing 20 countries from diverse
geographic regions shared past and current policies as well as
community activities that support World AMR Awareness Week
2023 and promote antimicrobial stewardship across human,
animal, and agricultural sectors.
As we finalise the year, WMA members are reminded of our
priceless role in leading clinical management, supporting
community engagement, and contributing to robust collaborative
research initiatives. Helen Keller expressed the value of these
collective opportunities: “We live by each other and for each
other.Alone we can do so little; together we can do so much.”Our
expertise can help build upon the scientific literature to mitigate
risk of emerging global health risks and protect community health
and well-being. We wish you and your families a healthy and
reflective holiday season, and we look forward to connecting at
the 226th WMA Council Meeting in Seoul!
Helena Chapman, MD, MPH, PhD
Editor in Chief of the World Medical Journal
editor-in-chief@wma.net
4
Your Excellencies, Honoured Guests,
The President-elect, Immediate
Past President, Council Chair, the
Secretary General,Council Members,
and Members of the World Medical
Association (WMA),The President
of the Nigerian Medical Association,
Dr. Uche Rowland Ojinmah, My
lovely wife,Asso.Prof.Joan Enabulele,
my Children, Efosa Enabulele,
Omorovbiye Enabulele, and
Osarumwense Enabulele,Dr. Patrick
Okundia, Former Commissioner for
Health, Edo State, and family. Dr.
and Dr. (Mrs.) Ofunre Eboreime,
Colleagues, Friends, Distinguished
Ladies and Gentlemen.
So soon, I am here again on this
rostrum, but this time not to deliver
an inaugural presidential address, but
a valedictory presidential address.
But before I proceed further, I wish
to heartily welcome everyone to this
auspicious ceremonial session of the
74th WMA General Assembly.
I congratulate the Rwanda Medical
Association (RMA) for courageously
hosting this Assembly.
As one who encouraged and
supported the RMA to bid for the
hosting of this General Assembly,
I feel very proud of them for their
excellent hosting of the Assembly.On
behalf of the WMA, I say thank you.
In some minutes from now, I shall be
handing over the reins of the WMA
presidential office, along with this
presidential medallion (and all the
WMA regional spirits surrounding
it) to a worthy successor, Dr. Lujain
Alqodmani.
When I informed some of my
colleagues and my fellow country
men and women that my presidential
hand over was at hand, many drew
back in consternation, and asked
why the tenure was so short. In my
response to them, I told them that it
may have appeared so short because
of the fact that my one-year tenure
was characterised by engagements
and activities that were undertaken at
a frenetic pace. I had to console them
with the common saying that it is not
how long or short a tenure is, but
how well the tenure was put to use.
When two years ago,in 2021,I sought
your collective democratic mandate
to serve you as President of WMA,
I had no illusions that we could
address all the issues and resolve all
the challenges facing the WMA and
health systems, globally, in just one
year.
In my inaugural presidential address,
I had pledged to make great efforts
to consolidate upon the work
of my predecessor in office, Dr.
Heidi Stensmyren, and to work
collaboratively with other leaders
and members of WMA, to propel a
progressive leadership that undertakes
initiatives and actions that will
enhance the visibility and fortunes of
WMA.
In line with my pledge, we truly
consolidated upon our previous gains,
and advanced initiatives that have
transformed the WMA into a more
visible organisation that resonates
positively in international circles,
in the minds of her constituent
members, and individual physicians
around the world.
Importantly,wewereabletoundertake
the following, amongst others:
1) Intense Public Advocacy for
Universal Health Coverage,
Resilient Health Care Systems, and
Resilient Health Workforce
In realisation of the great need to
reposition health care systems in a
post-COVID-19 era, we intensified
our advocacy efforts for the building
of more resilient health care
systems with a robust Physician-led
multidisciplinary primary healthcare
system, improved commitment to
Universal Health Coverage, “One
Health,” and greater investments in
the well-being, working conditions,
security and safety of the Human
Resource for Health.
While we note some gains from our
advocacy efforts, we nevertheless
admit that health disparities and
inequities still exist across the world.
It is therefore imperative that we
sustain our advocacy efforts.
It is also imperative that the
resolutions of the 76th World
Health Assembly and the recently
held United Nations (UN) High-
Level Meetings on Universal Health
Coverage and Pandemic Prevention,
Preparedness and Response, move
beyond mere non-binding political
declarations to real commitments
by governments to address the critical
issues that confront global health,
including the current global health
Osahon Enabulele
Valedictory Speech by the WMA President, Dr. Osahon Enabulele
Kigali, 6 October, 2023
Valedictory Speech by the WMA President, Dr. Osahon Enabulele
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5
workforce deficit of 10 million and
the burgeoning phenomenon of brain
drain, burnt-out, and violence in the
health sector.
2) Violence against Physicians and
other Health Professionals
In the last one year, there were
disturbing cases of violence against
physicians and other health care
professionals within and outside their
workplaces. Everywhere I visited in
the course of my tenure, there was
an evident consensus that this issue
of violence was of great concern to
physicians.
I am happy to state that we took
very decisive steps against these
unwarranted assaults and violence
against our colleagues, by showing
solidarity with them and loudly
condemning these despicable acts
of violence which undermine our
colleagues, our medical profession,
patients, and the health care delivery
systems of the affected countries.
While we must sustain our call
on physicians to keep faith with
our ethical codes, it is important
to continuously demand of
Governments and health institutions
across the globe to take practical
measures, including the enforcement
of legal and policy instruments, and
the recently launched Global Health
and Care Worker Compact, to stop
violence against physicians and other
health professionals.
3) Development of New Initiatives
i) The WMA Roundtable and
Leadership Series
One of the significant developments
recorded during the tenure was the
development of a new initiative
called the WMA Roundtable and
Leadership Series. This initiative
seeks to directly interface with
physicians across the world, with the
aim of improving their awareness
and perception of the WMA, and
impacting on their leadership,
educational and professional
development.
I am very happy to state that the
maiden edition of the WMA
Roundtable and Leadership Series
which was centred on WMA’s history,
scope of work, membership, and role
of National Medical Associations,
was successfully held on Friday, 29
September 2023.
As observed by most participants,this
maiden session was quite revealing
and provided an added spark to
further propel the initiative. I thank
all those who worked with me to
make this a reality.
ii) The WMA Global Healthcare
Excellence Award Scheme
It is my hope that the proposal
on the WMA Global Healthcare
Excellence Award Scheme will
some day be approved for expression
in the WMA, particularly as it is
primarily aimed at recognising the
sense of duty, commitment and
excellence of physicians and others
who contribute to the development
of healthcare systems,with the overall
aim of motivating physicians and
strengthening healthcare systems. I
thank Prof. Joseph Ana and members
of his team who worked with me to
develop the proposed scheme.
4) Defence of our Colleagues in the
Turkish Medical Association
During my tenure,we showed massive
solidarity with our colleagues facing
assaults from repressive regimes,
including the Dr. Sebnem Korur
Fincanci-led leadership of theTurkish
Medical Association (TMA), who
have been facing sustained assaults
on their fundamental human rights,
their medical professional autonomy
and clinical independence.
As a mark of solidarity with our
colleagues in the TMA, I visited
Ankara, capital of Turkey, where I
physically witnessed with sadness, the
court trial of leaders of the Turkish
Medical Association that took place
on Thursday, 22 June 2023, in the
Ankara Diskapi Court House, 31st
Civil Court, in Ankara, Turkey.
This unjust trial of our progressive
colleagues was simply because they
voiced out their opinions against the
ills in the system.
Before appearing in court, and with
a strong reliance on my background
experiences in struggles of this nature,
I directly addressed a rally in support
of our troubled colleagues, within the
precincts of the court house. I also
addressed a press conference to drive
home our case against the oppression
of our colleagues in Turkey.
I am happy to note that our physical
presence added to the atmosphere
in the court and sent a loud signal
to the Turkish Government and the
Judiciary that the WMA was robustly
in support of our colleagues.
I urge us to remain united in our
struggle against oppression of our
colleagues and to stoutly resist
attempts at undermining their
fundamental human and labour rights,
as well as their medical professional
autonomy and clinical independence.
5) Improved Sense of Belonging
In line with our commitment to
improve the sense of belonging
amongst our members, we undertook
several outreaches during my tenure.
I had the privilege to visit some
National Medical Associations and
regional bodies, including, amongst
others:
Valedictory Speech by the WMA President, Dr. Osahon Enabulele
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6
• Swedish Medical Association,
• Japan Medical Association,
• Taiwan Medical Association,
• Israeli Medical Association,
• German Medical Association,
• British Medical Association,
• Turkish Medical Association,
• Austrian Chamber of Physicians,
• CMAAO,
• And my home base – Nigerian
Medical Association.
I thank them for according me their
warm hospitality during these visits.
I must admit that these visits, though
gruelling, were important learning
points and a source of value addition
to the WMA, particularly as it
helped to reinforce our oneness as
professionals, and the commitment of
our members to the WMA.
I cannot easily forget my experiences
in Turkey when I visited the
earthquake regions of Adana and
Hatay Cities of Turkey, on Friday,
23 June, and Saturday, 24 June 2023,
respectively. My visit to Hatay city
was particularly revealing as I came
in close contact with many displaced
families, and orphans, living in
various shelter camps and struggling
for basic needs of life. I witnessed
many devastated communities and
had personal interactions with those
who lost their loved ones.
I was particularly moved by the sad
case of a Physician who lost his wife
and children during the earthquake,
but despite this, was still providing
healthcare to other injured victims.
I once again express our deep
sympathies and condolences to all
those who lost loved ones in recent
natural and man-made disasters. We
pray for the eternal repose of the souls
of all those lost in the wake of these
disasters.
6) Partnerships and Collaborations
In the last one year, we worked hard
to strengthen our association with
our collaborating partners and bodies,
including including the World Health
Organization (WHO).
One of my first assignments was
to visit the WHO headquarters in
Geneva, to join our partners in the
World Health Professions Alliance
(WHPA), to sign a Memorandum of
Understanding (MOU) with the Dr.
Tedros Adhanom Ghebreyesus-led
WHO on:
• Health workforce,
• Universal Health Coverage,
• Non-Communicable Diseases,
• Aging populations.
We also played our roles in the
WHO5thGlobalForumonHuman
ResourceforHealth,the76thWorld
Health Assembly, and the High-
Level Meetings of the 78th United
Nations General Assembly.
We sustained our associations with
the International Committee of
the Red Cross, World Veterinary
Association, World Psychiatry
Association, amongst others. It is
my hope that in due course, we
would have a formal partnership
with the Commonwealth Medical
Association.
7) Review of the Declaration of
Helsinki
Our internal work on revision of
the Declaration of Helsinki (DoH)
continued to make progress during
the period under review with hosting
of exciting and productive regional
revision sessions.
I commend the Dr. Jack Resneck Jr-
led DoH-Revision Committee for
the commitment and progress thus
far.
8) Associate Members and Junior
Doctors Network
I must appreciate the sustained
progress made during my tenure by
both the Associate Members (AM)
and the Junior Doctors Network
(JDN). I commend the Dr. Jacque
Hailer-led leadership of the AM and
the Dr. Uche Arum-led leadership of
the JDN for engineering progressive
leadership of the respective bodies,
with value added to the WMA.
9) Ukraine Help Fund
In solidarity with our colleagues in
Ukraine, we sustained the Ukraine
Help Fund which has been a great
source of support for delivery of
medical care in Ukraine.
On behalf of the WMA, I wish to
thank all NMAs and other bodies
who continue to make financial
donations to the Fund.
CHALLENGES
1) Awareness and perception
of WMA amongst individual
physicians and citizens.
Despite existing for over 75 years,
there is still need to create greater
awareness amongst individual
physicians and citizens, of what the
WMA does and stands for. There is
need to also deconstruct the wrong
perception in some quarters that the
WMA is a missionary body and that
the office of the WMA President is a
salaried office.
2) Relationship with the WHO and
the UN.
While the WMA has maintained
her international relationship with
the UN Bodies, including the WHO,
I wish to observe that the attitude
of these bodies to Civil Society
Organizations (CSOs), including the
Valedictory Speech by the WMA President, Dr. Osahon Enabulele
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7
WMA, has been very disappointing.
This certainly needs to change, if
the expected dividends from such
relationships are to be reaped.
I consider unfortunate, in fact totally
unacceptable,a situation where CSOs
like the WMA are left to struggle for
severely limited space with others, to
advance their positions within these
global bodies. Sometimes, the WMA
is left on the fringes, and only allowed
to make their depositions within 1 or
2 minutes.
The question that therefore needs
to be addressed is whether global
health can truly be advanced without
according bodies like the WMA,
their rightful place in such bodies.We
are serious about engagement; but are
they serious in their desire to engage
with us?
APPRECIATION
At this juncture, I wish to appreciate
our almighty creator and ever faithful
God for granting me abundant grace,
protection and blessings, in the last
3 decades of my medical leadership
journey.
That I rose from the very beginning
of our medical leadership ranks in
the University/Medical School,
through State, National, African,
and Commonwealth levels, up to
the global level, can only be through
the abiding grace of God Almighty.
I thank all those who supported me
in the course of my journey to the
exalted office of WMA President,
as well as those who supported our
work during my tenure, including my
friends in the 4th estate of the realm.
Without their support our work
would have been difficult.
I am thankful to the WMA Executive
Committee and Council for the
support offered me during my tenure.
I must admit that I was privileged to
work with a unique set of committed,
diligent and patriotic officers of the
WMA. I cannot thank enough, our
Secretary General, Dr. Otmar Kloiber,
and the entire WMA Secretariat
Staff. Their unflagging commitment,
sense of duty, industry, passion, and
support, was simply marvellous!
They are the best ever!
I dedicate this day to my parents,
who nurtured and prepared me for
my leadership and career path in life.
My dear mother, Evangelist Rachael
Ayi Enabulele, a disciplinarian, would
have wished to be here,but for certain
circumstances.
My late father, Elder Jonathan
Igbineweka Enabulele JP, had truly
looked forward to a day like this, but
never had the opportunity to witness
this moment, as he passed on in the
year 2013 when I was serving as
President of the Nigerian Medical
Association. Daddy, may your great
soul continue to rest in Perfect Peace!
My profound gratitude truly goes to
my parents.
Now, to my immediate family, my
wife, Asso.Prof. Joan Enabulele,
and my lovely three children, Efosa
Enabulele, Omorovbiye Enabulele,
and Osarumwense Enabulele. What
can I really say to them? They have
been a great source of strength. Their
support was a vital ingredient that
propelled me to continuously oil
and drive the engine of growth and
development in the WMA.
I appreciate their patience, tolerance,
care, love, and understanding. They
have always tolerated my absence
from home. But the good news is that
I will soon be coming back home.
I specially thank the President of the
Nigerian Medical Association, Dr.
Uche Ojinmah, all past Presidents of
NMA, and indeed all members of the
Nigerian Medical Association for the
varied levels of support extended to
me. I thank all physicians and leaders
of National Medical Associations in
Africa, and indeed across the globe,
for their support.
I acknowledge the Lion Killer’s
Team, my Presidential Team, family
and friends.
I must especially acknowledge the
presence and support of my special
Guests, colleagues, friends, and well-
wishers who travelled to Kigali, to
witness my valedictory session.
I thank the Governor of my State,
Edo State, Mr. Godwin Nogheghase
Obaseki, and the State Government,
for their support. I thank our King
and Oba of Benin, His Royal
Majesty, Omo N’Oba N’Edo
Uku Akpolokpolo, Oba Ewuare
II OGIDIGAN CFR, and His
Eminence, Alhaji Muhammad Sa’ad
Abubakar III, CFR, mni, The Sultan
of Sokoto, for their support.
I am profoundly grateful to Sir.Chief.
Dr. Gabriel Osawaru Igbinedion
CON, CFR, The Esama of Benin; as
well as the Manager of Independent
Television and Radio, Engr. Elvis
Obaseki, and all the Staff of ITV
Benin, for their unparalleled support.
I thank the Chief Medical Director
(Prof. Darlington Obaseki),
Management Team, and Staff of
the University of Benin Teaching
Hospital (where I practise), and the
former Chief Medical Director and
former Management Board of Lagos
University Teaching Hospital (where
I served as a Management Board
Member) for their support during my
1-year tenure.
Valedictory Speech by the WMA President, Dr. Osahon Enabulele
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8
My profound gratitude goes to my
Head of Department of Family
Medicine, Dr. Adewole Afolabi, and
all staff of the Department, for their
rare understanding and support.
CONCLUSION
Dear Colleagues,
Distinguished Ladies and Gentlemen,
It took me over 15 years of
engagement within the WMA and
four attempts at this office of WMA
President, before getting to the
very top. I therefore want to once
again express my eternal gratitude
to you, for the great privilege and
honour extended to me, the very
first Nigerian and first West African
physician, to serve as President of
WMA.
I hope I met your expectations!
I hope your judgement would be that
“I came, I saw, and truly acquitted
myself.”
As I formally hand over the baton, I
wish to assure our members that I will
continue to totally commit myself
to the mission, vision, and strategic
objectives of the WMA.
I also wish to once again urge our
members to remain faithful and
committed to the WMA.
Our members should always
remember that “for the WMA to be
that truly strong body they desire it
to be, its tree must be watered by their
collective efforts.”
I cannot end this address without
paying special tribute to our
colleagues who lost their lives in the
last one year. May their great souls
rest in perfect peace.
I wish my successor in office, Dr.
Lujain Alqodmani, success in her
tenure.
I pray God to grant you all journey
mercies back to your respective homes.
I thank you for your kind attention.
Long live the WMA!!!
Osahon Enabulele, M.B.B.S,
MHPM, FWACP, FNMA
Past President (2022-2023),
World Medical Association
osahoncmavp@gmail.com
Valedictory Speech by the WMA President, Dr. Osahon Enabulele
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9
Your excellency Dr. Sabin
Nsanzimana, Minister of Health
of Rwanda, World Medical
Association (WMA) Executive
Committee members, esteemed
colleagues, distinguished guests,
ladies and gentlemen, it is both a
privilege and an honour to stand
before you today in the beautiful city
of Kigali here in Rwanda.
I would like to extend my heartfelt
gratitude to the outgoing WMA
President, Dr. Osahon Enabulele
for his invaluable service to this
organisation. I thank the Kuwait
Medical Association for supporting
my candidacy for WMA presidency.
I would like to kindly ask my family
and friends who crossed thousands of
miles to be here with me today, please
stand. Your unwavering support has
been my foundation, and I am deeply
grateful for your presence.
A special thank you goes to my
parents, Mr. Radwan Alqodmani and
Ms. Wafaa Alobaid, who taught me
that the sky is not the limit, but just
the beginning.
And to Dr. Michele Ancona, my
husband,thank you for being my rock,
for supporting me, and for standing
strong by my side.
I am deeply committed to my role as
President of the WMA. I value the
trust that you, the members, have
placed in me.
Today, I wish to outline some of the
key issues we must address as an
association.
Gender Equality
In a world where gender disparities
are glaring especially in healthcare,
it’s time for action. During the
COVID-19 pandemic, we witnessed
a shocking ratio: only one woman
was vaccinated for every three men in
some countries. This disparity is not
only limited to vaccinations but also
extends to maternal healthcare.
I feel incredibly grateful for the
opportunity I had to receive top-
notch maternal healthcare services
when I welcomed my daughter
Yasmin into the world this past
February. However, it pains me to
acknowledge that this privilege isn’t a
universal reality for countless women
across the globe.
Inequalities persist in many corners
of the world, and it’s disheartening
to know that according to the
WHO, even in the European Union,
where women tend to outlive men,
a significant portion of them spend
most of their lives in poor health.
These disparities reach well beyond
health. It’s estimated that 200
million girls have undergone female
genital mutilation, over 100 million
girls are currently out of school,
and a staggering 140 million girls
are anticipated to marry before the
age of 18 in the coming decade.
Consequently, if the current trends
continue unchecked, it will take us
more than a century to close the
global gender gap.
Recent studies show that a significant
majority of the global health and
social care workforce are women,
constituting well over half. Despite
contributing a substantial value
to the health system, their crucial
contributions persistently remain
undervalued. Alarmingly, women
hold just a quarter of leadership
positions in healthcare. We witness
gender inequity manifest in many
ways, from sexual harassment and
gender-based discrimination by both
patients and colleagues to a noticeable
gender pay gap and instances of
violence within the workplace.
Therefore, the pursuit of gender
equality is not merely a moral
imperative-it is integral to the
attainment of universal health
coverage and is crucial for securing
the health and well-being of all –
leaving no one behind. It is essential
in addressing the social determinants
of health effectively.
The WMA will persistently advocate
for gender equality. This includes
fostering inclusive leadership
opportunities within organised
medicine and ensuring equal, high-
quality,and safe healthcare services for
women and a safe work environment
for women physicians and other
healthcare professionals.
Climate Change and Health
Colleagues, we are living in the era
of global crises, marked by the Three
Cs: climate change, COVID-19, and
conflict. In 2019, WMA declared a
climate emergency, recognising the
urgency of the situation. The impacts
of climate change are already here
and are disproportionately affecting
vulnerable populations, including
Lujain Alqodmani
Inaugural Address by the WMA President, Dr. Lujain Alqodmani
Kigali, 6 October, 2023
Inaugural Address by the WMA President, Dr. Lujain Alqodman
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10
children. An alarming one billion
children are impacted by changes in
their environment.
Climate change stands as the
paramount threat to public health,
presenting substantial risks to the
well-being of present and future
generations alike. The World Bank
projects that, by 2030, climate change
could plunge over 100 million people
back into extreme poverty, with a
considerable portion of this impact
being attributed to detrimental effects
on health.
The evidence is irrefutable. We have
recently experienced the hottest
summer on record, characterised by
extreme heat waves,rampant wildfires,
and escalating ocean temperatures,
and other climatic events-many of
which are the consequences of human
actions.
Given that we are gathered here in
Rwanda, it is crucial to emphasise
the immediate and lasting impacts
of these climate-related events in
the continent of Africa. The World
Health Organization states that the
continent experiences over 100 health
emergencies each year, making up a
staggering 70% of all natural disasters
recorded between 2017 and 2021.
Ladies and gentlemen, We are at a
tipping point. Accelerated action is
needed now more than ever. WMA
will continue to call for divestment
away from fossil fuels and focus
on building resilient, sustainable
healthcare systems.We can’t afford to
wait; the time for action is now.
Food Systems
The state of our food systems is
nothing short of alarming. Diet-
related illnesses have become the
number one driver of ill health
and premature deaths globally. A
staggering 1 in 5 deaths are linked
to unhealthy diets. Nearly 4 billion
people, that is more than one-third
of the world’s population, struggle to
access healthy diets and 1 in 3 people
on the planet is malnourished. This
situation is exacerbated by climate
change and the destruction of nature.
The human cost is mind-blowing,
and the economic costs are equally
devastating. The annual economic
burden of unhealthy diets is up 3.5
trillion USD per year
Hunger is also a critical issue; the
number of chronically hungry people
is on the rise, estimated at around
800 million in 2020.The future looks
bleak for over 100 million stunted
children who will never reach their
full potential, both physically and
mentally.
Our current food systems are not only
killing us but are also devastating our
planet.They are responsible for about
one-third of our total emissions and
are the principal driver of the global
extinction crisis, loss of biological
diversity, and destruction of nature.
As physicians and healthcare
professionals, we have a significant
role to play in addressing these
challenges. We must be proactive
in conducting dietary assessments,
providing professional counsel, and
supporting education and training.
But most importantly, we must drive
major advocacy efforts to transform
food systems for the better.
Universal Health Coverage (UHC)
Now, let’s imagine a world where
everyone, everywhere, has access to
safe,good- quality,and free healthcare
service whenever needed. This is not
a utopian dream; it is a basic human
right that the world is tragically failing
to fulfill. The COVID-19 pandemic
has underscored and exacerbated
existing shortcomings, underscoring
the imperative need for healthcare
systems that are robust, equitable, and
resilient.
Establishing such inclusive systems is
pivotal for achieving Universal Health
Coverage (UHC) and fortifying
health security. It contributes to
broader socioeconomic progress
and offers an opportunity for more
and better-directed investment in
the foundations of health systems.
An integrated approach, based on
primary health care, is vital to ensure
that no one is left behind.
WMA will continue to urge
governments to provide excellent and
safe working conditions and prioritise
health worker protections. Decent
working conditions must include fair,
equal, consistent, and timely pay for
all health workers.
Furthermore,healthcareprofessionals,
especially women and youth, need
to be protected from work-related
violence and harassment. We call on
governments to act to prevent and
eliminate such brutality by providing
an appropriate physical environment
and by developing and implementing
zero-tolerance laws.
UHC will not be achieved without a
holistic primary healthcare approach.
It serves as the initial point of
contact for individuals within the
health system, providing a platform
for prevention, early diagnosis,
and treatment. It’s a cost-effective
approach that prioritises equity and
accessibility, ensuring that healthcare
reaches the most vulnerable and
remote populations. By integrating
various healthcare services, from
maternal and child health to chronic
disease management, it creates
a patient- centered model that
promotes long-term health and well-
being for all.
Inaugural Address by the WMA President, Dr. Lujain Alqodman
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11
Emerging Technologies and Impact
on Medicine
As we embrace the age of artificial
intelligence and other emerging
technologies, we stand at the cusp
of a revolution in healthcare. These
advancements have the potential to
radically enhance healthcare delivery,
diagnostics, and patient management.
However, it is imperative that we
approach this new era with caution to
ensure that these technologies serve
to improve healthcare, rather than
complicate or compromise it.
WMA will delve into the ethical and
practical implications of assimilating
these technologies into healthcare.
Attentionmustbegiventodataprivacy,
bias, and the potential displacement
of healthcare workers. As physicians,
we have an ethical responsibility to
ensure the transparent and equitable
implementation of these technologies,
maintaining adherence to the highest
medical ethics and standards.
It is pivotal for WMA to be at the
forefront of this transformative era.
By pioneering the incorporation of
emerging technologies in healthcare,
we can establish guidelines and
protocols that uphold the integrity
of medical practice. This leading role
will also empower us to advocate for
policies that safeguard both healthcare
professionals and patients, while
promoting innovations that enhance
the entire healthcare ecosystem.
Youth
It is a common saying, ‘youth are the
future leaders,’ but I find this notion
somewhat constraining. It seems
to suggest that the youth should
patiently await their turn to enact
significant change.
My journey to the presidency of
WMA initiated within the Junior
Doctors Network. It was there
that my passion and dedication to
advocating for enhanced health
through organised medicine were
cultivated. I am determined to
stand by and support the network’s
ambitious and innovative members
who continually bring substantial
value to our organisation.
I am a fervent advocate for
intergenerational equality,particularly
in leadership roles. The voices of the
younger generation are resounding,
potent,andhavealreadydemonstrated
their capability to make a substantial
impact.
Recognising the value in this, it’s
paramount to appreciate that every
generation
brings its unique insights and valuable
experiences.
When we all-irrespective of age-work
together, we create more effective and
inclusive approaches to healthcare
and leadership.
In this cooperative and inclusive
environment, we discover a synergy
where diverse perspectives and
experiences unite, enabling us to
achieve outcomes that are far richer
and more impactful than what we
could accomplish individually.
Conclusion
In closing, I would like to express my
heartfelt gratitude to the Rwanda
Medical Association for hosting this
General Assembly.Thank you for your
hospitality, generosity and welcoming
us to your beautiful country.
We stand at a critical juncture-a
world in crossroads-as physicians, we
bear a tremendous responsibility to
maintain and protect the health and
well-being of all people.
As we look toward the future, let
us remember that the practice of
medicine is not just a profession; it
is a calling that transcends borders,
cultures, and languages. I take this
mantle of leadership humbly, ever
mindful of the gravity and importance
it holds to steer this esteemed
organization in expanding its reach,
impact, and relevance in a rapidly
evolving global landscape.
I feel this responsibility even more
now, not just because I have just been
inaugurated to lead the WMA, but
also as a new mother to my daughter
Yasmin. It reminds me that the work
we do today is not just for us, but for
the generations that follow.
Lujain Alqodmani,
BMSc, MBBS, MIHMEP
President (2023-2024),
World Medical Association
lujainalq@gmail.com
Inaugural Address by the WMA President, Dr. Lujain Alqodman
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12
The 224th Council Session of the
World Medical Association (WMA)
convenedinthecityofKigali,Rwanda,
marking a significant chapter in the
collective pursuit of advancing global
medical governance (Photo 1).
Welcoming New Members and
Addressing Key Issues
The session began under the guidance
of the Council Chair by welcoming
newly attending Council members
Dr. Bruce Scott (American Medical
Association), Sir Ian Gilmore
(British Medical Association), Dr.
Kitty Mohan (British Medical
Association), and Dr. Yongmao Jiang
(Chinese Medical Association).
A pivotal moment arose when
a proposal to amend the WMA
Council Resolution on Organ
Donation in China surfaced. The
ensuing debate underscored the
delicate balance between addressing
critical issues at the Council level
and deferring matters to specialised
committees. The Council decision to
send the issue to the Medical Ethics
Committee reflected the commitment
to a thorough examination of the
matter.
The Council approved the
appointment of the Credentials
Committee comprised of Dr.
Kitty Mohan (British Medical
Association), Dr. John Baptist
Nkuranga (Rwanda Medical
Association), and Dr. Pablo Requena
(Vatican Medical Association), three
individuals from constituent members
covering each of the three official
WMA languages (English, French,
Spanish). The diverse composition
of this committee, covering the three
official WMA languages, ensures a
fair and comprehensive evaluation of
credentials.
Leadership Reports: Navigating
Challenges and Celebrating
Achievements
The report of Dr. Osahon Enabulele,
the WMA President 2022-2023,
provided a panoramic view of the
WMA’s engagement on the global
stage. From supporting colleagues
in the Turkish Medical Association
to active participation in the 76th
World Health Assembly, the WMA
continues to play a crucial role in
advocating for the rights and well-
being of physicians worldwide.
The WMA’s engagement was
confirmed in the reports of the
Secretary General and Chair of
Council, highlighting effective
collaborations within the Executive
Committee.
Committee Reports: Shaping the
Future of Healthcare Policies
The Council, employing a consent
calendar for efficiency, approved
a multitude of committee reports.
Notable resolutions included
providing support for physicians
in Nepal, addressing human rights
demonstrations in Iran, advocating
for an immediate ceasefire in Sudan,
and standing against anti-LGBTQ
legislation in Uganda. These
resolutions exemplify the WMA’s
dedication to upholding ethical
standards and promoting the well-
being of individuals globally.
Advocacy and Communication
Workgroup: A Reflection on
Progress and Future Endeavours
The session delved into the work of
the Advocacy and Communication
Workgroup, revealing both
accomplishments and challenges.
While acknowledging the need
for continued advocacy efforts, the
decision to disband the workgroup
reflects a commitment to re-evaluate
strategies and align them with the
forthcoming Strategic Plan.
Global Solidarity and Support
The meeting concluded with an
appeal from the Indonesian Medical
Association for reinforcement in
the face of challenges in their home
country. This call for solidarity
highlights the interconnectedness of
the global medical community and
the importance of standing together
in times of adversity.
As the 224th Council Session was
adjourned, it became evident that our
collective efforts transcend borders,
cultures, and languages.The decisions
made during these deliberations shape
the trajectory of global healthcare,
emphasising the WMA’s role as a
unifying force in advancing medical
ethics, professionalism, and patient
care worldwide.
WMA General Assembly 2023 in
Kigali, Rwanda
The recently concluded WMA
General Assembly in Kigali, Rwanda,
marked a significant milestone in the
Magda Mihaila
The 224th Council Session: A Glimpse into
Global Medical Governance
The 224th Council Session: A Glimpse into Global Medical Governance
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13
organisation’s history. The Assembly
Ceremonial Session on Friday, 6
October 2023, paved the way for a
weekend of meaningful discussions,
acknowledgments, and transitions.
The session commenced with the
call to order by WMA President, Dr.
Osahon Enabulele, at the Radisson
Blu Hotel & Convention Centre.The
roll call and introduction of delegates
emphasised the global nature of the
WMA, with representatives from 49
constituent members and observers
from non-member associations
present.
The warm welcome by Dr. David
Ntirushwa, President of the Rwanda
Medical Association, reflected the
spirit of collaboration and shared
commitment among the WMA
members. Dr. Ntirushwa’s emphasis
on the importance of WMA
meetings as a platform for global
health discussions and collaboration
resonated with the diverse audience
gathered in Kigali. The traditional
Rwandan dance offered to the
participants added a cultural touch,
symbolising the unity and diversity
within the medical community.
Honourable Dr. Sabin Nsanzimana,
Minister of Health of Rwanda,
delivered a poignant address
highlighting the challenges faced
by the medical profession during
the COVID-19 pandemic. He
emphasised the need for resilience,
education, and a commitment to
fundamental principles like medical
ethics. Dr. Nsanzimana’s reference
to Rwanda’s tragic history served as
a powerful reminder of the strength
that can emerge from adversity.
The recitation of the Declaration
of Geneva in Kinyarwanda by Dr.
Damas Dukundane added a cultural
and inclusive dimension to the
session. The tribute to outgoing
President Dr. Osahon Enabulele by
Prof. Jung Yul Park underscored Dr.
Enabulele’s remarkable contributions
to the medical profession, human
rights advocacy, and his role as the
first West African president of the
WMA.
Dr. Enabulele’s valedictory address
provided a reflective overview of
his term, highlighting advocacy
efforts, defence of colleagues, and
a commitment to universal health
coverage. The installation of the new
President, Dr. Lujain Alqodmani, a
leading public health doctor from
Kuwait, marked a symbolic transition
as the first Arab woman to be elected
President. Dr. Alqodmani’s inaugural
address outlined her vision for the
future of the WMA.
During the General Assembly
Orientation Session,WMA Secretary
General, Dr. Otmar Kloiber, provided
a comprehensive overview of WMA
operations, parliamentary procedures,
and the goal of enhancing delegate
participation. This session aimed
to improve the efficiency and
effectiveness of the General Assembly,
ensuring that all delegates are well-
informed and engaged.
The Plenary Session, called to order
by Prof. Jung Yul Park on 7 October,
covered various important aspects,
including greetings, announcements,
and a moment of silence for Dr.
Anthea Mowat, past Interim Chair
of the Associate Members, and other
colleagues who have passed away
during the past year.
After the approval of the minutes of
the 2022 WMA General Assembly
in Berlin and the election of the
new President for 2024-2025, Dr.
Ashok Philip, former president of
the Malaysian Medical Association,
highlighted the democratic processes
within the WMA. Dr. Philip’s
acceptance speech as President-elect
of the WMA expressed gratitude and
commitment to collaboration for the
benefit of patients and the medical
profession.
The report of the Council, outlined
by Prof. Jung Yul Park, emphasised
the adherence to the WMA Bylaws
and the importance of unanimous
acceptance of agenda points in the
absence of opposition.
The WMA General Assembly in
Kigali marked a pivotal moment in the
global medical community’s efforts to
address pressing issues and uphold
ethical standards. The resolutions
adopted reflect a commitment to
human rights, medical ethics, and
global health, setting the stage for
continued collaboration and advocacy
in the years to come. The assembly’s
proceedings demonstrate the WMA’s
dedication to transparency,inclusivity,
and responsible governance, ensuring
that the medical community remains
a driving force for positive change
worldwide.
Human Rights Demonstrations in Iran
The Assembly adopted the proposed
revision of the WMA Council
Resolution on Human Rights
Demonstrations in Iran, reaffirming
the commitment to uphold human
rights globally.
Ceasefire in Sudan
A revised resolution for an immediate
ceasefire in Sudan and the protection
of healthcare was adopted, reflecting
the WMA’s concern for the well-
being of individuals in conflict zones.
Anti-LGBTQ Legislation in Uganda
The Assembly addressed the issue of
LGBTQ rights, adopting a resolution
condemning anti-LGBTQ legislation
in Uganda and emphasising the
importance of inclusivity.
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14
Support to Physicians in Nepal
Urgent attention was given to violence
against physicians in Nepal, with the
adoption of a resolution condemning
such acts and expressing solidarity
with the medical community in
Nepal.
Decisions by the Medical Ethics
Committee
United Nations Resolution for a
Moratorium on the Use of the Death
Penalty
The Assembly received information
on the minor revision of the WMA
Statement on the UN Resolution
for a Moratorium on the Use of
the Death Penalty, highlighting the
Committee’s commitment to ethical
considerations in capital punishment.
Advance Directives (Living Wills)
The Council forwarded a minor
revision of the WMA Statement on
Advance Directives for information,
underlining the importance of
patient autonomy and informed
decision-making.
Capital Punishment
The Assembly was informed about
the minor revision of the WMA
Resolution on Prohibition of
Physician Participation in Capital
Punishment, reinforcing the ethical
stance against physician involvement
in capital punishment.
Medical Ethics during Public Health
Emergencies
The proposed WMA Statement on
Medical Ethics during Public Health
Emergencies was adopted, reflecting
the evolving landscape of healthcare
during crises.
Biological Weapons
The revised WMA Declaration of
Washington on Biological Weapons
was adopted, addressing the ethical
implications of advancements in
biotechnology.
Armed Conflict and Other Situations of
Violence
The Assembly endorsed the revision
of the WMA Regulations in Times
of Armed Conflict, emphasising
ethical considerations during times of
violence.
International Medical Meetings
A new WMA Statement on
International Medical Meetings was
adopted, recognising the importance
of global collaboration and knowledge
sharing.
Decisions by the Socio-Medical
Affairs Committee
Forensic Investigation of the Missing
The Assembly received information
on the minor revision of the WMA
Statement on Forensic Investigation
of the Missing, highlighting the
Committee’s dedication to addressing
humanitarian issues.
Fungal Disease Diagnosis and
Management
The Council forwarded a revised
statement on Fungal Disease
Diagnosis and Management
for information, showcasing the
Committee’s focus on emerging
healthcare challenges.
Right of Rehabilitation of Victims of
Torture
The minor revision of the WMA
Statement on the Right of
Rehabilitation of Victims of Torture
was presented for information,
emphasising the importance of
rehabilitation in the aftermath of
human rights violations.
Ottawa Convention on Anti-personnel
Mines
The Council forwarded a revised
resolution in support of the Ottawa
Convention on Anti-personnel Mines
for information, aligning with global
efforts to address the humanitarian
impact of landmines.
Collaboration between Human and
Veterinary Medicine
A revised resolution on Collaboration
between Human and Veterinary
Medicine was presented for
information, recognising the
interconnectedness of human and
animal health.
Items Adopted by the Committee
Electronic Cigarettes and Other
Electronic Nicotine Delivery Systems
The proposed revision of the WMA
Statement on Electronic Cigarettes
and other Electronic Nicotine
Delivery Systems was adopted,
reflecting the Committee’s focus on
emerging public health challenges.
Forced Sterilization
The revised WMA Statement on
Forced or Coerced Sterilization
was adopted, highlighting the
ethical considerations surrounding
reproductive rights.
Postgraduate Medical Education
The Assembly endorsed the World
Federation for Medical Education
(WFME) Global Standards
for Quality Improvement in
Postgraduate Medical Education
2023, emphasising the importance of
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15
high standards in medical education.
Acknowledgement and Condemnation
of Human Rights Violations in China
After intense debate and several votes,
the Assembly adopted the WMA
Resolution on Acknowledgment
and Condemnation of Human
Rights Violations against the
Uyghurs and Other Minorities in
China, reaffirming the Association’s
commitment to human rights.
Key Financial Updates
The Treasurer, Dr. Rudolf Henke,
presented a comprehensive report
on the financial results for 2022
and the proposed budget for 2024.
The Association finished 2022 with
a solid surplus, and the proposed
budget for 2024 demonstrated fiscal
responsibility.
Associate Members and
International Collaborations
Dr. Jacques de Haller, Chair of
Associate Membership, delivered
a heartfelt report on the Associate
Members meeting, acknowledging
the loss of Immediate Past Chair
Dr. Anthea Mowat. The Assembly
approved the Associate Members
Report, recognising the ongoing
contributions of associate members to
WMA workgroups.
Insightful presentations from
international organisations, including
Dr. Sally Ndung’u and Prof.
Geneviève Moineau, added depth
to the discussions, emphasising the
global nature of medical challenges.
Open Session Highlights
The Open Session brought forward
critical topics, including the issue
of low salaries for junior physicians,
raised by Prof. Yali Cong. The
Secretary General’s suggestion
to collaborate with the Junior
Doctors Network to address this
concern demonstrates the WMA’s
commitment to supporting the rights
of medical professionals.
Fr. Pablo Requena (Vatican Medical
Association) underscored the
importance of focusing on a broad
range of issues and avoiding the
domination of political matters in the
WMA discussions.
The Hong Kong Medical Association
raised questions about the WMA
response to nuclear threats,prompting
a commitment from the WMA
President, Dr. Lujain Alqodmani, to
renew the organisation’s commitment
to its policy on nuclear war.
Global Advocacy and Future
Directions
Delegates addressed crucial global
issues during the Assembly, including
the role of the WMA in influencing
policy implementation, as raised by
Dr. David Ntirushwa (Rwanda
Medical Association). The
commitment to condemn countries
and institutions engaged in mass
destruction and global discrimination
was emphasised by Dr. Muhammad
Ashraf Nizami (Pakistan Medical
Association).
The WMA General Assembly
concluded with reminders about
upcoming events, such as the
Declaration of Helsinki regional
conferences and the World
Conference of Bioethics held in
Porto, Portugal, on 16-19 October
2023. The introduction of the WMA
Glossary and a video preview of the
75th General Assembly in Helsinki
in 2024 added a forward-looking
dimension to the closing remarks.
As the WMA General Assembly
adjourned, gratitude was expressed to
the hosts, delegates, officers, speakers,
observers, and the entire WMA staff.
The Assembly’s rich discussions
and decisive actions underscored the
WMA’s commitment to advancing
global health and medical ethics.
The foundation is established for
continued collaboration and progress
as we look towards the next WMA
General Assembly in Helsinki in
2024.
Magda Mihaila
Communication & Press Manager
World Medical Association
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Photo 1. Group photo of the General Assembly in Rwanda 2023. Credit: WMA
16
BACK TO CONTENTS
WMA DECLARATION OF WASHINGTON ON
BIOLOGICAL WEAPONS
Adopted by the 53rd WMA General
Assembly, Washington, DC, USA, October
2002, editorially revised by the 164th WMA
Council Session,Divonne-les-Bains,France,
May 2003, reaffirmed by the 191st WMA
Council Session, Prague, Czech Republic,
April 2012, and revised by the 74th WMA
General Assembly, Kigali, Rwanda, October
2023
PREAMBLE
Rapid advances in microbiology, molecular
biology, and genetic engineering have created
extraordinary opportunities for biomedical
research and hold great promise for improving
human health and the quality of life. However,
the proliferation of these technologies provides
the opportunity to create novel pathogens and
diseases and simplified production methods
for biological weapons. The technologies are
relatively inexpensive and, because production
is similar to that used in biological facilities
such as vaccine manufacturing, they are easy
to obtain. Capacity to produce and effectively
disperse biological weapons exists globally,
threatening governments and endangering
people around the world.
The consequences of a biological attack would
be insidious and devastating. Their impact
might continue with secondary and tertiary
transmission of the agent, weeks, months or
years after the initial epidemic. Given the
ease of travel and increasing globalization,
an outbreak anywhere in the world could be
a threat to all nations. A great many severe,
acute illnesses occurring over a short span of
time could overwhelm the capacities of health
systems worldwide.
Physicians and other health personnel are on
the frontline in alleviating human suffering
caused by epidemic disease and will bear
primary responsibility for dealing with the
victims of biological weapons.
Participants in biomedical research have
a moral and ethical obligation to consider
the implications of possible malicious use
of their findings. Through deliberate or
inadvertent means, genetic modification of
microorganisms could create organisms that
are more virulent, are antibiotic-resistant,
or have greater stability in the environment.
Genetic modification of microorganisms could
alter their immunogenicity, allowing them to
evade natural and vaccine-induced immunity.
Advances in genetic engineering and gene
therapy may allow modification of the immune
response system of the target population to
increase or decrease susceptibility to a pathogen
or disrupt the functioning of normal host genes.
Nonproliferation and arms control measures
can diminish but cannot completely eliminate
the threat of biological weapons. Thus, there
is a need for the creation of and adherence
to a globally accepted ethos that rejects the
development,production,possession and use of
biological weapons. International collaboration
is critical to build such a universal consensus.
The United Nations Biological Weapons
Convention (BWC) prohibits the development,
production, acquisition, transfer, stockpiling
and use of biological and toxin weapons.
Having reached almost universal membership,
the BWC constitutes a key element in the
international community’s efforts to address the
proliferation of weapons of mass destruction
and has established a strong norm against
biological weapons.
Medical associations and physicians have a
responsibility in educating the public and policy
makers about the implications of biological
weapons and to mobilize universal support
for condemning research, development, or
use of such weapons as morally and ethically
unacceptable.They have important societal and
ethical roles in demanding the full respect of
the BWC, stigmatizing the use of biological
weapons, guarding against unethical and illicit
research, and mitigating harm from use of
biological weapons.
RECOMMENDATIONS
Recognizing the growing threat of biological
weapons, the WMA and its constituent
members condemn the development,
production, or use of toxins and biological
agents that have no justification for
prophylactic, protective, therapeutic or other
peaceful purposes, and makes the following
recommendations:
Strengthening global preparedness and
response to health emergencies
Governments and national health authorities:
1. To develop a strategy for the effective
coordinated and timely access to vital
protective measures for new pathogens,
whatever their origin, for all populations
at risk. The strategy should assure surge
capacity to address mass casualty care.
2. In line with the WMA Statement on
Epidemics and Pandemics, to meet the
critical needs for:
• Adequate investment in public
health systems, including resources
and supplies, to enhance capacity
to effectively detect, investigate
and contain rare or unusual disease
outbreaks.
• An operative global surveillance
program to improve response to
naturally occurring infectious diseases
and to permit earlier detection and
characterization of new or emerging
diseases.
3. To provide to WHO adequate means
to fulfill its leadership role in ensuring
appropriate international cooperation and
coordination for surveillance and action on
emerging infectious diseases.
4. To support the development of a WHO
legally binding instrument on pandemic
prevention, preparedness and response,
integrating principles of equity and human
rights.
5. To develop adequate and targeted
health education and training for health
professionals, civic leaders, and the public
WMA Declarations, Resolutions, and Statements
17
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alike, as well as collaborative programs
of research to improve disease diagnosis,
prevention, and treatment.
6. To develop communications strategies
to inform health care professionals and
the public about acts of bioterrorism and
infectious disease outbreaks,including local
information on available medical services.
7. To fund research and development to
counteract biological weapons, including:
• to improve understanding of the
epidemiology, pathogenesis, and
treatment of diseases caused by
potential bioweapon agents and the
immune response to such agents;
• for new and more effective vaccines,
pharmaceuticals, and antidotes against
biological weapons; and
• for improving biological agent
detection and defense capabilities.
Physicians, Medical Associations and other health
entities:
8. To participate with local, national,
and international health authorities in
developing and implementing disaster
preparedness and response protocols for
acts of bioterrorism and natural infectious
disease outbreaks. These protocols should
be used as the basis for physician and public
education.
9. To support and fulfill the critical role of
physicians in early detection of unusual
clusters of diseases or symptoms,potentially
resulting from the use of biological
weapons, so that they can promptly report
it to the appropriate institutions.
10. Physicians in relevant specialties should:
• be alert to the occurrence of
unexplained illness and death in the
community;
• be knowledgeable of disease
surveillance and control capabilities
for responding to unusual clusters of
diseases, symptoms, or presentations;
• be familiar with the clinical
manifestations, diagnostic techniques,
isolation precautions, decontamination
protocols, and therapy/prophylaxis of
biological agents likely to be used in an
attack;
• utilize appropriate procedures to
prevent exposure to themselves and
others; and
• understand the essentials of risk
communication so that they
can communicate clearly and
nonthreateningly about issues such as
exposure risks and potential preventive
measures.
Counteracting biological weapons research
Governments and national health authorities:
11. To develop and implement national
and global raising awareness strategies
on the potential development of
biological weapons among researchers
and practitioners, with comprehensive
information on the reporting system to be
used if needed.
12. To reinforce accountable and transparent
supervision mechanisms and regulation of
biological and toxin laboratory work with
the potential for weaponized applications.
Physicians:
13. Recognizing the societal responsibility of
physicians as scientists and humanitarians,
to decry scientific research for the
development and use of biological
weapons and to advocate against the
use of biotechnology and information
technologies for potentially harmful
purposes.
Researchers:
14. To consider the implications and possible
applications of their work and carefully
balance the pursuit of scientific knowledge
with their ethical responsibilities to society.
Fostering global mechanisms monitoring the
threat of biological weapons
Governments:
15. To take necessary measures to guarantee the
respect and implementation of the BWC
and to reinforce its implementation with
appropriate means, ensuring transparency
and adequate accountability mechanisms
for Member State Parties.
Physicians, Medical Associations and other health
entities:
16. Toadvocate,incooperationwiththeUnited
Nations, including the WHO, and other
appropriate entities, for strengthening of
the Implementation Support Unit under
the BWC, including medical and public
health leaders in order to monitor the
threat of biological weapons, to identify
actions likely to prevent biological weapons
proliferation, and to develop a coordinated
plan for scrutinizing the worldwide
emergence of infectious diseases.This plan
should address:
• international monitoring and
reporting systems so as to enhance the
surveillance and control of infectious
disease outbreaks throughout the
world;
• the development of an effective
verification protocol under the BWC;
• education of physicians and public
health personnel about emerging
infectious diseases and potential
biological weapons;
• laboratory capacity to identify
biological pathogens;
• availability of appropriate vaccines and
pharmaceuticals; and
• financial, technical, and research needs
to reduce the risk of use of biological
weapons and other major infectious
disease threats.
WMA Declarations, Resolutions, and Statements
18
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WMA DECLARATION ON THE ETHICAL USE
OF MEDICAL TECHNOLOGY
Adopted by the 53rd WMA General
Assembly, Washington, DC, USA, October
2002,and revised by the 63rd WMA General
Assembly, Bangkok, Thailand, October
2012 and by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
Medical technology has come to play a
key role in modern medicine. It has helped
provide significantly more effective means
of prevention, diagnosis, treatment and
rehabilitation of illness, for example through
the development and use of information
technology, such as telehealth, digital
platforms and large-scale data collection and
analyses, or the use of advanced machinery
and software in areas like medical genetics
and radiology, including assistive, artificial,
and augmented intelligences.
The importance of technology for medical
care will continue to grow and the WMA
welcomes this progress. The continuous
development of medical technologies – and
their use in both clinical and research settings
– will create enormous benefits for the medical
profession, patients, and society.
However, as for all other activities in the
medical profession, the use of medical
technology for any purpose, must take place
within the framework provided by the basic
principles of medical ethics as stated in
the WMA Declaration of Geneva: The
Physician’s Pledge, the International Code
of Medical Ethics and the Declaration of
Helsinki.
Respect for human dignity and rights, patient
autonomy,beneficence,confidentiality,privacy
and fairness must be the key guiding points
when medical technology is developed and
used for medical purposes.
The rapidly developing use of big data has
implications for confidentiality and privacy.
Using data in ways which would damage
patients’ trust in how health services handle
confidential data would be counterproductive.
This must be borne in mind when introducing
new data driven technology. It is essential
to preserve high ethical standards and
achieve the right balance between protecting
confidentiality and using technology to
improve patient care.
Additionally, bias through for example social
differences in the collection of data may skew
the intended benefits of data driven medical
treatment innovations.
As medical technology advances and the
potential for commercial involvement grows,
it is important to protect professional and
clinical independence.
RECOMMENDATIONS
Beneficence
1. The use of medical technology should
have as its primary goal benefit for
patients’ health and well-being. Medical
technology should be based on sound
scientific evidence and appropriate
clinical expertise. Foreseeable risks and
any increase in costs should be weighed
against the anticipated benefits for the
individual as well as for society, and
medical technology should be tested or
applied only if the anticipated benefits
justify the risks.
Confidentiality and privacy
2. Protecting confidentiality and respecting
patient privacy are central tenets of
medical ethics and must be respected in
all uses of medical technology.
Patient autonomy
3. Theuseofmedicaltechnologymustrespect
patient autonomy, including the right
of patients to make informed decisions
about their health care and control access
to their personal information. Patients
must be given the necessary information
to evaluate the potential benefits and risks
involved, including those generated by the
use of medical technology.
Justice
4. To ensure informed choices and avoid
bias or discrimination, the basis and
impact of medical technology on medical
decisions and patient outcomes should
be transparent to patients and physicians.
In support of fair and equitable provision
of health care, the benefits of medical
technology should be available to all
patients and prioritized based upon
clinical need and not on the ability to pay.
Human rights
5. Medical technology must never be used
to violate human rights, such as use
in discriminatory practices, political
persecution or violation of privacy.
Professional independence
6. To guarantee professional and clinical
independence, physicians must strive to
maintain and update their expertise and
skills, i.e., by developing the necessary
proficiency with medical technology.
Medical curricula for students and
trainees as well as continuing education
opportunities for physicians must be
updated to meet these needs. Physicians
shall be included in contributions to
research and development. Physicians
shall remain the expert during shared
decision making and not be replaced by
medical technology.
7. Health care institutions and the medical
profession should:
• help ensure that innovative practices or
technologies that are made available to
physicians meet the highest standards
for scientifically sound design and
clinical value;
WMA Declarations, Resolutions, and Statements
19
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• require that physicians who adopt
innovations into their practice have
relevant knowledge and skills;
• provide meaningful professional
oversight of innovation in patient care;
• encourage physician-innovators to
collect and share information about
the resources needed to implement
their innovations safely, effectively,
and equitably; and
• assure that medical technologies are
applied and maintained appropriately
in accordance with their intended
purpose.
8. The relevance of these general principles
is stated in detail in several existing WMA
policies. Of particular importance are:
• WMA Declaration of Seoul on
Professional Autonomy and Clinical
Independence
• WMA Declaration of Helsinki
– Ethical Principles for Medical
Research Involving Human Subjects
• WMA Declaration of Taipei on
Ethical Considerations regarding
Health Databases and Biobanks
• WMA Statement on Augmented
Intelligence in Medical Care
• WMA Statement on Digital Health
• WMA Statement on Cyber-Attacks
on Health and Other Critical
Infrastructure
• WMA Statement on Access to
Health Care
• WMA Declaration of Lisbon on the
Rights of the Patient
• WMA Declaration of Oslo on Social
Determinants of Health
9. The WMA encourages all relevant
stakeholders to embody the ethics
guidance provided by these documents.
WMA STATEMENT IN TIMES OF ARMED CONFLICT
AND OTHER SITUATIONS OF VIOLENCE
Adopted by the 10th World Medical
Assembly, Havana, Cuba, October 1956,
edited by the 11th World Medical Assembly,
Istanbul, Turkey, October 1957, revised
by the 35th World Medical Assembly,
Venice, Italy, October 1983 and the 55th
WMA General Assembly, Tokyo, Japan,
October 2004, editorially revised by the
173rd WMA Council Session,Divonne-les-
Bains, France, May 2006, and revised by the
63rd WMA General Assembly, Bangkok,
Thailand, October 2012 and the 74th WMA
General Assembly,Kigali,Rwanda,October
2023*
*The WMA Regulations of the WMA in times of armed
conflict and other situations of violence adopted in 1956
were reclassified as a ‘Statement’ by the 63rd General
Assembly, Kigali, Rwanda, October 2023.
PREAMBLE
The primary task of the medical profession is
to promote health and save life; the primary
obligation of the physicians is to their
patients; in all their professional activities,
physicians should adhere to international
conventions on human rights, to international
humanitarian law and to the WMA’s
Declaration of Geneva, International Code
of Medical Ethics and other relevant WMA
declarations on medical ethics[1], as well as
to the Ethical Principles of Health Care in
Times of Conflict and Other Emergencies,
elaborated by civilian and military healthcare
organisations, including the WMA, under the
initiative of the International Committee of
the Red Cross.
In situations of armed conflict and other
situations of violence,governments,belligerent
armed forces and others in positions of
power must comply with their obligations in
accordance with international law, including,
as applicable, Geneva Conventions (1949)
and the Additional Protocols to the Geneva
Conventions (1977, 2005).
This obligation includes a requirement to
protect healthcare personnel and facilities (see
e.g. the WMA Declaration on the protection
and integrity of healthcare personnel in armed
conflicts and other situations of violence,
2022), including any means of transportation
devoted to the wounded and sick, to health
personnel or medical equipment.
This obligation also includes condemning
the targeting of health care facilities and
personnel and using denial of medical services,
including as a tactic or strategy in war, by any
party, wherever and whenever it occurs.
The WMA supports efficient, secure and
unbiased reporting mechanisms with
sufficient resources to collect and disseminate
data regarding assaults on physicians, other
healthcare personnel and healthcare facilities,
and to provide to the WHO and other relevant
agencies the necessary support to fulfill their
role in documenting attacks on healthcare
personnel and facilities.
Assaults against healthcare personnel must
be investigated and those responsible must
be brought to justice; to this end, adequate
enforcement mechanisms must be used, or
where relevant, developed, and necessary
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20
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resources must be guaranteed.
Physicians must be granted access to all
persons in need of care, including those
deprived of liberty.
Physicians have a responsibility to press
governments and other authorities for the
provision of the infrastructure and equipment
that is a prerequisite to health and healthcare,
including potable water, adequate food
and shelter, proper infrastructure, clinical
equipment and available healthcare personnel,
and the necessary personal protection
equipment (PPE).
Where conflict appears to be imminent and
inevitable, relevant authorities are responsible
for guaranteeing the protection of the health
infrastructure and for planning any necessary
repair in the immediate post-conflict period.
Respect of professional ethical rules
During times of armed conflict and other
situations of violence, the ethical standards
of the medical profession apply as in times of
peace. The professional duty to treat people
with humanity and respect applies to all
patients. The physician must always act in
accordance with medical neutrality and give
the necessary care impartially and without
discrimination.
Physicians must never be persecuted for
complying with any of their ethical obligations,
and may not be compelled by governments,
armed forces or others in positions of power,
to undertake any action that contravenes the
medical profession’s ethical rules.
The privacy of the sick, wounded and dead
must always be respected and confidentiality
duly respected.
Health care given to the sick and wounded,
civilians or combatants, cannot be used for
publicity or propaganda.
Physicians must not spread disinformation, or
manipulate facts for the public, for the media,
or for the social media outlets.
Ethics training on the issue of medical
treatment of prisoners of war and detainees
should be provided in medical schools and
during postgraduate training.
RECOMMENDATIONS
In situations of armed conflict and other
situations of violence, the physician must:
General principles
1. Not take part in any act of hostility and
refuse any illegal or unethical order;
2. Neither commit nor assist in violations of
international law;
3. Not abandon the wounded and sick, while
considering the physician’s own safety and
competence and the availability of other
viable options for care;
4. Promote medical neutrality by advocating
for and providing effective and impartial
patient care without discrimination;
no distinction must be made between
patients except based upon clinical facts;
5. Give special consideration to the most
vulnerable or marginalized parts of the
population in need of care (e.g. women,
children, older persons, people with
specific healthcare needs, and displaced
persons) and to their specific healthcare
needs while adhering to triage principles;
6. Respect the individual wounded or sick
person´s autonomy, trust and dignity;
7. Respect confidentiality, in line with
the Declaration of Geneva and the
International Code of Medical Ethics;
8. Give careful consideration to any dual
loyalties that the physician may be bound
by or conflicts of interest that may be
present.
Detention
9. Provide healthcare to anyone taken as a
prisoner;
10. Advocate for regular visits to prisons and
prisoners by physicians;
11. Never condone, facilitate or participate
in the practice of torture or any form of
cruel, inhuman or degrading treatment,
nor in any form of abuse, including forced
feeding, human trafficking or human
organ trafficking;
12. In line with the WMA International
Code of Medical Ethics, the WMA
Declaration of Tokyo, the WMA
Statement on the Responsibility of
Physicians in the Documentation and
Denunciation of Acts of Torture or Cruel
or Inhuman or Degrading Treatment,
the Istanbul Protocol and the United
Nations Standard Minimum Rules for
the Treatment of Prisoners (the Nelson
Mandela Rules), denounce acts of torture
or cruel, inhuman or degrading treatment
and punishments.
Forbidden activities
13. Never use the situation and the
vulnerability of the wounded and sick for
personal advantage;
14. Never make use of healthcare privileges
and facilities contrary to their intended
purposes;
Public health
15. Report to the appropriate authorities if
healthcare needs are not met;
16. Respect the legal obligations to report to
the appropriate authorities in matters of
epidemiology;
17. Respect the WMA Declarations of
Helsinki and the WMA Declaration of
Taipei on research and data management;
18. Denounce and intervene against any
WMA Declarations, Resolutions, and Statements
21
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unscrupulous practices, including
distribution of poor quality or counterfeit
medicines and materials;
19. Be aware of war-related mental health
trauma when caring for patients,internally
displaced persons and refugees.shall
remain the expert during shared decision
making and not be replaced by medical
technology.
Reference
1. WMA Declaration on the Protection
and Integrity of Medical Personnel in
Armed Conflicts and Other Situations
of Violence / WMA Statement on
Armed Conflicts
WMA STATEMENT ON FORCED OR
COERCED STERILISATION
Adopted by the 63rd WMA General
Assembly, Bangkok, Thailand, October
2012,and revised by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
The United Nations states forced or coerced
sterilisation is a violation of fundamental
human rights, including the right to health,
to information and privacy, and to be free
from torture and other cruel, inhuman
or degrading treatment or punishment.
The United Nations also states specific
populations are disproportionately affected
by forced or coerced sterilisation, including
women, women living with HIV, indigenous
and ethnic minority girls and women, persons
with disabilities, and transgender persons and
intersex persons.
The WMA recognises that no person,
regardless of age, disease or disability, creed,
ethnic origin, gender, nationality, political
affiliation, race, culture, sexual orientation,
social standing, or any other factor, should be
subjected to forced or coerced sterilisation.
A full range of contraceptive services,
including sterilisation, should be accessible
and affordable to every individual. The state
has a role to play in ensuring that such services
are available, along with private, charitable
and third sector organisations.
As with all other medical treatments,
sterilisation should only be performed on a
competent patient after an informed choice
has been made and the free and valid consent
of the individual has been obtained. Where a
patient is incompetent, a valid decision about
treatment must be made in accordance with
the patient’s best interest as well as with
relevant legal requirements and the ethical
standards of the medical profession before the
procedure is carried out.
The WMA condemns practices where a state
or any other actor attempts to bypass ethical
requirements necessary for obtaining free and
valid consent for sterilization, which must be:
• Free from material or social coercion;
• Not a condition of other medical
care (including safe abortion), social,
insurance, institutional or other
benefits and
• Obtained when the person is not
facing any stressor limiting their
capacity of discernment, such as
detention or a medical emergency
(unless sterilization is the subject of
the emergency).
RECOMMENDATIONS
Recalling the core ethical values of the medical
profession enshrined in its International Code
of Medical Ethics and the Declaration of
Geneva: The Physician’s Pledge, and its long-
standing commitment against torture and
other cruel, inhuman or degrading treatment,
the WMA condemns forced or coerced
sterilisation and calls on:
Its Constituent Members
1. To advocate against such practices
contrary to human dignity;
2. To support the provision of safe and ethical
sterilization services or interventions,
with due respect for the physical and
mental integrity of the persons, including
by guaranteeing their autonomous
reproductive choices;
Physicians
3. To be alert to situations and settings
where there is a risk of forced or coerced
sterilisation, particularly for vulnerable
and disproportionately affected persons,
to ensure consent is valid and freely given
and to oppose any form of involvement in
forced or coerced sterilisation.
WMA Declarations, Resolutions, and Statements
22
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WMA STATEMENT ON HUMAN HEALTH AS A PRIMARY
POLICY FOCUS FOR GOVERNMENTS WORLDWIDE
Adopted by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
Understanding that early life experiences
can impact health in later life and that the
major drivers of health lie outside healthcare
is essential to direct action to improve health
where it is most needed. This is supported
by Paragraph 11 of General Comment No.
14 of the Committee on Economic, Social
and Cultural Rights, and by Article 24 of
the Convention on the Rights of the Child,
both of which recognise the importance of
the role of the state in providing good living
standards and healthy environments for their
citizens. The WMA Declaration of Oslo on
Social Determinants of Health and WMA
Statement on Sustainable Development
acknowledge that conditions, including
environmental conditions, in which people
are born, grow, are educated, live, work and
age (sometimes termed “social” or “wider”
determinants”) are major influences on
healthy life expectancy, quality of life[i] and
the magnitude of health inequalities.
Human health is a cardinal component of a
society’s ability to prosper; declining human
health adversely affects a nation’s productivity,
and therefore a nation’s economy, which in
turn limits many actions to prevent ill health
and deliver healthcare to treat illness.
Therefore, in addition to health practitioners,
many actors share in the responsibility to
preserve and improve human health. For
example, the ability to influence these wider
determinants of health are spread across
multiple government departments.
A cardinal challenge in striving for improved
population health lies in the fact that decision
makers tend to focus on short-term economic
indicators, such as Gross Domestic Product
(GDP)/Gross National Income (GNI), as the
primary driver of government policy.
Investment in the health of the population
has a long-term positive economic impact,
but the focus on GDP/GNI often acts to
the detriment of health. Many activities that
increase GDP/GNI, such as smoking and the
use of fossil fuels, damage health. Conversely,
activities such as breastfeeding and parenting,
which improve health, are not measured in
GDP.
RECOMMENDATIONS
Recognizing this, the World Medical
Association and its constituent members on
behalf of their physician members, call on
Governments to:
1. Recognise that well-functioning health
systems accessible to all are important, but
the principal determinants of health and
wellbeing lie outside healthcare;
2. Prioritise population health and wellbeing
in government policy decisions and
incorporate metrics of population health
and wellbeing into measures of national
progress and performance;
3. Acknowledge that securing and
safeguarding population health and
wellbeing are crucial to a sustainable
future;
4. Promote equity in health and address
inequalities in whatever sphere they exist,
by supporting actions that address the
wider determinants of health.
WMA RESOLUTION ON INTERNATIONAL MEDICAL
MEETINGS IN COUNTRIES PERSECUTING PHYSICIANS
AGAINST MEDICAL ETHICS AND
HUMAN RIGHTS STANDARDS
Adopted by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
There are many countries in the world
where torture and other cruel, inhumane or
degrading treatment takes place. However, in
some countries, physicians are unable to speak
out against human rights violations, even if
they witness them,due to the severe repression
in the country. It is the WMA’s and the
broader medical community’s responsibility
to help draw attention to the fundamental
changes that are urgently needed in order
to guarantee physicians safe and sustainable
working conditions, and to allow them to
ethically practice their profession. One way
of showing this recognition is to refrain from
holding international events in such countries.
RECOMMENDATION
The WMA calls the medical community
worldwide to carefully evaluate the suitability
of holding international medical events in
countries where physicians are persecuted
and, where appropriate, to take a decision
on whether to refrain from such events or to
provide clear and explicit support for these
physicians at such events.
WMA Declarations, Resolutions, and Statements
23
WMA STATEMENT ON MEDICAL ETHICS
DURING PUBLIC HEALTH EMERGENCIES
Adopted by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
Public health emergencies (PHEs) are regular
occurrences that put the life and health of
populations at risk.They have multiple origins
and are frequently characterised by urgency,
uncertainty and rapidly escalating demands
to which health services may struggle to
respond. Public health emergencies frequently
transcend jurisdictional boundaries giving rise
to co-ordination challenges for governments
and other actors. They can also involve large
scale displacement of people. Some of the
PHEs are localised, some present threats
of international concern. Climate change,
conflict and extremes of global inequality are
direct drivers of PHEs.
World Health Organization (WHO) defines
a public health emergency as “an occurrence
or imminent threat of an illness or health
condition, caused by bioterrorism, epidemic
or pandemic disease, or (a) novel and highly
fatal infectious agent or biological toxin, that
poses a substantial risk of a significant number
of human fatalities or incidents or permanent
or long-term disability”. Public health
emergencies can result from a wide range of
hazards and complex emergencies.
PHEs confront physicians, other health
professionals, public authorities and at times
the international community with severe
challenges. Although fundamental ethical
principles in medicine remain unchanged,
the combination of urgency, uncertainty and
extreme shortages of health resources can
present health professionals with extreme
difficulties in applying them. The familiar
tension in medicine between obligations to
individual patients and obligations to the
public good can be distinctly pronounced
during PHEs. This is particularly the case
where the need for life-saving interventions
overwhelms the available supply. PHEs can
also require restrictions on individual and
population rights and liberties that present
their own ethical challenges.
This statement focuses on the medical ethical
aspects of public health emergencies.
BASIC PRINCIPLES
1. During a PHE, physicians and all other
health responders should consider the
following principles:
• The obligation to help reduce overall
suffering;
• The obligation to show full and equal
respect to all;
• The requirement for justice and
fairness in the allocation of scarce
resources;
• The requirement that any restrictions
on individual choice or liberty
must be proportionate, lawful and
evidence-based;
• The obligation to maximise overall
health outcomes.
2. Some physicians and health professionals
will solely be focussing on population
aspects of the response to PHEs. Their
primary concern will be maximising
benefits and minimising harms at a
population level. The above principles
will guide them as they seek to realise
the greatest overall benefit for the largest
number of people.
Issues of particular ethical concern during
PHEs
3. Although the basic ethical duties of
physicians do not change during a PHE,
their application in certain areas can be
challenging. Issues of particular ethical
concern during a PHE include but are not
limited to:
Confidentiality
4. Access to large amounts of accurate, real-
time data is an essential part of the health
response to many PHEs. Physicians and
other health professionals retain ordinary
duties of confidentiality to their patients.
Information can be disclosed during a
PHE where a patient or legal surrogate
consents to its disclosure.In the absence of
consent such information can be disclosed
where there is a lawful justification or
for overriding reasons of public interest.
The disclosure of information should be
limited only to the necessary information
for the treatment of PHEs. Consideration
must also be given to ensuring the ethical
use of data including what happens to the
data after the purposes for which it was
collected are achieved.
Consent
5. Patients retain the right to consent to
or refuse treatment at all times during a
PHE. Some compulsory interventions
that do not amount to treatment may
be acceptable where there is a lawful
and ethical mandate supporting them.
For example, where individuals present
a serious risk of harm to others, and
they refuse to accept necessary public
health restrictions, confinement may be
considered.
Restrictions of liberty
6. PHEs, particularly where they involve
emerging communicable pathogens, may
require restrictions on individual and
population freedoms. Social distancing
and self-isolation are highly effective
public health interventions and may be
mandated by law during a PHE. Any
interference with fundamental rights,
including restrictions of liberty, must be
justified in the public good, necessary,
proportionate, based on lawfully-provided
powers and authority, and only imposed
for as long as necessary based on scientific
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WMA Declarations, Resolutions, and Statements
24
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evidence. The basic needs of any confined
person must be met at all times.
Public engagement
7. PHEs can have a profound effect on
individuals, communities and societies.
They are frequently characterised by fear,
uncertainty, and involve severe socio-
economic disruption.During PHEs,there
is a risk of the widespread circulation of
misinformation including conspiracy
theories and direct attempts to undermine
medical and scientific expertise. Clear
communication of evidence-based medical
and scientific information, including the
justification for any decisions that impact
social or economic functions, is essential.
Active steps should be taken to tackle
misinformation and disinformation,
especially when it is coming from health
professionals.
8. PHEs frequently require challenging
decisions involving trade-offs between
fundamental goods. All people affected
have a right to know that such decisions
are being made and the criteria on which
the decisions are based.
Resource allocation and triage
9. Serious PHEs are often characterised by
extreme shortages of health resources.This
can present physicians and other health
professionals with difficult decisions. In
ordinary circumstances priority should
be given to those with the greatest health
need, provided they have capacity to
benefit from the health intervention.
Those with equal health needs have equal
rights to health resources, whether or not
the need arises directly from the PHE.
10. In some circumstances,where health needs
overwhelm available resources, it may be
necessary to triage patients. Triage is a
form of resource allocation that involves
sorting or prioritizing individuals based
on their health needs and their likelihood
of responding to an intervention. In
extreme conditions it can involve setting
aside some people for non-treatment
where others have a higher likelihood of
benefiting from treatment, or where more
people can be saved.
11. Any form of triage must be based on open
and defensible ethical principles and must
be flexible enough to respond to rapidly
changing circumstances. Triage must
principally be based on factors determined
by the medical community and directly
relevant to an individual’s health status.
12. Attention must also be paid to health
trade-offs arising from decisions made to
tackle public health emergencies. A focus
on tackling communicable pathogens may,
for example, require health resources to be
diverted away from other health needs.
Any such decision must be based on good
moral reasons.
The rights and interests of health professionals
13. There is a limit to the risks that health
professionals can be expected to take
during the exercise of their duties in
a PHE. Physicians and other health
professionals should be knowledgeable
of ethical and legal issues and disaster
response, including their rights and
responsibilities to protect themselves
from harm, issues surrounding their
responsibilities and rights as volunteers,
and associated liability issues. Where
health professionals are exposed to risk,
corresponding duties arise on employing
bodies to mitigate those risks as far as
possible.
14. Health professionals responding to PHEs
must be properly equipped to deal with
the risks they will face, including access to
appropriate personal protective equipment
(PPE) at all times.
15. Where health professionals face particular
risks as a result of their role in responding
to PHEs it may be appropriate for them
to have priority access to interventions
such as vaccines.
Research
16. Research is an essential part of the
health response to PHEs. Ethical
principles guiding research in ordinary
conditions are not changed during
PHEs. Undertaking research in PHEs
can nevertheless be challenging. Those
participating in research can also be
particularly vulnerable. It is essential
that research in PHEs is undertaken
with full respect for the principles set out
in the WMA Declarations of Geneva,
the WMA Declaration of Helsinki –
Ethical Principles for Medical Research
Involving Human Subjects, and the
WMA Declaration of Taipei on Ethical
Considerations Regarding Health
Databases and Biobanks.
PHEs of international concern
17. Some PHEs, such as those caused by
communicable pathogens or highly-
dispersed toxins, can rapidly cross
national boundaries and present regional
or global health risks. During these
emergencies of international concern,
the ethical principles outlined above
remain unchanged. Given the persistence
of serious global inequalities, particular
attention must however be paid to
transnational questions of justice and
fairness in the allocation of health
resources.
WMA Declarations, Resolutions, and Statements
25
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WMA STATEMENT ON NATURAL VARIATIONS
OF HUMAN SEXUALITY
Adopted by the 64th General Assembly,
Fortaleza, Brazil, October 2013 and revised
bythe74thWMAGeneralAssembly,Kigali,
Rwanda, October 2023
PREAMBLE
Individuals who identify as LGBTQIA+
(Lesbian, Gay, Bisexual, Transgender, Queer,
Intersex, Asexual, and other identities beyond
these) represent a broad and fluid spectrum of
natural sexual orientations, gender identities,
gender expressions, and sex characteristics.
While LGBTQIA+ people may share
common cultural and social experiences and
shared goals of justice and equity in the face
of detrimental, discriminatory treatment and
even violence, these are diverse communities
facing distinct challenges and with specific
needs in healthcare and beyond.
This statement is specifically focused on
lesbian, gay, and bisexual people.
Healthcare professionals encounter many
aspects of human diversity when providing
care, including different natural variations of
human sexuality.
A large body of scientific research indicates
that being lesbian, gay, or bisexual constitute
natural variations of human sexuality without
any intrinsically harmful health effects. They
do not constitute a disorder or illness that
requires treatment or cure and any efforts to
do so are contrary to the ethical practice of
medicine.
Homosexuality and bisexuality are
consequently not included in the World
Health Organization’s (WHO) International
Classification of Diseases (ICD 11).
However, direct and indirect discrimination,
both interpersonally and at the institutional
level, anti-homosexual or anti-bisexual
legislation and human rights violations,
stigmatisation, criminalisation of same-sex
partnerships, peer rejection, and bullying
continue to have a serious impact upon the
psychological and physical health of lesbian,
gay, or bisexual people. These negative
experiences are perpetuated by a lack of
education in society on the different natural
variations of human sexuality. They lead to
poorer health outcomes, including higher
prevalence rates of depression, anxiety
disorders, substance misuse, and suicidal
ideations and attempts. As a result, the suicide
rate among lesbian,gay,or bisexual adolescents
and young adults significantly higher than
that of their heterosexual peers.
These negative outcomes can be exacerbated
by other intersectional factors, including
but not limited to national origin, race,
ethnicity, gender, age, religion, gender
identity, socioeconomic status, or disabilities.
In addition, false and baseless pathologisation
of lesbian, gay, or bisexual identities leaves
such individuals at risk of being coerced
into so-called “conversion” or “reparative”
procedures. These harmful and unethical
practices, also sometimes referred to as sexual
orientation and gender identity change efforts
(SOGICE), are intended to suppress or
change a person’s natural sexual orientation
or gender identity. These methods have no
medical indication, lack any evidence of
effectiveness, and represent a serious threat
to the health and human rights of those
subjected to these practices. They can lead to
anxiety, depression, low self-esteem, substance
abuse, problems with intimacy, and suicide.
Negative experiences in healthcare may affect
the patient-physician relationship, leading
lesbian, gay, and bisexual individuals to avoid
accessing care where it is available. They
may also withhold their sexual orientation
from physicians due to the resulting lack
of confidence that they will receive the
appropriate treatment and concerns about the
safety and confidentiality of their healthcare
environment. Without this information, it
may be more challenging for physicians to
provide targeted care that takes into account
the specific health needs of lesbian, gay, or
bisexual patients.
Lesbian, gay, or bisexual physicians, medical
students, and other health professionals
also face discrimination, disadvantages,
marginalisation and bullying in the workplace,
in schools, in professional organisations,
and beyond. Harmful working and learning
environments can lead to stress and burnout,
especially among marginalised individuals.
RECOMMENDATIONS
1. The WMA strongly asserts that being
lesbian, gay, or bisexual does not represent
a disease, but rather natural variations
within the range of human sexuality.
2. The WMA condemns all forms of
stigmatisation, criminalisation of and
discrimination against people based on
their sexual orientation.
3. The WMA asserts that psychiatric or
psychotherapeutic support, when needed,
must not focus upon the variations of
sexuality itself, but rather upon conflicts
which arise between those variations and
religious, social and internalised norms
and prejudices, as well as the health needs
of the individual patient.
4. The WMA unequivocally condemns so-
called “conversion” or “reparative” methods.
These constitute violations of human
rights and are unjustifiable practices
that should be denounced and subject to
sanctions and penalties. It is unethical
for physicians to participate during any
step of any such procedures.
5. The WMA calls upon all physicians to:
• classify physical and psychological
diseases on the basis of clinically
relevant symptoms according to
ICD 11 criteria regardless of sexual
orientation, and to provide quality,
evidence-based care in accordance
with internationally recognised
treatments and protocols and in
keeping with the principles set forth
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in the WMA International Code of
Medical Ethics;
• provide a safe,respectful,and inclusive
healthcare setting for lesbian, gay, and
bisexual patients;
• foster safe, respectful, and inclusive
work and learning environments for
lesbian, gay, and bisexual physicians,
medical students, and other health
professionals;
• engage in continuing education and
professional development to better
understand the specific health needs
of lesbian, gay, and bisexual patients
and the benefits of certain treatments;
• where appropriate, involve patients’
same-sex partners and same-sex
parents in healthcare discussions in
keeping with the patient’s preferences,
respecting their consent, and with due
regard for patient confidentiality;
• speak out against legislation and
practices violating the human rights
of lesbian, gay, and bisexual people,
which may also negatively impact the
healthcare system at large;
• reject and refuse to participate in
any step of so-called “conversion” or
“reparative” methods.
6. The WMA calls upon constituent
members and professional associations to:
• advocate for safe and inclusive working
and learning environments for
lesbian, gay, and bisexual physicians,
medical students, and other health
professionals;
• establish and enforce non-
discriminatory policies in keeping
with the WMA Statement on Non-
Discrimination in Professional
Membership and Activities of
Physicians;
• create guidelines for physicians
outlining the specific physical and
mental health challenges facing
lesbian, gay, and bisexual patients,
where appropriate;
• Where possible, promote changes to
medical education, specialty training
and CME/CPD curricula to create
sensitivity and awareness of the
specific health needs of lesbian, gay,
and bisexual patients;
• establish channels for lesbian, gay, and
bisexual physicians to report incidents
of discrimination or bias against
themselves or lesbian, gay, or bisexual
patients;
• in environments where confidentiality
and patient safety are guaranteed and
data cannot be abused, encourage
voluntary data collection in the
clinical setting and regular reporting
on the health outcomes of lesbian, gay,
and bisexual patient groups, while also
taking intersectionality into account,
to ensure and further improve targeted
and appropriate healthcare provision;
• actively condemn so-called
“conversion” or “reparative” methods
as unethical.
7. The WMA calls upon governments to:
• reject and repeal anti-homosexual or
anti-bisexual legislation;
• condemn and ban so-called
“conversion” or “reparative” methods;
• promote policies that counteract
health-related and other inequities
caused by overt and implicit
discrimination against lesbian, gay,
and bisexual people;
• encourage education from an early age
on diverse natural variations of human
sexuality to increase acceptance and
with the ultimate aim of promoting
better physical and mental health for
all individuals.
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WMA STATEMENT ON PRIMARY HEALTH CARE
Adopted by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
Primary health care (PHC) is a key part of any
health system, due to its wide coverage and
distribution, its accessibility and its ability to
solve the health problems of the population.
For this reason,it is a fundamental element for
social cohesion that corrects health inequalities
between people and territories, guaranteeing
equity in health care, and energizing close,
accessible,and efficient health care that adapts
to health changes.
PHC must enhance its positive aspects:
high quality, safe, comprehensive, integrated,
accessible, available, and affordable for
everyone and everywhere, provided with
compassion, respect, and dignity to solve
the majority of the health problems of the
population.
The PHC approach is foundational to
achieving our shared global goals in Universal
Health Coverage (UHC) and the health-
related Sustainable Development Goals
(SDGs).
PHC comprises a broad range of personal
medical care, including preventive, diagnostic,
palliative, therapeutic, curative, counseling
and rehabilitative care, over time. It is not
an exclusive disease-centered approach, but
a person-centered approach. Furthermore,
PHC is multi-sectoral health care and
aims to empower individuals, families and
communitiestotakeanactiveroleinimproving
their health. PHC should be provided in a
manner that is accessible, comprehensive and
led by a physician to ensure appropriate and
high-quality care.It offers the full spectrum of
essential health services across all ages.
PHC usually is the first contact of the people
with the health care system. It can address the
majority of health needs of the population
through comprehensive and integrated
services in a continuous and longitudinal way.
PHC offers a comprehensive care of essential
health services across all ages.
Strong PHC is vital for efficient, cost-
effective, equitable, appropriate and
sustainable health care systems. A significant
portion of health needs can be addressed at
the primary care level, redistributing the
workload and relieving strained emergency
systems as well as secondary or tertiary
health care. The provision of longitudinal
care and a trustful patient-primary physician
relationship will reduce parallel care demand
and unnecessary referrals. Continuity of care
has also been shown to reduce mortality, acute
hospitalizations and out-of-hours care.
PHC contributes to the prevention, early
detection, risk-factor identification and
mitigation, and timely response to infectious,
communicable diseases and noncommunicable
diseases outbreaks, and optimal adherence to
treatments and rehabilitation.
Robust PHC can enhance the responsiveness
of health systems by adapting to the existing
or future health needs of the population,
contributing to a socially accountable care by
actively engaging and mobilising communities,
and allowing patients access to participatory
and multidisciplinary care.
PHC is in a unique position to address the
social determinants of health inequalities and
to enhance individual physical and mental
health and social well-being.
Specialist education in general practice/
family medicine has developed differently
in different regions. In some countries the
specialty is as comprehensive and reputed as
other specialties.
Where case management or coordination
might limit access to appropriate medical
care, patients should have the freedom to see
a physician appropriate for the services they
need, regardless of specialty. Above all, the
best interests of the patient must be
paramount.
PHC must consider the new challenges that
health systems are facing, such as the high
prevalence of chronic diseases, the risks of
epidemics and pandemics, the environmental
impact and climate change on health or the
problem of antimicrobial resistance, as the
main threats to health in the coming years, as
indicated by the World Health Organization,
prioritizing PHC actions and acting on these
risks to respond to the main global health
challenges.
RECOMMENDATIONS
The World Medical Association recommends
that national governments/national health
authorities:
1. Strengthen PHC within health systems
and plan and ensure adequate financial
resources and equipment provision in
PHC facilities, including a sufficient,
well-trained supply of primary care
physicians–family physicians, general
internists, general pediatricians, and
obstetricians/gynecologists – to meet the
nation’s current and projected demand
for health care services.
2. Promote PHC with adequate human
and material resources and means to
make it more decisive, effective, efficient
and sustainable.
3. Ensure responsiveness to the health needs
of the population through adaptation of
health systems and enable community
participation through adaptation of
PHC systems to the population health
needs.
4. Establish functional referral systems
and mechanisms that foster the
coordination and integration of
care across different levels (primary,
secondary, tertiary) and the collaboration
of PHC physicians with other medical
specialists ensuring care continuity.
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5. Ensure workforce planning and adequate
size of the PHC workforce by providing
decent working conditions for the PHC
workforce, including the improvement of
working conditions and of remuneration,
use of recruitment and retention
strategies that take special consideration
of hard-to-reach geographic areas and
isolated socio-demographic groups and
prioritize training of sufficient medical
and paramedical personnel to ensure
adequate future staffing in PHC.
6. Develop other administrative support
mechanisms to assist primary care
physicians in the logistics of their
practices, along with enhanced efforts to
reduce administrative activities unrelated
to patient care,to help ensure professional
satisfaction and practice sustainability.
7. Promote PHC as close health care
connected to people as a basis for positive
knowledge.
The World Medical Association recommends
that its constituent members as well as medical
professionals:
8. Advocate for a sustainable PHC
system that delivers integrated and
comprehensive services inclusive
of promotive, preventive, curative,
rehabilitative and palliative care.
9. Increase the resolution capacity and
reduce the bureaucratic burden of the
PHC.
10. Reaffirm the need for high quality PHC
services through the development and
use of clinical guidelines, standardized
training and accreditation of the PHC
workforce.
11. Develop professional autonomy and
involvement in the management of PHC
physicians.
12. Work with national governments and
academia to optimize the higher and
postgraduate education of the PHC
personnel. Such actions can include:
• Developandexpandmedicaleducation
programs to educate primary care
physicians in increasing numbers.
• Promote training opportunities
for medical graduates to fulfill the
estimated demand of the PHC
workforce, as well as primary care
experiences for all students that
feature increasing levels of student
responsibility and use of ambulatory
and community-based settings.
• Make available Continuous Medical
Education that considers the particular
needs of the PHC workforce.
• Advocate for the establishment of
a structured specialized education
for general practitioners and family
medicine doctors or other specialized
education programmes for physicians
working in PHC and give it prestige
and make it attractive.
13. Ensure that in a context of violence
or in a military setting, PHC can also
be delivered according to the needs of
the population, ethically and with high
quality.
14. Provide students career counseling related
to the choice of a primary care specialty
and ensure that primary care physicians
are well-represented as teachers, mentors,
and role models to future physicians.
15. Enhance the visibility of primary care
faculty members and encourage positive
attitudes toward primary care among all
faculty members.
16. Encourage efforts to align the
representation of PHC physicians with
specialized/ hospital-based physicians in
political decision making and national
medical organizations and to reduce
inappropriate remuneration imbalances
between physicians with comparable
training in different levels of care.
17. Advocate for PHC systems that involve
patients and communities and can adapt
and respond to specific settings and
population health needs.
18. Support the appropriate use of
technologies, information systems, digital
devices and big data tools that foster and
improve PHC services.
19. Support research on health service
delivery in the primary care setting,
promoting the research culture.
20. Fulfill the international commitment of
States to strengthen PHC as an essential
step towards achieving universal health
coverage, building sustainable PHC and
towards achieving the highest attainable
standard of health (Astana Declaration).
21. To promote, through PHC a more
accessible, close and humane medicine,
centered in the person, and prioritizing
the needs and interest of patients.
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WMA STATEMENT ON ELECTRONIC CIGARETTES AND
OTHER ELECTRONIC NICOTINE DELIVERY SYSTEMS
Adopted by the 63rd WMA General
Assembly, Bangkok, Thailand, October
2012 and revised by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
Electronic cigarettes (e-cigarettes) and other
electronic nicotine delivery systems (ENDS)
are products designed to deliver nicotine to a
user in the form of an aerosol.These products
are usually composed of a mouthpiece,
a rechargeable battery-operated heating
element, a replaceable cartridge that contains
liquid nicotine and/or other chemicals, and
an atomizer that, when heated, turns the
contents of the cartridge into an aerosol.
This aerosol is then inhaled by the user and
exhaled. These products are often made to
look like other tobacco-derived products like
cigarettes, cigars, pipes, toys and electronics
that appeal to young people. They can also be
made to look like everyday items such as pens
and USB memory sticks. ENDS and their
risks are outlined in more detail in the WMA
Statement on Health Hazards of Tobacco
Products and Tobacco-Derived Products.
Nicotine exposure, no matter how it is
delivered, can affect brain development and
lead to addiction. No standard definition of
e-cigarettes exists, and manufacturers use
different designs and different ingredients.
Quality control processes used to manufacture
e-cigarettes are substandard or non-existent,
and few studies have been done to analyze the
level of nicotine delivered to the user and the
composition of the aerosol or vapor produced.
Unknown amounts of nicotine are delivered to
the user, and the level of absorption is unclear,
leading to potentially toxic levels of nicotine in
the system, especially in children, adolescents
and young adults. E-cigarettes and ENDS
may also contain other ingredients toxic or
carcinogenic to humans including delivery
solvents, propylene glycol, glycerin, pulegone,
formaldehyde, acetaldehyde, acrolein, and
heavy metals, such as chromium, copper, zinc,
tin and lead.
Manufacturers and marketers of e-cigarettes
and ENDS often claim that use of their
products is a safe or safer alternative to
smoking cigarettes, particularly since
e-cigarettes and ENDS they do not produce
carcinogenic smoke. However, no studies
have conclusively determined that the aerosol
is not toxic or carcinogenic. There is some
evidence of a risk of carcinogenicity of the
respiratory tract due to long-term, cumulative
exposure to nitrosamines and to acetaldehyde
and formaldehyde. As with tobacco products,
the safest option is to abstain from using
e-cigarettes and ENDS.
Evidence already exists that e-cigarettes
and ENDS are harmful and not safe. Risks
include:
• appeal to children, adolescents and
young adults, through packaging
and marketing designed to appeal to
these age groups, and especially when
flavors like strawberry or chocolate are
added to the cartridges. These factors
can increase nicotine addiction among
young people, and may be a gateway
to experimenting with other tobacco
products. Packaging and marketing
targeted to young people has
contributed to the dramatic increase
in e-cigarette and ENDS use which
in some regions is more popular than
tobacco smoking.
• the belief promoted by manufacturers
that these devices are acceptable
alternatives to scientifically proven
cessation techniques, when neither
their value as therapeutic aids for
smoking cessation nor their safety as
cigarette replacements is established.
Evidence reveals that these products
are harmful to health and not safe.
In addition, evidence on the use of
ENDS as a way to decrease tobacco
use in adults is inconclusive;
• inconsistent and unknown dosage,
manufacturing processes, and
ingredients, including the potential
for abusing or manipulating the
product, e.g., by adding cannabis, and
simultaneous use with other tobacco
products (dual or poly use);
• high potential of toxic exposure
to nicotine by children, either by
ingestion or dermal absorption from
contents of a nicotine cartridge,
because the cartridges and refill
liquids are readily available over the
Internet and are not always sold in
child resistant packaging;
• worse clinical outcomes in patients
with the SARS-COV2 virus who also
use e-cigarettes.
RECOMMENDATIONS
1. That e-cigarettes and ENDS be subject
to the WHO Framework Convention on
Tobacco Control, and to jurisdictional
smoke-free laws and regulations.
2. That the manufacture and sale of
e-cigarettes and ENDS be subject to
national regulatory bodies as either a
new form of tobacco product or as a
drug delivery device. At a minimum,
regulations should address maximum
strength of nicotine fluids, tank size
on vaping devices, product labeling,
and child-resistant packaging. This
recommendation also applies to devices
using synthetic nicotine.
3. That clinical testing, large population
studies and full analyses of e-cigarette
ingredients and manufacturing processes
be conducted to determine their level of
risk, viability, and efficacy as tools for
tobacco cessation.
4. That e-cigarettes and other ENDS
should never be marketed as a valid or
efficacious method for smoking cessation
without validated clinical research that
is assessed by appropriate regulatory
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bodies. In all other instances, plain
package marketing should be required, in
accordance with the WMA Resolution
on Plain Packaging of Cigarettes, E-
Cigarettes and Other Smoking Product.
5. That the sale, marketing, distribution,
and accessibility of e-cigarettes and
other tobacco products to children and
adolescents be prohibited.
6. That the production, distribution and
sale of flavored e-cigarette cartridges and
candy products that depict or resemble
tobacco products be prohibited.
7. That the sale of e-cigarettes and ENDS
via the internet be prohibited in order
to prevent access to these products by
minors.
8. That physicians, pediatric practitioners
and dentists inform their patients of the
potential risks of using e-cigarettes and
ENDS, e.g., addiction, cardiovascular
disease, lung disease, impact on brain
development due to nicotine, physical
injuries,etc.,even if regulatory authorities
have not taken a position on the efficacy
and safety of these products.
9. That the WMA and its members support
further research on the harmful effects
of e-cigarettes and ENDS, especially in
children, adolescents and young adults.
WMA RESOLUTION CONDEMNING THE VIOLENCE
AGAINST PHYSICIANS IN NEPAL
Adopted by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
The WMA is deeply concerned at the
increasing rate of violence against health
professionals and facilities in Nepal. The
Nepal Medical Association, a WMA member,
documented at least seven incidents of
misbehaviors and physical assault on medical
personnel in the last 15 days, as well as
vandalism in health institutions.
RECOMMENDATIONS
1. Recalling its policies on Workplace
Violence in the Health Sector and on
the Protection and Integrity of Medical
Personnel in Armed Conflicts and Other
Situations of Violence, the WMA and
its members condemn in the strongest
terms any form of violence against health
personnel and facilities, and express its
solidarity with its Nepalese colleagues.
2. The WMA and its members urge
the Nepalese authorities to commit
to preventing and ending violence
against health personnel through the
implementation of robust and coordinated
policies, in particular:
• Immediate security measures to
guarantee a safe environment for
health personnel and facilities in the
country;
• An appropriate funding dedicated to
the protection of health personnel and
facilities;
• Adequate accountability mechanism,
with rapid responses from the
authorities against perpetrators of
attacks on health personnel.
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WMA RESOLUTION FOR AN IMMEDIATE CEASEFIRE
IN SUDAN AND THE PROTECTION OF HEALTH CARE
Adopted by the 223rd WMA Council,
Nairobi, Kenya, April 2023. Revised
and adopted by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
Violent fighting has broken out since April
2023 in Khartoum and in several cities of
Sudan between the Sudan Armed Forces
(SAF) and Rapid Support Forces (RSF), an
independent paramilitary force.
Amnesty International reports extensive
war crimes with mass civilian victims in
both deliberate and indiscriminate attacks
by the conflicting parties as well as sexual
violence against women and girls. Rampant
looting has affected hospitals, medical
facilities, and humanitarian warehouses across
various regions. This widespread looting
has exacerbated an already dire situation by
depriving communities of essential medical
and humanitarian resources. Even if supplies
manage to enter Sudan, the challenge lies in
safely delivering them to conflict-affected
regions, where they are critically required [1].
The WMA and its constituent members
join the United Nations Security Council in
condemning in the strongest terms all attacks
on the civilian population,United Nations and
associated personnel and humanitarian actors,
as well as civilian objects, medical personnel
and facilities, and the looting of humanitarian
supplies [2].
RECOMMENDATIONS
1. The WMA supports the call by the UN
Security Council to conflicting parties
to immediately cease hostilities, facilitate
humanitarian access and establish a
permanent ceasefire arrangement and to
resume the process towards reaching a
lasting, inclusive and democratic political
settlement in Sudan.
2. The WMA calls upon all parties in
conflicts to:
• Respect the ethical principles of health
care, including medical neutrality, to
guarantee the safety of patients and
health personnel, and take immediate
steps to ensure that they are not
targeted or affected by the fighting,
including the provision of safe passage
of health care personnel and patients
where evacuation is required;
• Ensure that hospitals and healthcare
facilities have adequate supplies and
staffing to provide care to those in
need and facilitate humanitarian aid;
• End immediately gender-based
violence,including sexual violence as a
tactic of war to terrorize people.
3. The WMA urges the Sudanese authorities
to ensure impartial and independent
investigations into all alleged gross
violations and abuses of human rights
and serious violations of international
humanitarian law; and for perpetrators to
be held accountable.
References
1. Sudan: “Death came to our home”: War
crimes and civilian suffering in Sudan –
Amnesty International
2. Security Council Press Statement on
Sudan | UN Press, 02.06.2023
WMA RESOLUTION IN SUPPORT OF THE MEDICAL
ASSOCIATIONS IN LATIN AMERICA AND THE CARIBBEAN
Adopted by the 58th WMA General
Assembly, Copenhagen, Denmark, October
2007, reaffirmed with minor revision by
the 207th WMA Council session, Chicago,
United States, October 2017 and revised by
the 74th WMA General Assembly, Kigali,
Rwanda, October 2023
PREAMBLE
A lack of physicians, especially in vulnerable
and peri-urban areas, is a worldwide
phenomenon that has serious implications
for health systems, demanding policies to
assure the provision and retention of health
personnel. The implementation of programs,
such as the More Doctors Program (PMM),
in deprived areas in Latin America and the
Caribbean has provided doctors to support
primary health care which would otherwise
not be carried out due to the shortage of
doctors.
In particular, the PMM has provided a great
number of foreign doctors, predominantly
from Cuba, to work in the primary health care
systems where the distribution of primary care
physicians was insufficient.
Specifically,during the COVID-19 pandemic,
Cuba has sent thousands of Cuban doctors
abroad, to meet the demands of many
countries. In addition, international health
establishments, such as the Pan American
Health Organization, have facilitated the
placement of Cuban doctors.
WMA Declarations, Resolutions, and Statements
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However, programs like the PMM also give
cause for concern:
• Potential health benefits are
undermined due to the widespread
allocation of doctors to non-priority
areas and local substitution effects.
• The Cuban government keeps three-
quarters of the health personnel’s
salaries, and many doctors complain
of dreadful working conditions.
• Documented reports reveal
arrangements between the Cuban
government and certain Latin
AmericanandCaribbeangovernments
to bypass credentialing systems
established, to verify physicians’
credentials and competence and
protect patients. As a result, patients
may be put at risk by unregulated
medical practices and unqualified
physicians.
RECOMMENDATIONS
Recalling its Statement on Ethical Guidelines
for the International Migration of Health
workers, whereby “Physicians who are
working, either permanently or temporarily,
in a country other than their home country
should be treated fairly in relation to other
physicians in that country” and that bilateral
agreements require “due cognizance of
international human rights law, so as to effect
meaningful co-operation on health care
delivery”, the WMA:
1. Condemns any policies or actions by
governments that subvert or bypass
the accepted standards of medical
credentialing and medical care;
2. Calls on the governments to work with
medical associations within the region
on all matters related to physician
certification and the practice of medicine
and to respect the role and rights of these
medical associations and the autonomy of
the medical profession;
3. Urges, as a matter of utmost concern,
governments to respect the WMA
International Code of Medical Ethics,the
Declaration of Madrid on Professionally-
led Regulation, the Declaration of Seoul
on Professional Autonomy and Clinical
Independence and the Statement on
Ethical Guidelines for the International
Migration of Health workers;
4. Calls for adequate and sustainable
investment in national health care systems
and medical education as a matter
of priority to ensure that the highest
standard of care is available to the entire
population.
WMA RESOLUTION ON ACKNOWLEDGEMENT
AND CONDEMNATION OF THE HUMAN RIGHTS
VIOLATIONS AGAINST THE UYGHURS
AND OTHER MINORITIES IN CHINA
Adopted by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
In October 2020, the WMA passed a
Resolution which formally condemned the
treatment of the Uyghur population in the
Xinjiang region of China. The resolution also
repeated the July 2019 call of the UN Human
Rights High Commissioner for independent
international observers to be allowed into the
region.
The Office of the High Commissioner for
Human Rights (OHCHR) published a report
on 31 august 2022 on the “Assessment of
human rights concerns in the Xinjiang Uyghur
Autonomous Region, People’s Republic of
China”. The report’s assessments include
findings that serious human rights violation
have been committed in XUAR and that
patterns of restrictions have a discriminatory
component. The OHCHR furthermore
inter alia finds that allegations of forced
medical treatments and adverse conditions of
detention are credible.
“The purpose of the WMA is to serve
humanity by endeavouring to achieve the
highest international standards in Medical
Education, Medical Science, Medical Art
and Medical Ethics, and Health Care for all
people in the world”. Uyghur birth rates have
been cut through involuntary IUDs, abortions
and sterilisations [1]. All of these acts require
the involvement of medical professionals.
The People´s Republic of China is continuing
its campaign in a manner that is dependent
upon continued and extensive medical
involvement, engaging in the most egregious
violations of human rights,which risk bringing
the entire medical profession into disrepute. It
is therefore morally incumbent on the WMA
and its members to take a strong stand against
such reprehensible actions.
In October 2020, the WMA recognised and
condemned the treatment of the Uyghurs
in China. As there is now incontrovertible
WMA Declarations, Resolutions, and Statements
33
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WMA RESOLUTION ON ANTI-LGBTQ
LEGISLATION IN UGANDA
Adopted by the 223rd WMA Council,
Nairobi, Kenya, April 2023. Revised
and adopted by the 74th WMA General
Assembly, Kigali, Rwanda, October 2023
PREAMBLE
The WMA is gravely concerned about the
“Anti-Homosexuality law” that was passed in
the Ugandan parliament on March 21, 2023
and signed into law by Ugandan President
Yoweri Museveni in May. The WMA
originally condemned the bill in a press
release issued on March 24.
The Ugandan law criminalizes homosexual
acts and makes them punishable by death
or life imprisonment. A provision on the
“promotion” of homosexuality is also of grave
concern, exposing anyone who “knowingly
promotes homosexuality” to as much as
twenty years in prison.
This kind of legislation challenges the role of
physicians to objectively provide information
to patients and, where appropriate, those close
to them. Physicians could face disciplinary
action or retribution for pointing out in the
context of treatment that homosexuality is
a natural variation of human sexuality. This
can impact the professional practice of a
physician, as can be seen in other countries
that have implemented similar legislation. It
can also impact the health of individuals and
the population as a whole if patients of the
LGBTQ+ community are fearful of accessing
healthcare or of being forthcoming with
information when they require medical care.
As stated in its Statement on Natural
Variations of Human Sexuality and supported
in its Statement on Transgender People, the
WMA condemns all forms of stigmatisation,
criminalization of and discrimination against
people based on their sexual orientation.
The WMA reasserts that being lesbian,
gay, or bisexual are natural variations within
the range of human sexuality and that
discrimination, both interpersonally and at
the institutional level, anti-homosexual or
anti-bisexual legislation and human rights
violations, stigmatisation, criminalization
of same-sex partnerships, peer rejection and
bullying continue to have a serious impact
upon the psychological and physical health of
lesbian, gay or bisexual people.
Further, the WMA emphasises that everyone
has the right to determine one’s own gender
and recognises the diversity of possibilities
in this respect and calls for appropriate legal
measures to protect the equal civil rights of
transgender people.
RECOMMENDATIONS
Therefore, the WMA, reaffirming its
statements on Natural Variations of Human
Sexuality and on Transgender People, calls
on:
1. Ugandan authorities to immediately
repeal the Anti-Homosexuality law;
2. WMA Constituent members to condemn
the Ugandan law and advocate against
any similar legislation that is proposed or
enacted.
evidence surrounding their abuse, it is
incumbent on the Chinese Medical
Association to join other constituent
bodies of the WMA by acknowledging and
condemning this abuse.
RECOMMENDATION
In light of the mounting body of evidence,
including the report of 31 August 2022
from the OCHCR, of medical involvement
in severe human rights violations against
the Uyghur people and other minorities in
China, the WMA asks the Chinese Medical
Association to acknowledge the concerns
set out in the report by the UN High
Commissioner for Human Rights and comply
with the 2020 WMA Resolution on human
rights violations against Uyghur People in
China.
Reference
1. https://apnews.com/article/ap-top-news-
international-news-weekend-reads-
china-health-269b3de1af34e17c1941a51
4f78d764c
WMA Declarations, Resolutions, and Statements
34
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WMA RESOLUTION ON HUMAN RIGHTS
DEMONSTRATIONS IN IRAN
Adopted by the 222nd WMA Council
Session, Berlin, Germany, October 2022
and revised and adopted by the 74th WMA
General Assembly,Kigali,Rwanda,October
2023
PREAMBLE
The WMA is deeply concerned by the violent
repression of protesters against the Iranian
regime.
In its report to the 52nd
Human Rights
Council (March 2023), the United Nations
Special Rapporteur on the situation of
human rights in the Islamic Republic of Iran,
denounces the persistent violent response
by the Iranian security forces leading to
deaths of protesters, severe injuries and
thousands arrestations and detentions, with
life-imprisonment and death sentences.
The report documents cases of solitary
confinement, ill-treatments and inhumane
conditions of detention, as well as denial of
access to healthcare[1].
The WMA reaffirms its Resolution
supporting the Rights of Patients and
Physicians in the Islamic Republic of Iran,
its statements on solitary confinement and
in support of a moratorium on the use of the
death penalty.
RECOMMENDATIONS
1. The WMA condemns the persistent use
of brutal and lethal force against protesters
and calls on the Iranian authorities to:
• Immediately end all forms of violence,
torture and ill-treatment of protesters
and ensure that all perpetrators
responsible for violence, torture and
ill-treatment are held accountable;
• Fully adhere to its human rights
obligations, including the right to
peaceful demonstration and to the
enjoyment of the highest attainable
standard of physical and mental
health;
• Respect the autonomy of physicians
and in particular their ethical duty to
provide care to anyone on the basis of
medical need alone, and
• Ensure that healthcare equipment
and facilities are used for health care
purposes only.
2. The WMA urges the international
community to support efforts to promote
accountability for recent and long-
standing violations carried out with
impunity in Iran.
Reference
1. Report of the United Nations Special
Rapporteur on the situation of human
rights in the Islamic Republic of Iran,
March 2023
WMA RESOLUTION ON MEDICAL WORKFORCE
Adopted by the 50th World Medical
Assembly, Ottawa, Canada, October
1998, revised by the 60th WMA General
Assembly, New Delhi, India, October 2009
and the 74th WMA General Assembly,
Kigali, Rwanda, October 2023
PREAMBLE
The medical workforce is essential to
healthcare systems. To meet the present
and future health needs of the global
populations, adequate healthcare services
in all fields of medicine should be provided.
This requires ensuring sufficient numbers
of trained physicians in all countries taking
into consideration evolving populational
healthcare needs as well as physicians’ right
to international mobility, while preserving
the well-being and safety of both patients and
physicians.
Population growth in many parts of the
world, combined with ageing populations
in other regions point toward an increasing
shortage of physicians. Comprehensive and
extensive medical workforce planning on
both the national level and the international
levels is therefore essential, within an
ethical coordinated global framework, as
recommended in WHO Global Code of
Practice on the international Recruitment of
Health Personnel. In this regard, the WMA
reaffirms its Statement on Ethical Guidelines
for the International Migration of Health
Workers, and its Resolution on Task shifting
in dealing with the significant global shortages
of medical workforce[1].
Inadequate working conditions and the
lack of support to the medical workforce
has exacerbated the workforce shortage
situation causing physicians to leave their
home countries. This phenomenon occurred
especially during the COVID-19 pandemic,
which has renewed focus on physicians’ well-
being and safety.
In this regard the WMA reaffirms its policies
on Bullying and Harassment within the
Profession, Physician well-being, Protection
WMA Declarations, Resolutions, and Statements
35
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and Integrity of Medical Personnel in Armed
Conflicts and Other Situations of Violence,
Workplace Violence in the Health Sector,
Epidemics and Pandemics, the Medical
Profession and COVID-19, Digital Health,
as well as Augmented Intelligence in
Healthcare, Gender Equality in Medicine
and Medical Education.
Thriving both professionally and personally
is critical for the medical workforce to carry
out their vital responsibilities, and to ensure
quality healthcare services.
The World Health Organization (WHO) has
developed several instruments that support
the medical workforce, and acknowledge the
global urgency to support and protect health
personnel, in particular:
• The Global health and care worker
compact, a technical tool provided
to prevent harm, provide support,
safeguard rights,and ensure inclusivity
of the health workforce across the
world.
• The Global Strategy on Human
Resources for Health: Workforce
2030, to identify and implement
solutions to the healthcare workforce
problems.
RECOMMENDATIONS
The WMA stresses the need for
comprehensive and gender equal measures to
guarantee physicians’well-being and safety via
an adequate working environment, including
in emergency contexts, and emphasizes on the
employer’s responsibility to ensure it.
The WMA calls on the following stakeholders
to:
WHO and other relevant international entities
1. Strengthen the management of the
medical workforce through international
cooperation and consensus.
2. Provide timely data and information
to guide the international and national
efforts on medical workforce recruitment
and retention.
3. Identify the skills, knowledge and ways of
working that the evolving workforce will
require in the future.
Academic institutions
4. Ensure that the education, training and
development of the medical workforce
meets the highest possible standards,
including student support, and that
they are carried out with solidarity,
consideration and mutual respect.
5. Conduct and publish research on
the impact of working conditions of
physicians on the quality of healthcare
services provided, and on the effectiveness
of interventions aimed at ensuring
workplace safety.
6. Include clinical informatics and digital
health literacy in medical training and
education to ensure the workforce is
equipped with the skills and knowledge
to harness existing and emerging
technologies, in accordance with the
principle of confidentiality, to improve
health outcomes.
Governments / Health authorities
7. Guarantee the ethical international
recruitment of health personnel,
considering the rights, obligations
and expectations of source countries,
destination countries and migrant health
personnel, in reference to WHO Global
Code of Practice on the International
Recruitment of Health Personnel.
8. Develop and implement Positive Practice
Environments in health care settings in
line with the World Health Professions
Alliance (WHPA) campaign in order to
increase physician retention.
9. Establish an appropriate monitoring and
reporting mechanisms at institutional and
system level, to document deviations from
best practices for healthcare workplaces,
e.g. unacceptable working conditions,
shortage of staff and equipment. Such
a database should be made available to
professional organizations and other
relevant stakeholders.
10. Ensure that appropriate and safe patient to
physicians’ ratios are maintained between
the populations and the medical workforce
at all levels, including mechanisms to
align supply with population healthcare
need, and address access to care in rural
and remote areas, based on evidence-
based workforce planning, accepted
international norms and standards where
these are available, and in accordance
with the WMA Statement on Access to
Healthcare.
11. Directly address the obligations of
hospitals’commercial management and/or
representative organizations to ensure safe
and healthy working conditions.
12. Allocate sufficient financial resources for
the education, training and development
of the medical workforce to meet the
health needs of the entire population in
the country in reference to the WMA
Statement on Medical Education.
13. Combat discrimination and foster
inclusive policies for physicians and
personnel from foreign countries.
14. Adequately engage and collaborate
with medical professional bodies on the
development and implementation of
policies impacting on medical practice,
such as policies around Universal Health
Coverage, reimbursement, and allocation/
distribution of medical personnel, in
accordance with the WMA Declaration
of Seoul on Professional Autonomy and
Clinical Independence.
15. Adequately invest in the recruitment and
retention of the needed medical workforce
via the improvement of working
conditions, including:
• provision of fatigue management and
safe rostering practices, including
WMA Declarations, Resolutions, and Statements
36
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consideration of a maximum of weekly
working hours for physicians in all
health care establishments to prevent
burnout and sustain motivation,
• access to appropriate facilities,
equipment, treatment modalities, etc
• adequate support from other trained
healthcare professionals,
• protection from harassment, violence,
workplace stress, stigma and forced
labour,
• access to career development
opportunities at all professional
levels, including promotion of equity,
inclusion and diversity,
• adequate professional support and fair
remuneration.
16. In partnership with health professions’
organisations, timely anticipate potential
imbalances between the supply and
demand of medical workforce in order
to assess future needs in human resources
and design plans to meet those needs.
17. Address telemedicine in the contractual
responsibilities of recruited physicians
while recognizing the diverse needs
of the medical workforce by enabling
greater work-life balance, through flexible
and remote working where clinically
appropriate.
18. Develop transparent memoranda of
understanding between countries where
migration of physicians is an issue of
concern.
WMA constituent members
19. Promote WHPA Positive Practice
Environments campaign to create health
care settings that are high quality and
supportive workplaces.
20. Advocate for governments to develop
policies to support the recruitment of
physician candidates from within their
own countries.
21. Actively advocate for the protection of
physicians from harm, while promoting
adequate working and living conditions.
22. Work with the government to devise
appropriate policies addressing
multidisciplinary practice.
23. Promote regular evaluation and
improvement of the workforce planning
solutions’ impact and effectiveness.
Terminology:
– The term “medical workforce” in the text
refers to physicians.
– According to WHO Health Workforce-
related terminology:
“Health workforce” refers to health workers
considered collectively.
“Health workers” are all people primarily
engaged in actions with the primary intent of
enhancing health.
WMA Declarations, Resolutions, and Statements
37
UPDATE ON THE REVISION OF THE
WMA DECLARATION OF HELSINKI
Following the WMA Nairobi Council
meeting in April 2023, the workgroup to
revise the Declaration of Helsinki (DOH) met
on 23-25 September 2023 in Copenhagen,
Denmark, in conjunction with a Regional
Expert meeting for Europe graciously hosted
by the Danish Medical Association, and
in partnership with the American Medical
Association (AMA) and the World Medical
Association (WMA). The main topic of
discussion was new and emerging trial
designs. Expert speakers hailed from Europe,
the World Health Organization (WHO), the
U.S. Food and Drug Administration, and the
International Federation of Associations of
Pharmaceutical Physicians. The workgroup
is made up of constituent members from the
United States (Chair), Bangladesh, Belgium,
Brazil, China, Denmark, Finland, Germany,
Israel, Italy, Japan, Malaysia, the Netherlands,
Nigeria, South Africa, Taiwan, United
Kingdom, Uruguay, the Vatican, and the
Associate Members, and was led by the Chair
Dr. Jack Resneck, Jr.
Ethical Review Committees
At the Copenhagen meeting, the workgroup
discussed the complexities and difficulties
of ethical review committees, especially the
quality of research proposals being presented
for consideration and the qualifications of
committee members. The workgroup also
discussed the use of the terms “patient,”
“subject,” and “research participant,” and
whether or not the Declaration could set out
ethical requirements of investigators who are
not physicians.
Shared Decision-Making
The group then addressed the distinction
between participants who are under active
medical treatment and also research
participants. The concern is that the shared
decision-making by a physician involved
in both contexts could be interpreted as
paternalistic. However, the final decision
about participation in trials rests with the
patient. The workgroup concluded that these
concerns will need to be assessed,and the final
decisions on language will need to be made on
a case-by-case basis.
New and Emerging Trial Designs
On 3 October 2023, the workgroup met in
conjunction with the hybrid WMA General
Assembly Meeting in Kigali, Rwanda. Results
from the meeting include:
• Workgroup members discussed and agreed
with replacing “research subjects” with
“research participants.”
• Consistent with the previous workgroup
meeting in Copenhagen, there was
consensus among the workgroup that the
Declaration needs to address researchers
and research team members beyond
physicians. There may be places where
guidance specifically applies to physicians,
in which cases the word “physician” should
be retained. To this end, there was general
support for the AMA-drafted and drafting
group-reviewed edits to paragraph 2
that speaks to the applicability of the
Declaration.
• The workgroup chair shared with
meeting participants that experts at the
Copenhagen meeting expressed that
research with minimal or no social value
was an ethical issue that the Declaration
may need to address. Workgroup members
discussed the AMA-drafted and drafting
group-reviewed edits to paragraph 17
that raised the issue of the social value of
research.
• Meeting participants discussed whether
the Declaration needs to further address
the need for ethics committees to be
sufficiently trained and have access
to necessary resources. Participants
considered replacing the word “training”
with the word “education” or “expertise” in
paragraph 23.
Public Comment Period
The AMA’s proposed two-part public
comment structure beginning in early
2024 was accepted by the Council. Strong
momentum and international participation
in the revision process are encouraged for the
intended adoption of the revised Declaration
at the 2024 General Assembly meeting in
Helsinki, Finland.
Next Steps
The next meeting of the workgroup will
be held in conjunction with the WMA
Regional Expert Meeting for the Pacific at
the Tokyo Odaiba Hotel in Tokyo, Japan,
from 30 November to 1 December 2023. It
is generously hosted by the Japan Medical
Association, in partnership with the AMA
and the WMA.
Future regional meetings will be held at
the Vatican in January 2024 as well as
Johannesburg, South Africa, in February
2024. Members are encouraged to follow the
events listing on the WMA website (https://
www.wma.net/what-we-do/events/) for up-
to-date information.
Office of International Relations
American Medical Association
WMA Declarations, Resolutions, and Statements
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38
For this interview, Dr. Lujain
Alqodmani, the WMA President,
highlights her academic background and
training, shares current global challenges
for the medical community, describes
upcomingWMA activities,and promotes
the UN Decade of Action on Nutrition
(2016-2025), with Dr. Helena
Chapman, the WMJ Editor-in- Chief.
Please share a brief summary of
your professional education and
training in medicine.
I completed my medical education at
Kuwait University in 2012, followed by
a valuable internship with the World
Health Organization’s climate and
health unit,where I contributed to the
development of a global vulnerability
guide on climate and health.
Subsequently, I dedicated five years
to serving patients in the Emergency
Department of Amiri Hospital in
Kuwait, concurrently spearheading
quality control initiatives within the
department. Although the experience
was enriching, I grew increasingly
cognizant of the importance of
addressing the fundamental origins
of illness, aligning with Sir Marmot’s
philosophy: “we are sending people
back to the same environment that
made them sick in the first place”.
This awareness led me to actively
engage in global health initiatives
through my involvement with the
Kuwait Medical Association, the
Junior Doctors Network,and Women
in Global Health.
Motivated by my desire to effect
larger-scale change, I made a pivotal
career transition from clinical practice
to the realm of global health policy,
emphasising the need to approach
healthcare from a population-based
perspective rather than solely an
individual-focused one. To equip
myself with the necessary tools
and expertise, I pursued a master’s
degree in international healthcare
management, policy, and economics
at Scuola di Direzione Aziendale
(SDA) Bocconi in Milan, Italy, where
I deepened my understanding of the
intricate interplay between health
policies and their broader socio-
economic impact.
Given my unwavering commitment
to sustainability and health issues,
I was honoured to join the team
at EAT (https://eatforum.org/
about/), a global evidence-based
platform for sustainable food system
transformation, where I could
contribute my insights and skills
to the intersection of health and
sustainability within the context
of food systems. Presently, I am
dedicated to further advancing
my knowledge in the field of
epidemiology and population
health as a doctoral candidate at
the esteemed London School of
Hygiene and Tropical Medicine.
My research focuses on uncovering
crucial insights into the dynamics of
disease prevalence and the broader
determinants of population health.
What has motivated you to pursue this
WMA leadership position, and what
international impacts do you hope to
achieve over your tenure?
My decision to pursue the WMA
leadership position stems from my
profound belief in the organisation’s
pivotal role in representing and
advocating for the global physician
community. Having actively engaged
with the WMA for the past eight
years and closely witnessed its
impactful initiatives, I was driven to
contribute more significantly to its
mission and vision.
Recognising the WMA as an
influential platform that effectively
addresses complex ethical dilemmas
and establishes robust standards for
medical practice worldwide, I am
committed to leveraging its extensive
repository of policies and statements
to amplify its voice and impact within
the global health arena. My primary
objective is to enhance the WMA’s
relevance as a dynamic global actor,
ensuring that its wealth of knowledge
is more widely disseminated, and its
policies more actively implemented to
effect tangible change.
In alignment with this vision, I am
dedicated to broadening the WMA’s
global reach, particularly in the
Eastern Mediterranean Region, by
fostering an inclusive environment
that encourages the active
participation and representation of
physicians from diverse backgrounds
and geographies. In this pursuit, I
aim to promote gender diversity
and equity within the organisation,
advocating for the empowerment
of women leaders through
structured mentorship programs, the
establishment of safe and equitable
work environments, and the advocacy
for gender parity in remuneration.
Moreover, I am committed
to nurturing the professional
development of WMA members,
equipping them with the necessary
Lujain Alqodmani
Interview with the WMA President
Interview with the WMA President
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39
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Interview with the WMA President
tools and knowledge to effectively
address the evolving challenges posed
by climate change on global health.
By fostering comprehensive capacity-
building initiatives, I seek to ensure
that our members are well-prepared
to proactively address the multifaceted
impacts of climate change on health
outcomes (Photo 1).
Recognising the transformative
potential of artificial intelligence
in medicine, I intend to initiate
constructive dialogues within the
WMA, facilitating a comprehensive
exploration of the benefits and
potential risks associated with its
integration into medical practice. By
fostering an inclusive environment
that encourages the active
participation of junior doctors in
WMA meetings, I aim to cultivate
a collaborative and nurturing space
that not only benefits from their fresh
perspectives but also encourages their
active engagement in shaping the
future of global healthcare policies.
Aside from the ongoing COVID-19
pandemic, what are the three greatest
global challenges that physicians
currently face, and how can the WMA
address these challenges?
Beyond the relentless impact of the
COVID-19 pandemic,there are three
overarching challenges that physicians
grapple with on a global scale, which
the WMA is actively working on:
• Violence against Healthcare
Professionals: The persistent
threat of violence against
physicians and healthcare
personnel remains a distressing
issue worldwide, posing a
significant threat to the well-being
and safety of those dedicated
to saving lives. The WMA has
consistently condemned such
acts, exemplified by the urgent
resolution adopted during the
WMA General Assembly in
Kigali condemning violence
against physicians in Nepal. To
combat this challenge, the WMA
continues to advocate for safe
work environments for healthcare
professionals, particularly women
and youth who are more vulnerable
to such acts of violence. Moreover,
the organisation is actively
engaged in addressing the issue of
violence during conflicts and wars,
emphasising the protection of
healthcare facilities and personnel
in conflict zones, as seen in recent
instances in Sudan,Ukraine,Gaza,
Syria, and Yemen.
• Implications of Artificial
Intelligence and Emerging
Technologies: The rapid
advancement of artificial
intelligence and other emerging
technologies in the medical field
poses complex ethical and practical
challenges for physicians. The
WMA recognises the necessity
of navigating these developments
cautiously, to safeguard patient
safety, data confidentiality, and
equitable access to healthcare,
while fostering a culture of
innovation. By initiating proactive
discussions and policy frameworks
that address the implications of
these technologies, the WMA
remains at the forefront of
ensuring that the integration of
such advancements complements
and enhances the role of physicians
without replacing their vital
contributions to patient care.
• Climate Emergency and its
Impact on Health: With climate
change exerting an increasingly
detrimental influence on public
health, including the escalation
of extreme weather events and
the exacerbation of health crises,
the WMA advocates for robust
education and capacity-building
programs for physicians within the
healthcare sector. By prioritising
the integration of climate change
education in medical curricula
and promoting comprehensive
awareness campaigns, the WMA
stresses on the need to actively
equip healthcare professionals
with the necessary tools and
Photo 1. World Medical Association General Assembly in Berlin 2022. Credit: World Medical Association
40
knowledge to effectively adapt to
and mitigate the adverse health
effects of climate change (Photo 2).
As WMA President, what do you
hope to accomplish over the next few
months,and how can WMA leadership
help support these efforts?
As President of the WMA, my
immediate focus is to spearhead
several pivotal initiatives over the
next few months. Recognising the
critical need for inclusive spaces and
support systems, I am committed
to fostering a stronger network for
women leaders within the WMA
through the introduction of dedicated
“women-in-medicine” dinners at
upcoming WMA meetings. These
gatherings will serve as a platform for
fostering mentorship opportunities
and facilitating open discussions on
pressing issues faced by women in the
field.
Furthermore,I am resolute in tackling
the issue of sexual harassment within
the context of WMA meetings,
aiming to initiate a comprehensive
process that officially addresses
and combats such misconduct.
By implementing robust policies
and frameworks, we can ensure
the creation of a safe and inclusive
environment that upholds the highest
standards of professional conduct and
respect for all participants.
Amid the complex geopolitical
challenges, particularly the ongoing
conflicts and wars, I am committed
to amplifying the WMA’s voice in
advocating for medical neutrality,
the adherence to international law,
and the protection of healthcare
infrastructure and personnel. This
will involve active representation
and advocacy for these critical
principles in various international
forums, fostering a unified global
commitment to safeguarding the
integrity of healthcare services in
conflict zones.
Additionally, I am dedicated to
championing the cause of climate
change action, with a particular focus
on integrating health considerations
into countries’ climate action plans.
Building upon the recent collaborative
efforts with other healthcare
professional organisations, including
the signing of an open letter that calls
on governments to end fossil fuels
dependency, I will lead the WMA
delegation at the 28th Conference of
Parties (COP28) in Dubai, United
Arab Emirates, to advocate for urgent
and comprehensive measures to
identify the root causes of the climate
crisis, vocalise the need for resilient
low-carbon healthcare systems,
and encourage the development of
capacity building programs to better
equip healthcare professionals to face
climate change impacts.
To fortify the global reach and
impact of the WMA, I will actively
engage with national medical
associations, fostering open and
constructive dialogues to encourage
their membership in the WMA,
particularly in the Middle East region.
By cultivating these partnerships, we
can strengthen the collective voice
of physicians worldwide, fostering
a more cohesive and influential
platform for discussing global health
challenges.
Lastly, in partnership with the WMA
ExecutiveCommittee,Iaimtodevelop
a robust and inclusive new strategy
for the organisation that reflects the
contemporary challenges faced by
physicians globally. By prioritising
an inclusive and participatory
approach, we can guarantee that the
WMA remains agile, responsive, and
effective in its mission to advocate for
the welfare and professional interests
of physicians worldwide.I am grateful
for the unwavering support of the
WMA leadership and look forward
to our continued collaboration in
achieving these critical objectives.
With your WMA leadership in the
Environment Caucus and global
leadership and expertise in sustainable
food systems, what should WMA
members understand about the UN
Decade of Action on Nutrition (2016-
2025)? HowcantheWMAsupportthis
global initiative, including the 2030
Interview with the WMA President
BACK TO CONTENTS
Photo 2. General Assembly of the United Nations 2023. Credit: Dr. Lujain Alqodmani
41
Agenda for Sustainable Development,
towards the elimination of hunger,
food insecurity, and malnutrition?
I am deeply committed to
highlighting the crucial significance
of the UN Decade of Action on
Nutrition (2016-2025) to all WMA
members.This global initiative serves
as a critical framework for addressing
the complex global challenges related
to nutrition, hunger, food insecurity,
and malnutrition. WMA members
must recognise that the UN Decade
of Action on Nutrition plays a pivotal
role in fostering a comprehensive
and collaborative approach to
improving global nutrition outcomes.
It emphasises the need for integrated
efforts across multiple sectors,ranging
from healthcare to agriculture,
education, and policy-making, to
effectively tackle the underlying
causes of malnutrition and food
insecurity.
To support this significant global
initiative, the WMA can play a vital
role in several key areas:
• Advocacy and Policy
Development: The WMA
can actively advocate for the
prioritisation of nutrition and
sustainable food systems within
national and international policies.
By engaging with policymakers
and stakeholders, the WMA
can promote evidence-based
approaches that emphasise
the crucial linkages between
nutrition, health, and climate and
biodiversity sustainability.
• Capacity Building and
Education: The WMA
should offer and encourage
the development of targeted
capacity-building programs
and educational resources to
empower healthcare professionals
to effectively address nutrition-
related challenges within their
communities. These initiatives
can include training programs
that emphasise the importance
of balanced diets, nutrition
education, and sustainable food
production practices.
• Research and Knowledge
Sharing: By fostering a culture
of collaboration and information
exchange, the WMA can
contribute to the generation of
valuable insights that can inform
evidence-based interventions and
policies in the field of nutrition
and sustainable food systems.
• PartnershipsandCollaborations:
The WMA can actively engage
with various stakeholders,
including governmental and
non-governmental organisations,
international agencies, and other
relevant institutions, to foster
meaningful partnerships that
support the goals of the UN
Decade of Action on Nutrition
(2016-2025). By leveraging the
collective expertise and resources
of these diverse stakeholders, the
WMA can amplify its impact
and contribute to the creation of
holistic and sustainable solutions
to address global nutrition
challenges.
Furthermore, by aligning its efforts
with the broader 2030 Agenda for
Sustainable Development, the WMA
can contribute to the achievement
of Sustainable Development Goal
2. These efforts include prioritising
sustainable and equitable food
systems, which can help eliminate
hunger, food insecurity, and
malnutrition, ultimately fostering a
healthier and more sustainable future
for all.
Lujain Alqodmani,
BMSc, MBBS, MIHMEP
President (2023-2024),
World Medical Association
lujainalq@gmail.com
Interview with the WMA President
BACK TO CONTENTS
42
The World Medical Association (WMA)
Associate Membership is a wonderful
world – a world of original thinking, a
world of free speech,a world of new ideas
and initiatives, a world of commitment
and friendship – and an invaluable
place at the heart of the WMA.
WhatdoesitmeantobeanAssociate
Member of the WMA?
The WMA is the umbrella
organisation for 115 National
Medical Associations around the
world (“Constituent Members”),
representing more than 10 million
physicians. In addition, there are
more than 2,000 individual WMA
Associate Members. It is quite an
impressive number of individual
doctors who are interested in
contributing to WMA activities,
discussing important issues raised in
its various bodies and workgroups,
and being informed about key issues
affecting global physicians. Associate
Members can participate in the
discussions at the heart of WMA’s
activities as well as contribute as
individual members to workgroups
organised by the Associate Members,
serve as a delegate of the Associate
Members,andattendWMAmeetings
and sessions. It also highlights the
benefit of forming part of a global
network of colleagues, having
contacts (and making friends) all over
the world – a very special experience!
Who can become an Associate
Member?
Physicians across the world can
become a WMA Associate Member,
regardless of whether their own
National Medical Association
is a member of WMA. A very
active group within the Associate
Membership, the Junior Doctors
Network (JDN) offers a platform for
colleagues who have graduated within
the previous 10 years or who are
pursuing postgraduate training, and
Past Presidents and Past Chairs of the
WMA also have their own network
within the Associate Membership.
Associate Membership requires an
annual fee of US$75; however, JDN
members do not pay membership fees
for the first five years after graduation,
and Past Presidents and Chairs
do not pay membership fees. The
current Associate Membership rules
can be found on the WMA website
(https://www.wma.net/wp-content/
uploads/2022/10/A M1-Rules-
Associate-Membership-Oct2022-1.
pdf).
What are the structures of the
Associate Membership?
The WMA Associate Membership
is led by a Steering Committee of
nine, with a Chairperson at its head,
and representatives of the different
segments of the membership. The
team meets virtually every two months
and is responsible for structuring the
work and organising various activities.
What are the tasks of Associate
Members?
One of the main tasks that we perform
as WMA Associate Members is
to respond to WMA consultations
when documents are circulated for
review. This opportunity allows us
to express our views and gain insight
on the full range of issues covered
by WMA policies and statements.
This is done either individually by
all Associate Members, who receive
information and respond via email,
or by an ad hoc workgroup organised
by the Associate Member Steering
Committee. No need to stress how
interesting this process is!
Another role of Associate Members
is to participate in WMA workgroups
as delegates, nominated by the
Steering Committee. For example,
among other Workgroups, there
are currently Associate Member
delegates in the WMA Workgroup
on the Revision of the Declaration
of Helsinki as well as the Workgroup
on Environment (chaired by an
Associate Member).In fact,Associate
Members are represented in most
WMA workgroups. Associate
Members also use the active support
of members for organising webinars
on pressing topics (e.g. health
workforce, disinformation) and
serving on the Steering Committee
(e.g. annual elections depending on
the Committee’s function).
What is the contribution of
Associate Members to the WMA?
The main contribution of the
Associate Members is the ability
to freely express their perspectives
as individual physicians, based on
specific professional experiences.
Associate Members do not represent
medical associations, which leaves
them free from the constraints and
political correctness inherent to
such organisations. For example,
Associate Members have contributed
to establishing rules to ensure the
Jacques de Haller
A Few Words about WMA Associate Membership
A Few Words about WMA Associate Membership
BACK TO CONTENTS
43
safety of LGBTQ+ delegates at
WMA meetings or advocating that
such meetings should not be held in
geographic settings where physicians
are persecuted. Currently, they are
preparing documents for the WMA
on the issues of ageing physicians or
of medical neutrality, especially as the
latter term is still a poorly defined
concept in the scientific literature.
Words from the Chairperson
As Chairperson, I have had
the privilege of succeeding two
remarkable personalities, Dr. Joe
Heyman and Dr.Anthea Mowat,who
each exhibited their own outstanding
talents, expertise, and distinctive
touch with the WMA. I am very
grateful to be seconded by such a
supportive Steering Committee.
With my primary tasks of keeping
the WMA Associate Membership
in good spirits and harmony and
encouraging diversity – diversity
of opinion, but also, in our global
organisation, diversity of feelings
and of medical and political culture
– we recognise that diversity does
not happen automatically. It must
be actively fostered, giving everyone
the opportunity to share their
perspectives and engage in collective
dialogue. As we reflect upon our
unique contributions to the WMA, I
encourage you to join and contribute
to the Associate Membership
activities – indeed, it is a wonderful
world!
Jacques de Haller, MD
Chairperson, Associate Members,
World Medical Association
mail@jdehaller.ch
A Few Words about WMA Associate Membership
BACK TO CONTENTS
44
The spread of communicable, non-
communicable diseases and their
syndemics across the world is a
dynamic and complex phenomenon,
as well as the design of effective,
appropriate, efficient, and culturally
relevant interventions to reduce
their impact on population health.
Developingaholisticviewtoapproach
such a complexity is an urgent
need. Working through networks to
conduct and expand the scope and
reach of transdisciplinary research is
a way of moving forward. This is in
line with contemporary approaches
of international health organisations
that evolved from being disease-
centred to include psychosocial and
environmental perspectives rooted in
a transdisciplinary global health vision
[1,2]. Transdisciplinary research is
defined as integrated knowledge from
multiple academic disciplines and
non-academic stakeholders to address
societal challenges [3]. Guided by
the principle that ‘scientific rigour
should meet societal relevance’, this
perspective offers an opportunity to
leverage expertise across disciplines
to collaborate on pressing health
concerns across geographical regions
and incorporate evidence-based
research findings into policy and
practice.
Notably, three key global initiatives
and guidance documents have
highlighted this holistic and
collaborative perspective to address
the burden of communicable and
non-communicable diseases, and
impacts on human, animal, and
environmental health. First, in
September 2015, the United Nations
(UN) approved the 2030 Agenda for
Sustainable Development (https://
sdgs.un.org/2030agenda) at the UN
Sustainable Development Summit,
building upon the recognition that
basic human needs, such as housing,
water, food, gender equality, food
insecurity, poverty alleviation, and the
environment, are deeply connected
[4]. As the benefits of reaching
these 17 ambitious goals are felt
Dennis Pérez Chacón
Forming a Transdisciplinary Research Network
to Address Diseases and their Syndemics
Yisel Hernández Barrios
Yosiel Molina Gómez
Forming a Transdisciplinary Research Network to Address Diseases and their Syndemics
Helena Chapman
Martha Chang de la Rosa
María del Carmen Zabala Arguelles
BACK TO CONTENTS
Claudia Patricia Nieto-Sánchez
45
Forming a Transdisciplinary Research Network to Address Diseases and their Syndemics
across all aspects of our society, a less
fragmented research environment and
generation of common languages can
promote a more integrative science
[5]. Second, in January 2016, the
World Health Organization (WHO)
launched the Global Action Plan on
Antimicrobial Resistance, adopted at
the World Health Assembly in May
2015, which aimed to guarantee safe
and effective clinical management
for infectious diseases [6]. The
WHO has compiled a library of
approved national action plans on
antimicrobial resistance (AMR),
supporting all nations to reexamine
and update their national action plans
to combat AMR and participate in
World AMR Awareness Week each
18-24 November (https://www.who.
int/campaigns/world-antimicrobial-
awareness-week). Third, in October
2022, the Quadripartite organisations
(WHO; UN Environmental
Programme, UN; World
Organization for Animal Health,
WOAH; Food and Agriculture
Organization of the UN, FAO)
published the One Health Joint
Plan of Action 2022-2026, which
incorporated six action tracks to
promote implementation efforts of
the One Health concept (human-
animal-environment nexus) across
global initiatives [7].
These initiatives are particularly
relevant in the Latin America and
Caribbean (LAC) region, recognised
with diverse geographic, political,
and socioeconomic variation. Before
the onset of the coronavirus disease
2019 (COVID‑19) crisis, overall
population health status remained
unequal across and within LAC
countries. Improvements observed in
non-communicable disease outcomes
in the LAC region were slower, when
compared with other geographic
regions, while communicable diseases
and injuries persisted as relevant
health issues. As smoking, alcohol
drinking, and obesity remained
critical risk factors for poor health,the
quality of care and universal health
coverage were unfulfilled promises
[8]. Additionally, the LAC region
was massively and disproportionately
affected by the COVID-19 pandemic,
when compared to other regions, and
major disruptions in routine health
care provisions exposed fragile health
systems [9].
With the intention of contributing
to address global health priorities,
the inaugural meeting of the
Transdisciplinary Research Network
on Communicable and Non-
communicable Diseases and their
Syndemics (Red de Investigación
Transdisciplinar sobre Enfermedades
Transmisibles, No Transmisibles y
sus Sindemias, RIT) was held on
29-31 August 2023, in Varadero,
Cuba (Photo 1). Supported by the
Strengthening Collaboration for
Syndemics in Cuba (SCS Cuba),
a partnership between the “Pedro
Kourí” Tropical Medicine Institute
(Instituto de Medicina Tropical
“Pedro Kourí”, IPK), the Institute of
TropicalMedicineofAntwerp(IMT),
and the National Institute of Hygiene,
Epidemiology and Microbiology
(Instituto Nacional de Higiene,
Epidemiologia y Microbiologia,
INHEM),this event aimed to identify
knowledge gaps affecting research
conducted in the LAC and other
regions. The meeting was funded by
the Belgium Directorate-General
for Development Cooperation and
Humanitarian Aid (DGD).
To support a robust meeting agenda,
the organising committee promoted
five objectives: 1) expanding
interdisciplinary and transdisciplinary
research collaborations among
researchers representing the IPK,
ITM, and INHEM, among
other national and international
institutions; 2) identifying alternative
funding mechanisms that can
strengthen research capacity related
to transdisciplinary approaches; 3)
detecting synergies and ongoing
collaborative projects among the
RIT Network; 4) finding formative
spaces to strengthen interdisciplinary
and transdisciplinary research
collaborations; and 5) communicating
research findings that highlight the
value of theoretical-methodological
capacities on vulnerability and
syndemics.A total of 50 professionals,
representing Belgium, Canada, Cuba,
Dominican Republic,France,Mexico,
and the United States, met in-person
and virtually to present scientific
topics and discuss overall challenges
and areas to strengthen collaborative
research networks. In this article, the
authors will describe the background
of the RIT Network, discuss
theoretical and methodological
aspects related to health-related
social vulnerabilities, and share the
consensus on next steps to strengthen
capacities and research networks.
Background of the RIT Network
The IPK´s institutional model,
developed between 2009 and 2019,
included institutional, national, and
international projections for the LAC
region based on three dimensions:
research (social,geospatial,and health
economic studies), capacity-building
(using a participatory and dialogic
pedagogical model), and economic
contributions (human and financial
resource mobilisation). Through
IPK`s research experiences,the model
implementation provided theoretical
and methodological support for
applied social and transdisciplinary
research on infectious diseases,
offered quantitative and qualitative
methodologies and tools to describe
and understand disease transmission
dynamics, and illustrated how
social science contributions can
strengthen global health research
[10]. Specifically, capacity building
on qualitative and mixed methods
research has been institutionalised
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46
Forming a Transdisciplinary Research Network to Address Diseases and their Syndemics
within the postgraduate and doctoral
programs,and IPK´s networking with
biomedical and social sciences has
expanded across selected national and
international institutions. Building
upon the IPK’s model, the RIT
Network framework offers a holistic
view of applying social sciences
and transdisciplinary approaches to
global health research, especially for
infectious disease prevention and
control.
Primary Thematic Focus of
Vulnerability
Recognising that vulnerabilities and
other social phenomena mediating
health outcomes increase during
public health crises, this first meeting
of the RIT Network aimed to promote
the need for urgent integration of
social sciences’ perspectives into
the public health community. With
robust scientific talks and collective
discussions organised into two main
sessions, the content and focus
reveal the disciplinary heterogeneity
of the panellists´ backgrounds (e.g.
anthropology,economy,epidemiology,
health administration, psychology,
social communication, sociology,
medicine, public health, urbanism
and architecture) and the complex
relationships encountered during
their research collaborations.
Theoretical Perspectives and Analytic
Frameworks
Dr. Maria del Carmen Zabala
(Latin-American Faculty of Social
Sciences, Cuba) presented the scope
and challenges for social protection
of vulnerable groups for COVID-19
in Cuba. She shared two types of
analyses connecting health and social
vulnerabilities – health vulnerability
to differential access and risk related
to social determinants of health
(SDOH), and social vulnerability
emphasising pre-existing social
conditions, poverty, and inequality.
By applying an intersectional lens
in vulnerability analysis, she agreed
that a policy tool can help diversify
interventions that hinder access to
health services.
Dr. Helena Chapman (George
Washington University, USA)
elaborated on using the One Health
approach to better understand the
impacts of changing ecosystems on
vulnerability. She highlighted that
natural and anthropogenic changes
within the surrounding environment
(e.g. extreme temperatures, poor
air quality, vector-borne disease
transmission) can increase risk of
population exposure to harmful
conditions, emissions or disease
vectors, and health systems must be
prepared to address these emerging
One Health risks. By incorporating
innovative data – including remote
sensing and other geospatial data,
qualitative research, citizen science
applications, social media technology,
and community mobilisation – she
commented that the development of
disease early warning systems and
aerosol monitoring tools can help
inform risk to vulnerable communities
and prepare health decision-makers
to manage key health challenges for
the decade of action [11].
Dr. Adolfo Álvarez (INHEM,
Cuba) defined SDOH as the process
resulting from complex interactions
of factors and conditions throughout
the lifespan, and discussed the Cuban
theoretical and methodological
model of SDOH and its contribution
to understanding vulnerability. In
his view, vulnerability is related to
diverse environments (e.g. personal,
professional, familiar, economic,
political),where he noted that specific
factors or conditions can socially
influence the exposure to individual
or population health risks as well as
the ability to respond and adapt to
health risks.
DisciplinaryPerspectivesofApproaching
Vulnerability
Dr. Koen Peeters (ITM, Belgium),
trained as a social and cultural
anthropologist, argued that
understanding the inherent logic and
rationale for the implementation of
established interventions and value for
participating stakeholders can reduce
misconceptions and stereotypes
and increase their acceptability
and effectiveness. Then, Dr. Yamilé
Ferrán (Faculty of Communications,
University of Habana, Cuba),
trained as a social communicator,
used vulnerability as a framework to
discuss how public communication
focused on health-related outcomes
can provide a sustainable, humanistic,
and inclusive cultural context to
community interventions.
Dr. Diana Sagastume and Dr. Ellen
Mitchell (ITM, Belgium), Dr.
Armando Seuc (INHEM, Cuba),
Dr. Alina Martinez (IPK, Cuba),
and Dr. Ángel Escobedo (Institute
of Gastroenterology, Cuba) shared
valuable insights to the discussion on
health-related vulnerability based on
the evidence-based literature and their
global health research experiences in
Belgium, Cuba, and other nations.
They collectively discussed the
unique contributions of applying a
vulnerability lens to evaluate current
health initiatives that aim to reduce
mortality due to diabetes,tuberculosis
(TB), and parasitic infections in the
LAC region.
Highlights from Empirical Research on
Vulnerability
Dr. Yisel Hernández (IPK, Cuba)
provided insight on syndemics
research that explored health-
related vulnerability in the context
of the global COVID-19 pandemic,
including social and environmental
factors,theoreticalandmethodological
approaches, and main contributions
BACK TO CONTENTS
47
and limitations. Then, Dr. Alberto
Baly (IPK, Cuba) described a
study conducted in a tertiary-
level Cuban hospital to explore
associations between health-related
vulnerability and the COVID-19
clinical presentation. Next, Dr. Anna
Pomaro (Center of Population and
Development, CEPED, France) and
Dr. Yadira Díaz (Center of Youth
Studies, Cuba) presented an analysis
of how the definition of vulnerability
changed during the COVID-19
pandemic in Cuba. They identified
vulnerability-related risks and
challenges of different population
groups and analysed the impact
of the COVID-19 pandemic on
reestablishing social and community
networks and access to health services.
Dr. Claudia Nieto and Dr. Stefanie
Dens (ITM, Belgium) described how
they applied different methodological
approaches to better understand
how living conditions, socio-
economic status, mobility routines,
and health-seeking itineraries are
related in a specific context and
space that influences overall risk and
vulnerability. Then, Dr. Bienvenido
Veras-Estévez (Universidad
Católica del Cibao, Dominican
Republic) mentioned self-perceived
vulnerabilities related to HIV/AIDS
and TB in urban and marginalised
(bateyes) communities in the
Dominican Republic.He stressed that
strengthening links with community
leaders and families for HIV/TB care
can help minimise vulnerabilities and
stigma through the implementation
of prevention programs, access to
primary health care services, social
security protection, and access to
community and national resources,
noting the significant impact of the
COVID-19 pandemic (e.g.challenges
in TB and COVID-19 control) [12].
Next, Dr. Mabel Carabali (McGill
University, Canada) questioned the
way that ethnic and racial population
data are being used and interpreted
in relation to health issues in the
LAC region, based on her research
experiences examining the paradox
of dengue severity and socioeconomic
distribution of Afro-Colombian
residents. Considering SDOH and
other health gaps, she described
analytical findings on the racial
context that generated differential
health outcomes that could exacerbate
health-related vulnerabilities.
Dr. Dayana Rodríguez (IPK, Cuba)
and Dr. René González (Faculty of
Geography, University of Habana,
Cuba) used epidemiological,
environmental, and spatial data to
classify territories with different
vulnerability levels within a particular
Cuban municipality. Then, Dr. Luis
Fonte and Dr. Yisel Hernández
(IPK, Cuba) presented risk factors
related to helminths and compared
scenarios with different hygiene,
socioeconomic, and environmental
conditions that could influence
vulnerability to parasitic infections
affecting the Cuban populations.
These collective talks provided
information on how understanding
these risk factors could provide a
framework to develop appropriate
and timely health interventions to
mitigate risk to infectious diseases.
Dr. Lisandra Fuentes (Interamerican
University of Mexico, Mexico)
revealed vulnerabilities in men
who have sex with men from
Cuba and Mexico, considering the
influence of selected dimensions
like socioeconomic conditions,
stigma and discrimination, support
networks, and gender roles. Then,
Dr. Clare Barrington (UNC, USA)
raised the importance of determining
the economic, emotional, and health
access impact of the COVID-19
pandemic on female sex workers
living with HIV in Tanzania and the
Dominican Republic.
Collective Analysis and Discussion on
Vulnerability
Using a participatory process to
guide the meeting participants in
their reflections on vulnerability, Dr.
Geydis Fundora (Latin American
Faculty of Social Sciences, University
of Havana, FLACSO, Cuba)
presented the basic principles of a
methodological framework to build
territorial profiles of individuals and
families with social disadvantages in
the Cuban context. As part of the
process, participants reflected on
vulnerable individuals (e.g. individual
characteristics or unfavourable
environmental conditions) –
elderly, pregnant women, migrants,
people living with HIV/AIDS,
low income status, disabilities,
absence of a supportive network,
and inability to mobilise assets. The
collective discussion highlighted the
importance of defining vulnerability
as a construct that implies a condition
of risk as well as understanding
the resilience needed to respond to
community risks, considering the
complexity when addressing and
defining vulnerable populations.
As the panellists shared empirical
findings on diverse scenarios
that incorporate vulnerability in
prevention and control approaches,
participants described the theoretical,
methodological, and practical gaps
that can drive mainstream data
collection, analysis, and reporting to
build profiles of social vulnerability
in current public health research
and practice. Notably, participants
commented that as vulnerable groups
are identified using existing policies
or certain sociodemographic variables
as a reference point, associations
among vulnerability, marginalisation,
and poverty factors often derive into
misconceptions and stigmatisation.
They suggested that health status and
medical conditions represent two key
dimensions of the methodological
Forming a Transdisciplinary Research Network to Address Diseases and their Syndemics
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48
framework that can be adapted to the
public health field.
Next Steps for the RIT Network
This inaugural meeting of the RIT
Network provided an open forum
for meeting participants of diverse
specialties to identify common
interests, streamline opportunities
for capacity building and
transdisciplinary research, brainstorm
on funding alternatives, and discuss
future directions for the network, as
they connect to health-related social
vulnerabilities on communicable and
non-communicable diseases and their
syndemics. Developing capacities
in transdisciplinary research was
deemed relevant to address complex
public health issues and fulfil
current funding schemes. Initial
agreements to formalise the RIT
Network were adopted, including
the promotional logo, documentation
and project portfolio, constitution as
a consortium, member recruitment,
and annual meetings.
The collective discussion on funding
opportunities was led by Dr. Jorge
Fraga (IPK, Cuba), director of
the Department of Science and
Innovation and project coordinator
of SCS Cuba, and Dr. Maria Eugenia
Toledo (IPK, Cuba), a scholar
with numerous successful funding
applications. Participants highlighted
the potential synergies between
the IPK-INHEM-ITM inter-
institutional collaboration and other
funding alternatives (e.g. Global
Fund to Fight AIDS, Tuberculosis
and Malaria, Pan American Health
Organization, WHO Special
Programme for Research and
Training in Tropical Diseases,
MediCuba Europe, other European
Union sources). Specifically, Flemish
Interuniversities Council (Vlaamse
Interuniversitaire Raad, VLIR),
Academy of Research and High
Education (Académie de recherche
et d’enseignement supérieur, ARES),
and Horizon Europe were recognised
as potential organisations to promote
academic mobility and create
consortia based on the RIT Network’s
competencies.
As the scope and rigour of social
science research may be poorly
understood and valued by biomedical
research groups, the urgency for
strengthening capacities, identifying
and formalising inter-institutional
academic collaboration, generating
joint programs with transdisciplinary
lens, identifying users for training
programs, and visualising capacity
building within research projects,
were proposed as alternatives to close
the knowledge gap. Dr. Marta Castro
(IPK, Cuba), director of the IPK
Department of Academics, described
the ever-growing number of IPK
training programs each year, and
highlighted that IPK is strategically
placed to support the RIT Network
within inter-institutional spaces as
members move toward achieving
established goals.
Asidefromthesuccessfulfirstmeeting
of the RIT Network in August 2023,
two additional concrete actions have
helped advance the RIT Network.
First, IPK researchers were invited
to present the importance of the RIT
Network to address global health
issues during the Cuban National
School of Public Health (Escuela
Nacional de Salud Pública,ENSAP)’s
Annual Conference 2023, which
was held on 23-27 October 2023
(https://eventosensap.sld.cu/index.
php/ensap23/2023). Second, IPK
and the Faculty of Social Sciences of
the Cuban University of Cienfuegos
advanced the formalisation of an
official inter-institutional agreement
in October 2023. These actions were
led by two RIT Network members:
Dr. Noralydis Rodríguez (ENSAP,
Cuba) and Dr. Vanesa Fernández
(Faculty of Social Sciences of the
University of Cienfuegos, Cuba).
As the second meeting of the RIT
Network is planned for August 2024,
RIT Network coordinators, together
with network membership, foresee
collaborative efforts to improve team
organisation, refine short-, medium-,
and long-term commitments
and goals, and generate regular
communication channels.They invite
all scientific and social disciplines
– including global physicians – to
leverage their expertise by joining
the RIT Network that can foster
Forming a Transdisciplinary Research Network to Address Diseases and their Syndemics
Photo 1. Participants attending the inaugural meeting of the Transdisciplinary Research Network on Communicable and
Non-communicable Diseases and their Syndemics in Varadero, Cuba on 29-31 August 2023. Credits: RIT Network
BACK TO CONTENTS
49
interdisciplinary and transdisciplinary
work for current and future
collaborations in communicable and
non-communicable disease and their
syndemics.
References
1. Peters DH, Adam T, Alonge
O, Agyepong IA, Tran N.
Implementation research: what
it is and how to do it. BMJ.
2013;347:f6753
2. Peters DH, Tran NT, Adam
T. Implementation research in
health: a practical guide: World
Health Organization; 2013.
3. Wright Morton L, Eigenbrode
SD, Martin TA. Architectures
of adaptive integration in large
collaborative projects. Ecology
and Society. 2015;20(4).
4. United Nations. Transforming
our world: the 2030 Agenda
for Sustainable Development.
New York: United Nations;
2015. https://sdgs.un.org/
publications/transforming-our-
world-2030-agenda-sustainable-
development-17981.
5. Cohen CR, Lescano AG,
Mardones FO, Menon P,
Thirumurthy H, Ssali S.
Advancing global health and
the sustainable development
goals through transdisciplinary
research and equitable publication
practices. Advances in Global
Health. 2022;1(1).
6. World Health Organization.
Global action plan on
antimicrobial resistance.
Geneva: WHO; 2016. https://
www.who.int/publications/i/
item/9789241509763 2016.
7. World Health Organization.
Library of AMR national
action plans [Internet]. 2011
[cited 2023 Nov 20]. Available
from: https://www.who.int/
teams/surveillance-prevention-
control-AMR/national-action-
plan-monitoring-evaluation/
library-of-national-action-plans
8. Organisation for Economic Co-
operation and Development;
World Bank. Health at a
Glance: Latin America and the
Caribbean 2020. Paris: OECD
Publishing; 2020. https://doi.
org/10.1787/6089164f-en
9. Organisation for Economic Co-
operation and Development;
World Bank. Health at a
Glance: Latin America and the
Caribbean 2023. Paris: OECD
Publishing; 2023. https://doi.
org/10.1787/532b0e2d-en
10. Pérez Chacón D, Castro
Peraza M, Hernández Barrios
Y. La investigación social en
la prevención y el control de
enfermedades infecciosas:
experiencias contemporáneas del
Instituto de Medicina Tropical
“Pedro Kourí“ e instituciones
colaboradoras.Revista Cubana de
Medicina Tropical. 2020:71(3).
Spanish.
11. World Health Organization.
Urgent health challenges for
the next decade [Internet]. 2020
[cited 2023 Nov 20]. Available
from: https://www.who.int/
news-room/photo-story/photo-
story-detail/urgent-health-
challenges-for-the-next-decade
12. Chapman HJ, Veras-Estévez
BA. Lessons learned during
the COVID-19 pandemic to
strengthen TB infection control:
a rapid review. Glob Health Sci
Pract. 2021;9(4):964-77.
Speakers of the RIT Network’s
Inaugural Meeting:
Stefanie Dens, Ellen Mitchell,
Claudia Patricia Nieto-Sánchez,
Koen Peeters, Diana Sagastume,
and Veerle Vanlerberghe (Institute
of Tropical Medicine in Antwerp,
ITM, Belgium); Alberto Baly, Marta
Castro, Luis Fonte, Jorge Fraga, Yisel
Hernández Barrios, Alina Martínez,
Yosiel Molina Gómez, Dennis Pérez
Chacón, Dayana Rodríguez, Maria
E. Toledo, and Felix Valdés (“Pedro
Kourí”Institute of Tropical Medicine,
IPK, Cuba); Adolfo Álvarez, Martha
Chang de la Rosa, and Armando
Seuc (National Institute of Hygiene,
Epidemiology, and Microbiology,
INHEM, Cuba); Geydis Fundora
and María del Carmen Zabala
Arguelles (Latin American Faculty
of Social Sciences, University of
Havana, FLACSO, Cuba); Yamilet
Ferrán (Faculty of Communications,
University of Habana, Cuba); René
A. González (Faculty of Geography,
University of Habana, Cuba);
Claire Barrington (University of
North Carolina, UNC, USA), Anna
Pomaro (Center of Population and
Development, CEPED, France);
Mabel Carabali (McGill University,
Canada); Yadira Díaz (Center
of Youth Studies, CESJ, Cuba);
Ángel Escobedo (Institute of
Gastroenterology, Cuba); Lisandra
Fuentes (Interamerican University of
Mexico, Mexico); Helena Chapman
(George Washington University,
USA); and Bienvenido Veras-Estévez
(Universidad Católica del Cibao,
Dominican Republic).
Acknowledgments:
The authors appreciate the support
of the individual and institutional
members of the RIT Network.
Forming a Transdisciplinary Research Network to Address Diseases and their Syndemics
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50
Authors
Dennis Pérez Chacón, PhD
“Pedro Kourí” Tropical
Medicine Institute
Havana, Cuba
dennisperezchacon@gmail.com
Yisel Hernández Barrios, MSc
“Pedro Kourí” Tropical
Medicine Institute
Havana, Cuba
yhbarrios@ipk.sld.cu
Yosiel Molina Gómez
“Pedro Kourí” Tropical
Medicine Institute
Havana, Cuba
yosiel.molina@ipk.sld.cu
Helena Chapman, MD, MPH, PhD
George Washington University
Washington DC, USA
hjchapman@gwu.edu
Martha Chang de la Rosa, MSc
National Institute of Hygiene,
Epidemiology and Microbiology
Havana, Cuba
mchang@inhem.sld.cu
María del Carmen Zabala
Arguelles, PhD
Latin American Faculty
of Social Sciences
Havana, Cuba
mzabala@flacso.uh.cu
Claudia Patricia Nieto-Sánchez,
DPH, PhD
Institute of Tropical Medicine
Antwerp, Belgium
cnieto@itg.be
Forming a Transdisciplinary Research Network to Address Diseases and their Syndemics
BACK TO CONTENTS
51
Antimicrobial drugs have been
fundamental in modern human and
veterinary medicine, revolutionising
healthcare and saving countless
lives. However, their uncontrolled,
excessive use, and limited accessibility
have provoked a pressing crisis:
antimicrobial resistance (AMR).This
natural yet exacerbated occurrence,
fueled by misuse in human, animal,
and agricultural domains, poses a
formidable threat to global health.
AMR was recognised as one of the
top 10 global health threats, causing
an estimated five million deaths
due to resistant bacterial infections
in 2019 [1]. Of these bacterial
infections, six pathogens – Escherichia
coli, Staphylococcus aureus, Klebsiella
pneumoniae, Streptococcus pneumoniae,
Acinetobacter baumannii, and
Pseudomonas aeruginosa – were linked
to 3.5 million of the total number of
these deaths [1].
The challenges posed by AMR
transcend immediate health risks,
encompassing projections that signal
a staggering cost of up to US$100
trillion to the global economy by
2050 [2]. This economic threat is
intricately connected to the slowing
of the antibiotic pipeline for drug
development and commercialisation
that has persisted since the 1980s.
The inertia in this pipeline, coupled
with the inappropriate use and abuse
of antimicrobial agents, has been a
catalyst for pathogen adaptation and
the pervasive emergence of AMR [3].
Pharmaceutical and biotechnology
industries encounter significant
challenges related to antibiotic
development, high economic
investment with a high risk of failure,
a need to steward new antibiotics to
preserve their efficacy, and lengthy
clinical development time [4,5].
Scientific evidence has shown that
AMR can result from the misuse
or abuse of antimicrobial agents in
humans, livestock, and agriculture,
which stresses the need to better
understand the complex factors that
drive AMR transmission and spread.
Since AMR is directly linked to
human, animal, and environmental
health, the One Health approach is
essentialtofosterrobustcollaborations
across scientific disciplines, sectors,
and geographic regions, to achieve
established objectives, such as
indicators of national health plans
or Sustainable Development Goals
(SDGs) [6].
“Antimicrobial resistance must be
addressed urgently, through a One
Health approach involving bold,
long-term commitments from
governments and other stakeholders,
supported by the international
organisations.” – Dr. Monique Eloit,
Director General of the World
Organisation for Animal Health
(WOAH) [7]
Addressing Combating AMR
Over the past decade, global leaders
have taken significant strides to
increase AMR awareness, promote
antibiotic stewardship across the
human, animal, and agricultural
sectors, and urge immediate and
collaborative action to combat AMR.
Table 1 presents selected World
Health Assembly (WHA) resolutions
relevant to AMR that were adopted
during WHA proceedings. In 2015,
the World Health Organization
(WHO) published the Global Action
Plan on Antimicrobial Resistance,
which aimed to enhance antibiotic
prescribing practices and scientific
research for new antimicrobial agents
[8]. The five objectives include:
1) improving AMR awareness; 2)
enhancing surveillance and research
to advance the scientific literature; 3)
promoting infection control measures;
4) emphasising the appropriate
use of antimicrobial agents across
sectors; and 5) advocating for
increased political commitment
for medications and vaccines [8].
That same year, the WHO Global
AMR and Use Surveillance System
(GLASS) (https://www.who.int/
initiatives/glass) was publicised, as a
joint global effort that emphasised
Pablo Estrella Porter
The Road to the Antimicrobial Resistance
High-Level Meeting 2024
Helena Chapman
Caline Mattar
The Road to the Antimicrobial Resistance High-Level Meeting 2024
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52
the second objective of the Global
Action Plan on Antimicrobial
Resistance. This effort marked
the first steps toward standardising
AMR global surveillance data
collection and sharing.
Furthermore, in 2022, the One Health
Joint Plan of Action 2022-2026 was
launched, incorporating six action
tracks to guide leaders in addressing
emerging global risks [9]. Notably,
action track 5 (curbing the silent
pandemic of AMR) focused on two
parts – maintaining antimicrobial
effectiveness and guaranteeing access
and availability of antimicrobial
agents when appropriate – in humans,
livestock, and agriculture. Finally,
organised by the WHO, the World
Organisation for Animal Health
(WOAH), the Food and Agriculture
Organization of the United Nations
(FAO), and the United Nations
Environment Programme (UNEP),
the World AMR Awareness Week
(WAAW) is an annual celebration
each November that aims to
increase awareness about AMR
prevention and control. The 2022
and 2023 themes were “Preventing
Antimicrobial Resistance Together”
(https://www.who.int/campaigns/
world-amr-awareness-week/2023),
noting that AMR affects all global
citizens and that multidisciplinary
and cross-sectoral collaborations are
key to promote best practices for
the appropriate and cautious use of
antimicrobial agents.
“Antimicrobial resistance is one of the
greatest threats we face as a global
community […] there is no time to wait
and I urge all stakeholders to act on and
work urgently to protect our people and
planet and secure a sustainable future for
all.” – Ms. Amina Mohammed, UN
Deputy Secretary-General and Co-
ChairoftheInteragencyCoordination
Group on Antimicrobial Resistance
(IACG) [10]
Prioritising a Collective Global
Response in Addressing AMR
To date, an estimated 170 countries
have established AMR National
Action Plans, yet multi-sectoral
collaborations, sustainable political
commitment, financing and
educational and research investment
are widely inconsistent [11]. The
WHO launched two guidelines in
2023, to help streamline global AMR
efforts that can inform policies and
interventions. First, the WHO Global
Research Agenda for Antimicrobial
Resistance incorporated a total of 40
research themes that can help spark
implementation initiatives related to
surveillance, diagnosis, and treatment
and provide evidence by 2030 [12,13].
Second, the WHO Core Package of
Interventions to Support National
Action Plans offered additional support
for Member States to evaluate and
strengthen their national action plans
[9]. These interventions mirror the
people-centred framework around
four pillars – such as 1) infection
prevention; 2) access to essential
health services; 3) timely, accurate
diagnosis; and 4) appropriate, quality-
ensured treatment – to reduce AMR
transmission and spread [11].
The United Nations General
Assembly’s (UNGA) High-Level
Meetings on Health represent crucial
platforms for addressing urgent global
health challenges. The historical
significance of prior UNGA Health-
related Meetings demonstrates a
legacy of international collaboration
that shaped global health policies and
proved effective in addressing health
crises, such as the case of human
immunodeficiency virus / acquired
immunodeficiency syndrome (HIV/
AIDS),where funding and investment
increased after the first HLM occurred
in 2001. Over the past two decades
(2001-2019), 10 UNGA Health
High-Level Meetings focused on
primaryhealthconcerns:fouronHIV/
AIDS, three on non-communicable
diseases, one on tuberculosis, one on
universal health coverage, and one on
AMR. These gatherings, convening
Heads of State, governments, health
experts, and stakeholders, are essential
in addressing the burgeoning threat
of AMR, undermining the efficacy
of life-saving drugs and potentially
rendering common infections lethal
[14].
During the 2016 UNGA High-Level
The Road to the Antimicrobial Resistance High-Level Meeting 2024
Resolution Year Description
WHA39.27 1986 The Rational Use of Drugs
WHA47.13 1994 The Rational Use of Drugs
WHA51.17 1998
Emerging and other Communicable
Diseases: Antimicrobial Resistance
WHA54.14 2001 Global Health Security: Epidemic Alert and Response
WHA58.27 2005 Improving the Containment of Antimicrobial Resistance
WHA60.16 2007 Progress in the Rational Use of Medicines
WHA66.22 2013
Follow up of the report of the Consultative
Expert Working Group on Research and
Development: Financing and Coordination
WHA67.25 2014 Antimicrobial Resistance
WHA68.7 2015 Global Action Plan on Antimicrobial Resistance
Table 1. List of selected WHA resolutions relevant to antimicrobial resistance
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53
Meeting on AMR, the political
declaration on AMR was adopted,
which recognised the global threat
of AMR and stressed the need
for urgent collective action among
global leaders, governments, and
health organisations to develop
national action plans, policies, and
interventions to combat AMR. This
declaration, which supported the
Global Action Plan on Antimicrobial
Resistance launched in 2015,
incorporated the One Health
approach, thereby laying the
groundwork for ongoing initiatives
and discussions [15]. These meetings
have proven instrumental in sharing
best practices and raising awareness
to combat AMR, highlighting the
vital role of affordable antimicrobial
medicines in achieving the SDGs
[16,17].
“Antimicrobial resistance threatens
the achievement of the Sustainable
Development Goals and requires a
global response. Member States have
today agreed upon a strong Political
declaration that provides a good basis
for the international community to
move forward. No one country, sector or
organisationcanaddressthisissuealone.”
– H.E. Peter Thomson, President of
the 71st session of the UN General
Assembly [18]
As the 2024 UNGA High-Level
Meeting on AMR approaches, we
have an invaluable opportunity
to reflect on the progress made
towards the 2016 AMR High-Level
Meeting recommendations, stimulate
change, and establish actionable
commitments.The active engagement
of national, regional, and global
professional societies, academia,
and the AMR research community
will be essential in crafting specific
commitments, particularly in
bolstering financial investments
for education, behaviour change,
and research and development, and
further developing the evidence
base for effective global strategies
to tackle AMR [19]. Unfortunately,
no specific, measurable, achievable,
relevant, and time-bound (SMART)
targets were included in the 2016
AMR High-Level Meeting findings,
which hindered implementation
and evaluation efforts [15]. There is
an urgent need for the 2024 High-
Level Meeting to result in actionable
interventions and indicators to
measure progress globally.
Current WMA Activities on AMR
AMRhasbeenalongstandingpriority
for the World Medical Association
(WMA). The engagement started in
2015,shortly after the adoption of the
Global Action Plan on Antimicrobial
Resistance at the 68th WHA. The
WMA has served as a convenor
for health professional associations
as well as early career and youth
through the Junior Doctors Network
(JDN). To address this critical sector,
the JDN AMR Working Group
was established in 2016, and JDN
members were selected to be part of
the Quadripartite Youth Engagement
Working Group, in collaboration
with the WHO, WOAH, FAO, and
UNEP.
Additionally, the WMA has
contributed to multiple expert
advisory groups at the WHO, namely
on Health Workforce Curricula
for AMR, Behavior Change, and
Stewardship. Communication
strategies for health professionals
have been at the centre of continued
efforts and collaboration with the
WHO, particularly towards the
development and review of target
messages and themes for the WAAW.
One core activity is a WAAW social
media campaign that emphasises the
effects of AMR on the day-to-day
practice of physicians globally as well
as raises awareness of the One Health
approach and equity.
AMR is a multifaceted issue that
requires multi-stakeholder dialogue
and collaboration. Since AMR affects
people differently, the prevalence of
higher rates of multi-drug resistant
organisms is significantly increased
in low- and low-middle income
countries (LMICs). Within the
same country, socio-economic
status, race, education, and gender
are all differentials of AMR rates.
Recognising this burden, the WMA
will continue to advocate for the
inclusion of equity as a cornerstone for
interventions to tackle AMR. It aims
to partner with various civil society
organisations active in this space,
youth organisations, pharmaceutical
and veterinary colleagues, industry,
and the WHO.
Key Actions for National Member
Associations and Members
This year, we have encountered a
crucial turning point for the AMR
agenda. As we prepare for the
UNGA High-Level Meeting on
AMR in September 2024, effective
advocacy at local, national, and
international levels is needed to
ensure the inclusion of priorities and
targets to effectively curb increasing
AMR. Since AMR is a global
challenge requiring a unified
response, local and national education
and awareness initiatives are essential
for physicians of all specialties
to contribute their expertise
and leadership. Strengthening
partnerships with governmental
bodies, pharmaceutical sectors, and
allied health professionals will amplify
theimpactoftheseefforts.Specifically,
the WMA’s focus on health equity
will propel key discussions to identify
timely solutions that reduce AMR
spread.
National Medical Associations
(NMAs) hold a critical position in
driving change at local, national,
and international levels. They can
The Road to the Antimicrobial Resistance High-Level Meeting 2024
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54
help foster the inclusion of specific
actionable objectives within the
National Action Plans following the
Global Action Plan on Antimicrobial
Resistance. At the local level,
empowering awareness campaigns
need to be strategically tailored,
educating communities and health
professionals about the impact
of AMR. At the national level,
NMAs can actively collaborate with
health authorities, engage in policy
development, and advocate for the
integration of AMR mitigation
strategies within health system
frameworks.At the international level,
NMAs can actively participate in
AMR mitigation programs facilitated
by international bodies, contributing
valuable insights and experiences,
while advocating for a harmonised
global approach to tackle AMR.
As we approach the 2024 UNGA
High-Level Meeting on AMR,
NMAs hold the power to drive
actionable change by advocating
for equitable, comprehensive
strategies to combat AMR on
a global scale. Incorporating a
focus on research investment and
encouraging collaborations between
medical professionals and diverse
stakeholders worldwide will reinforce
the international fight against AMR.
The united efforts of NMAs can
spearhead a call for increased funding
and resource allocation toward
sustainable interventions to address
this critical global health challenge.
References
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Geneva: WHO; 2023.
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human-health
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resistance [Internet]. 2023 [cited
2023 Nov 3]. Available from:
https://w w w.who.int/news/
item/22-06-2023-who-outlines-
40-research-priorities-on-
antimicrobial-resistance
14. One Health Global Leaders
Group on Antimicrobial
Resistance. The Road to UN
General Assembly High-Level
meeting on AMR in 2024
[Internet]. 2023 [cited 2023 Nov
3]. Available from: https://www.
amrleaders.org/resources/m/
item/the-road-to-un-general-
assembly-high-level-meeting-on-
amr-in-2024
15. Rodi P, Obermeyer W, Pablos-
Mendez A, Gori A, Raviglione
MC. Political rationale, aims,
and outcomes of health-related
high-level meetings and special
sessions at the UN General
Assembly: a policy research
observational study. PLoS Med.
2022;19(1):e1003873.
16. United Nations. Concept Note
on UNGA High-level Meeting
on Antimicrobial Resistance
[Internet]. 2016 [cited 2023
Nov 3]. Available from: https://
w w w.un.org/pga /70/from-
the-president/lettres/hlm-on-
antimicrobial-resistance-23-
august-2016-2/
17. UN General Assembly. Political
Declaration of the High-Level
Meeting of the General Assembly
on Antimicrobial Resistance:
draft resolution [Internet]. 2016
[cited 2023 Nov 3]. Available
from: https://digitallibrary.
un.org/record/842813
18. World Health Organization. At
UN, global leaders commit to
act on antimicrobial resistance
[Internet]. 2016 [cited 2023 Nov
3]. Available from: https://www.
who.int/news/item/21-09-2016-
at-un-global-leaders-commit-to-
act-on-antimicrobial-resistance
19. Getahun H. The road to UN
General Assembly High-
Level meeting on AMR in
2024 [Internet]. 2023 [cited
2023 Nov 10]. Available from:
https://www.amrleaders.org/
docs/librariesprovider20/glg/
copenhagen-unga-2023.pdf
Authors
Pablo Estrella Porter,
MD, MPH
PhD student, Universidad de Valencia
Hospital Clínico
Universidad de Valencia
Valencia, Spain
pestrellaporter@gmail.com
Helena Chapman, MD, MPH, PhD
Milken Institute School
of Public Health,
George Washington University
Washington DC, United States
hjchapman@gwu.edu
Caline Mattar, MD, FIDSA
Associate Program Director, Infectious
Diseases Fellowship Program
Associate Professor of Medicine,
Division of Infectious Diseases
Washington University School
of Medicine in St. Louis
St. Louis, Missouri, United States
mattar.caline@gmail.com
The Road to the Antimicrobial Resistance High-Level Meeting 2024
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56
With more than 1.3 million annual
deaths attributed to the resistance to
antimicrobial agents – and almost five
million deaths in 2019 – global efforts
to combat antimicrobial resistance
(AMR) are a significant priority for
leading health organisations [1]. This
global burden has accelerated the need
to build a strong collaboration among
leading international organisations –
Food and Agriculture Organization
of the United Nations (FAO), United
Nations Environment Programme
(UNEP),World Health Organization
(WHO), and World Organization
for Animal Health (WOAH) – to
use the One Health approach to help
address complex global health issues
(including AMR), leading to the
creation of the Quadripartite. Over
the past few years, there has been
an emphasis on encouraging youth
engagement in scientific and advocacy
activities that accelerate progress
toward the United Nations (UN)
Sustainable Development Goals.
To illustrate the key voice of youth
in combating AMR, the inaugural
Quadripartite Working Group on
Youth Engagement for AMR was
formed in October 2023. A total of
14 leaders from diverse youth-led
organisations were selected, including
academic, non-governmental, and
professional organisations of medical,
pharmacy, and veterinary disciplines
[2]. The objective of this working
group is to develop timely strategies
that support youth engagement
in AMR initiatives across global
organisations. On 5-6 October 2023,
the Quadripartite Working Group on
Youth Engagement for AMR met at
the WHO Headquarters in Geneva
to share insights and discuss their
work plan for 2023-2025 (Photo 1).
At this milestone event, organisation
representatives, as well as the World
Medical Association (WMA)’s
Junior Doctors Network (JDN)
representative, shared key AMR-
related achievements that resulted
in noteworthy local, national, and
international impacts. Over the
past decade, the JDN has been
actively involved in the World AMR
Awareness Week (WAAW) annual
campaigns, social media initiatives,
educational programs, consultations,
and publications. These efforts
underscore the JDN’s commitment
to AMR awareness and advocacy
for mitigation strategies, especially
the formation of an AMR Working
Group.
Looking ahead, the High-Level
Meeting on AMR at the UN General
Assembly (UNGA) in 2024 presents
a historic opportunity to renew the
global commitment to address AMR
and support youth engagement.
Over the forthcoming two-year
mandate, the Quadripartite Working
Group on Youth Engagement for
AMR is preparing to channel its
efforts into three pivotal objectives,
strategically aimed at strengthening
initiatives to combat AMR with a
youth perspective. It also provides
an open space to propose innovative
approaches that places youth in the
centre of this global discussion.
Objective 1: Prioritise Enhancing
Youth Visibility
The first objective aims to establish
a comprehensive database that
compiles all AMR-related youth
events, which is intended for
inclusion in the pre-WAAW agenda.
This task also involves the creation
of an engaging introductory video
on AMR that stresses an immediate
call for action for youth engagement
and active participation in spreading
relevant messages. Additionally,
the Youth Working Group aspires
to participate in and potentially
host a supplementary event at the
upcoming World Health Assembly
(WHA) and the UNGA, to ensure
that a youth approach is integrated
into these high-level events.
Exploring collaborative opportunities
with regional offices from the
Quadripartite members to expand the
scope for greater youth engagement
and message dissemination, while
leveraging existing youth networks
and resources, fortifies the spread of
AMR messaging.
Objective 2: Promote Awareness
and Capacity Building
The second objective supports the
development of a comprehensive
calendar that highlights key AMR-
related days and associated campaigns
that targets awareness efforts and
strategic planning. Conducting
webinars, workshops, and roundtable
discussions, including dedicated
sessions during the WAAW, serves
to educate and engage the youth
demographic. Supporting and
facilitating the successful launch
and implementation of the AMR
youth advocacy toolkit is pivotal for
equipping and empowering youth
advocates. The preparation of concise
AMR messaging to render its appeal
Pablo Estrella Porter
Advocating for Change: Junior Doctors’ Role in
Global Antimicrobial Resistance Initiatives
Advocating for Change: Junior Doctors’ Role in Global Antimicrobial Resistance Initiatives
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57
Advocating for Change: Junior Doctors’ Role in Global Antimicrobial Resistance Initiatives
to youth audiences is integral to
fostering a deeper understanding
of this global threat and sustaining
community engagement to combat
AMR.
Objective3:BridgetheGapbetween
Youth and Stakeholders
The third objective recognises that
efficient communication between
youth and stakeholders hinges
on enhanced health messaging.
The compilation of a documented
repository containing key action
points and messages for the
Quadripartite leadership is essential
for amplifying youth-driven messages.
A comprehensive youth consultation
to gather diverse perspectives and
insights on AMR ensures a holistic
understanding of youth perceptions
and involvement. Additionally, the
collaborative creation of a youth
policy statement strengthens the
groundwork for youth participation
at major global assemblies like the
WHA and UNGA, which can
promote a cohesive approach to
tackling AMR.
These collective endeavours of
health-related early career and
diverse youth-focused organisations
within the Quadripartite Working
Group highlight the crucial role of
the younger generation in advocating
for change and combating the global
threat of AMR. Moving forward, the
year 2024 represents a key moment
to renew global commitment and
amplify youth voices in the fight
against AMR,emphasising the crucial
role of intergenerational collaboration
in shaping a resilient future. These
three objectives underscore the shared
pledge to magnify youth participation
and fortify joint efforts to address the
critical global challenge of AMR.
As junior doctors, we urge our
JDN colleagues to actively engage
in this critical and pressing health
concern that will redefine our global
health landscape in the coming
years. Additionally, we call upon
all physicians in leadership roles
to champion interprofessional
collaboration and advocate for
the active involvement of youth
in our joint efforts to combat and
overcome the AMR challenges.
Together, by nurturing this inclusive
and collaborative approach, we can
effectively address and mitigate the
threats posed by AMR, safeguarding
the future of global health security.
References
1. World Health Organization.
New WHO report highlights
progress, but also remaining
gaps, in ensuring a robust pipe-
line of antibiotic treatments to
combat antimicrobial resistance
(AMR) [Internet]. 2023 [cit-
ed 2023 Nov 2]. Available from:
https://www.who.int/news/
item/15-05-2023-new-who-re-
port-highlights-progress-but-al-
so-remaining-gaps-in-ensuring-
a-robust-pipeline-of-antibiot-
ic-treatments-to-combat-antim-
icrobial-resistance-%28amr%29
2. World Health Organization.
Quadripartite launches the
Working Group on Youth En-
gagement for Antimicrobi-
al Resistance [Internet]. 2023
[cited 2023 Nov 2]. Available
from: https://www.who.int/
news/item/05-10-2023-quad-
ripartite-launches-the-work-
ing-group-on-youth-engage-
ment-for-antimicrobial-resist-
ance
Pablo Estrella Porter,
MD, MPH
PhD student, Universidad de Valencia
Hospital Clínico
Universidad de Valencia
Valencia, Spain
pestrellaporter@gmail.com
BACK TO CONTENTS
Photo 1. Quadripartite launches the Working Group on Youth Engagement for Antimicrobial Resistance. Credits: WHO
(https://www.who.int/news/item/05-10-2023-quadripartite-launches-the-working-group-on-youth-engagement-for-anti-
microbial-resistance)
58
Antimicrobial resistance (AMR),
recognised as the “silent pandemic,”
continues to represent one of the top
10 significant global risks affecting
population health and well-being.
One recent systematic report by
the Antimicrobial Resistance
Collaborators concluded that almost
five million deaths were associated
with bacterial AMR infections,
including 1.2 million deaths as a direct
result of bacterial AMR infections
in 2019 [1]. This global burden,
which was documented as highest
in western sub-Saharan Africa and
lowest in Australasia, were linked
to six primary pathogens, including
Escherichia coli, Staphylococcus aureus,
Klebsiella pneumoniae, Streptococcus
pneumoniae, Acinetobacter baumannii,
and Pseudomonas aeruginosa [1].
The World Bank reported that an
estimated US$9 billion investment
each year in AMR control across low-
and middle-income countries would
help support human and animal
public health surveillance systems,
which would ultimately reduce excess
health expenditure across public and
private health facilities, enhance
economic productivity (reduce annual
gross domestic product losses),
and help advance progress toward
the 2030 Agenda for Sustainable
Development [2].
Over the past decade, global health
leaders have developed several key
guidance documents to address the
AMR global burden. In February
2014, the Global Health
Security Agenda (https://
globalhealthsecurityagenda.org/)
was adopted as a global effort of 40
countries (now, 70 countries), to
implement the International Health
Regulations (2005) and strengthen
infectious disease preparedness,
monitoring, and response through
11 action packages (now, 9 action
packages), including AMR [3]. In
May 2015, the Global Action Plan
on Antimicrobial Resistance was
approved at the 68th World Health
Assembly (WHA) (Resolution
WHA68.7), to support multisectoral
national action plans (including the
One Health approach) through five
primary objectives (increasing overall
understanding of AMR, improving
AMR surveillance and research,
reducing risk of AMR infections,
promoting antimicrobial stewardship,
and advocating for economic
investment in AMR efforts) [4]. In
October 2015, the WHO Global
Antimicrobial Resistance and Use
Surveillance System (GLASS)
(https://www.who.int/initiatives/
glass) was launched to underpin the
five objectives of the Global Action
Plan on Antimicrobial Resistance, as
well as stress the need for surveillance
data standardization.
In September 2016, the United
Nations (UN) General Assembly held
the High-Level Meeting on AMR
Credit:
AnaLysiSStudiO
/
shutterstock.com
WMA Members Contribute Insight on Global Efforts
to Combat Antimicrobial Resistance
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Global Efforts to Combat Antimicrobial Resistance
59
to collectively discuss the driving
factors related to AMR across human,
animal, and agricultural sectors, and
encourage national leaders to develop
and implement national action plans
to combat AMR. The second High-
Level Meeting on AMR will be held
in September 2024, where leaders
will discuss national action plans and
ensure international commitments to
reach established AMR targets [5].
In October 2022, the Quadripartite
Organizations (WHO; Food and
Agriculture Organization of the UN,
FAO; UN Environment Programme,
UNEP; World Organisation for
Animal Health, WOAH) published
the One Health Joint Plan of Action
2022-2026, which intends to guide
stakeholders in managing merging
global health threats using six action
tracks, including combating AMR
across human,animal,and agricultural
sectors [6].
After the 68th WHA, the inaugural
World Antibiotic Awareness Week –
later renamed World Antimicrobial
Awareness Week in 2020 and World
AMR Awareness Week (WAAW)
in 2023 (https://www.who.int/
campaigns/world-antimicrobial-
awareness-week) – was celebrated in
November 2015, and now recognised
annually from 18-24 November.
This annual event provides a global
platform to increase understanding
of the emerging risks and spread of
AMR and promote evidence-based
practices to reduce AMR spread
[7]. Using the WAAW 2023 theme,
“Preventing Antimicrobial Resistance
Together”, health leaders emphasised
that multidisciplinary, cross-sectoral
collaborations can contribute to
reducing AMR risk and spread by
supporting infection control practices
and antimicrobial stewardship across
human, animal, and agricultural
sectors. Health leaders coordinated
in-person and virtual activities, press
releases, and social media campaigns
to encourage community members
to become actively engaged in these
local and global events.
Ensuring the development and
adoption of robust national action
plans and guidelines on AMR that
enhance human and animal disease
surveillance systems and promote
antimicrobial stewardship across
human, animal, and agricultural
sectors will be crucial to strengthen
national capacity and help achieve
national health objectives including
the 2030 Agenda for Sustainable
Development. In this article,
physicians from 20 countries –
Argentina, Australia, Ecuador, India,
Kenya, Malaysia, Myanmar, Nigeria,
Pakistan, Philippines, Poland,
Republic of Korea, Rwanda, Spain,
Taiwan,Trinidad and Tobago,Turkey,
Uganda, United Arab Emirates, and
Uruguay – shared perspectives and
reflections about local and national
efforts to combat AMR through
relevant policies and WAAW 2023
activities across their national health
systems.
Argentina
The Ministry of Health of Argentina,
a country of approximately 44
million residents, has recognised
the global risk of AMR, driven by
the inappropriate use and misuse
of antibiotics, which can cause poor
therapeutic results (including adverse
effects) and increase economic costs.
Recent studies have examined varying
rates of AMR and antimicrobial
prescriptions across geographic
regions of Argentina, which confirms
the complex dynamics of AMR
risk in the country [8]. To address
this burden, national health leaders
supported the development of
WHONET-Argentina in 1989, as a
network of more than 95 laboratories
(e.g. Institute of Health, National
Reference Laboratory, state and local
hospitals) that monitor AMR in the
general population. Also, in 2015,
the National Commission for the
Control of Antimicrobial Resistance
(Comisión Nacional de Control
de la Resistencia Antimicrobiana,
CoNaCRA) was established, as a
joint resolution (Resolución Conjunta
834/2015 and 391/2015) of the
Ministries of Health and Agriculture,
Livestock, and Fisheries, to ensure
continued AMR monitoring in the
country [9].
The Medical Confederation of the
Argentine Republic (Confederación
Médica de la República Argentina,
COMRA)iscommittedtotherational
use of medications that adhere to the
WHO’s guidelines. First, COMRA
members actively promote the
rational use of antimicrobial agents
through the COMRA National
Therapeutic Formulary (Formulario
Terapéutico Nacional de la COMRA,
FTN COMRA) (https://comra.org.
ar/medicamentos/), a scientific tool
developedin1978.Thistoolisregularly
revised, based on scientific research
studies,and provides a list of the most
effective and safe pharmaceutical
prescriptions. Second, the COMRA
Medication Commission (Comisión
de Medicamentos) coordinates
regular meetings with representatives
of other professional associations that
support pharmacists,biochemists,and
dentists as well as CoNaCRA leaders.
Over the past year, health leaders
across Argentina have contributed
to the development of significant
national and regional actions to
raise awareness of AMR risks for
population health. In March 2023,
the Ministry of Health of Argentina
hosted the fourth meeting of the
WHO Global Antimicrobial
Resistance Surveillance and
Evaluation Collaborating Centres
Network in the city of Buenos Aires
[10].InJuly2023,thecountryadopted
the Law No, 27680: Prevention and
Control of Antimicrobial Resistance
(Ley N° 27.680: Prevención y Control
Global Efforts to Combat Antimicrobial Resistance
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60
de la Resistencia Antimicrobiana),
which ensures the responsible use
of antibiotics in human and animal
health services and product sales [11].
This policy also stresses the need
to register clinical diagnoses that
require the prescription of systemic
antimicrobial agents.
As COMRA members, we urge all
physicians to carefully educate our
patients upon prescribing antibiotics,
in order to promote responsible
prescribing practices for clinicians
and discourage patients from any
self-medication activities. As we
recognise WAAW 2023, we can lead
collaborative efforts that strengthen
physician-laboratory networks
(like WHONET), promote strict
adherence to national guidelines,
update guidelines and policies with
the evidence-based literature, and
increase community engagement
activities with the public.
Australia
The Australian Medical Association
(AMA) recognises AMR as one of
the most serious global One Health
threats of the 21st century. In 2022,
the AMA – the peak representative
body for Australia’s doctors –
released the research report entitled,
Antimicrobial Resistance: The Silent
Global Pandemic, which demonstrated
that AMR has the potential to
undermine global health care systems
as well as food safety and supplies
[12].
AMR is also a key priority for the
Australian Government. In 2014, the
Antimicrobial Use and Resistance
in Australia (AURA) Surveillance
System was established to monitor
antimicrobial usage and resistance
in Australia to inform antimicrobial
stewardship practices [13].
Subsequently, in 2015, the National
Centre for Antimicrobial Stewardship
was developed to monitor the quality
of antimicrobial use and implement
antimicrobial stewardship activities.
More recently,in 2020,the Australian
Government released Australia’s
National Antimicrobial Resistance
Strategy — 2020 and beyond, which
was based on previous findings from
the National Antimicrobial Resistance
Strategy 2015–2019 [14]. This novel
strategy sets a 20-year One Health
vision to coordinate action across
all sectors where antimicrobials are
used, minimise the development
and spread of AMR, and ensure the
continued availability of effective
antimicrobials. To support this
strategy, the Australian Government
assembled an Antimicrobial
Resistance Governance Group
(ARGG), to oversee implementation
of the strategy, provide national
coordination and links between
sectors, and advise government. This
year, the Australian Commission
on Safety and Quality in Health
Care — which plays a key role with
respect to antimicrobial stewardship
and is responsible for the AURA
Surveillance System — is producing
a range of resources to complement
events being planned during the
WAAW 2023 [13,15]. Additionally,
the Australian Centre for Disease
Control (CDC) is currently being
established, to improve Australia’s
response to public health emergencies,
including AMR [16].
Although Australian health leaders
have supported these policies and
practices, Australia is lagging in
several key areas, including public
awareness and understanding of
AMR, antimicrobial stewardship,
and coordination and incentives
for research and development [12].
The AMA is also concerned about
the expansion of prescribing rights
in Australia, particularly those
that fall outside of a medically-led
collaborative model. For instance,
several pharmaceutical trials in
Australia have allowed pharmacists
to prescribe a range of medicines
(including antibiotics), but these
trials undermine Australia’s National
Antimicrobial Resistance Strategy
— 2020 and Beyond and have the
potential to contribute to AMR.
As AMR requires a global response,
one country’s actions will not have
a significant impact if other nations
continue to act independently of one
another. As a high-income country
with an advanced health care system,
Australia is well placed to lead global
efforts to control the growing threat
of resistant infections and other
health threats, particularly in the
Asia-Pacific region.The AMA would
like to see Australia become a global
leader and support a coordinated,
sustained, and unified One Health
approach to addressing AMR and
other emerging health threats [12].
Ecuador
The Ecuadorian health system,
supporting 17 million residents,
has recognised the AMR threat
and the need for prompt action in
the Americas region. According
to the National Reference Center
of Antimicrobial Resistance at the
National Institute of Health Research
(Instituto Nacional de Investigación
en Salud, INSPI) in Ecuador, there
were 55,106 documented cases of
bacterial resistance – E. coli (61%),
K. pneumoniae (21%), S. aureus
(10%), and P. aeruginosa (8%) – in
the WHONET system in 2017
[17]. In hospitals within rural areas,
resistant strains were identified, and
detected genes (e.g. K. pneumoniae
carbapenemase, extended spectrum
beta lactamases) were primarily
associated with resistance to
aminopenicillins, cephalosporins,
quinolones,phosphonates,sulfamides,
and, to a lesser extent, aminoglycosides
[18].
In Ecuador, health leaders face
Global Efforts to Combat Antimicrobial Resistance
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61
various risk factors associated
with AMR. These include the
indiscriminate use of antimicrobials,
self-medication, dispensing without
a prescription, a high incidence of
health care associated infections,
lack of awareness of the seriousness
of AMR, and insufficient training
(e.g. continuing education courses)
on AMR at health and academic
institutions. Additionally, the use
of antimicrobials in farm animals
and agriculture, compounded by
a shortage of laboratories for case
monitoring, further contributes to
the challenges in addressing AMR.
In response, the government of
Ecuador implemented the National
Plan for the Prevention and Control
of Bacterial Resistance (2019-2023)
in 2019 [19]. This plan describes
national steps toward strengthening
the WHONET monitoring system,
providing training within the
health care system, establishing
sentinel hospitals, prohibiting
the use of colistin in animals, and
striving to control the dispensing of
antimicrobials without a prescription
[19,20].The effectiveness of the latter
effort, however, still faces challenges.
As we recognise WAAW, our global
community must help develop cost-
effective measures in the health care
system to mitigate AMR, such as
training health care personnel and
the public to address the use and
abuse of antimicrobials. Health
leaders should lead efforts to regulate
the indiscriminate sale of antibiotics
without a prescription, maintain
epidemiological surveillance controls,
and establish agreements with the
agricultural industry to oversee the
use of antimicrobials in production
[21]. Despite these advances, much
remains to be done, and fostering
greater awareness and concrete action
in Latin America is essential to
combat AMR.
India
The Ministry of Health and Family
Welfare of India has identified AMR
as one of the primary 10 national
health priorities, as AMR threatens
the ability to effectively treat
infectious diseases like tuberculosis
[22]. In 2014, the nation joined the
Global Health Security Agenda, to
collectively and globally enhance
infection prevention and control.
In 2022, India was selected for the
Group of Twenty (G20) presidency
(2022-2023), and G20 health
ministers agreed that AMR was one
of the three key health-related priority
areas that needed to be addressed
following the One Health approach.
Over the past decade, health leaders
across India have supported the
implementation of key legislation,
guidelines, and activities to combat
AMR. First, based on achievements
from the National Health Policy of
1983 and National Health Policy of
2002, the National Health Policy 2017
was launched, which recognised the
need for a robust health system to
address changing health priorities
[23]. Second, the National Centre
for Disease Control’s National
Programme on the Containment
of Antimicrobial Resistance was
established, as part of the 12th Five-
Year Plans (2012-2017) (as national
economic development plans) [24].
Third, the National Action Plan
on Antimicrobial Resistance (NAP-
AMR) 2017-2021 was adopted, to
strengthen educational and awareness
initiatives, infection control
guidelines, audit and feedback, and
antimicrobial stewardship [22-
24]. Fourth, pharmacy licensing
regulations included the Pharmacy
Act of 1948, and the Pharmacy Practice
Regulations of 2015, which govern
pharmacy practice in India [25].
These policies reinforce the control of
over-the-counter (OTC) antibiotic
sales, as pharmacies are required to
have a licensed pharmacist on duty,
and these pharmacists are expected to
ensure that antibiotics are dispensed
only with a valid prescription. Finally,
Indian physicians have contributed
to community events, mainstream
media, and social media technology
(e.g. YouTube) that educate the
public about the responsible use of
antibiotics.
As AMR remains a significant
challenge in our nation, physicians
should actively lead and contribute to
public awareness campaigns on media
platforms (e.g. YouTube, mainstream
media commercials) throughout the
year, which can educate the wider
community about the dangers of
OTC antibiotic misuse.As physicians
should serve as role models for
responsible antibiotic prescribing
within the medical community, they
must keep up-to-date with the latest
evidence-based research on antibiotic
guidelines. They can also strengthen
physician-pharmacist collaborations
across local hospitals and pharmacies,
in order to ensure that antibiotics
are dispensed only with valid
prescriptions.
Kenya
As physicians in Kenya, a country
in Sub-Saharan Africa with a
population of 50 million residents,
we are cognizant that AMR is a
global threat that requires urgent
collaborative action within and
among countries [26,27]. In Kenya,
like other Sub-Saharan countries,
the primary drivers of AMR include
weak public health systems causing
limited awareness of its implications
in human and animal health among
the general public, poor infection
control practices in hospitals, and
antimicrobial misuse and overuse as a
result of easy OTC access and high
levels of self-medication [28]. As
poverty drives the AMR burden – and
noting that high poverty rates (27%)
Global Efforts to Combat Antimicrobial Resistance
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62
exist in the nation – there is national
concern about the high burden of
infectious diseases (e.g. HIV/AIDS,
zoonoses) due to impoverished living
conditions, poor husbandry practices,
and low vaccination coverage levels
[29]. As a low-middle income
country, the Kenyan health system
shares similar challenges as other
African nations, including poor
health infrastructure and oversight to
AMR guidelines, weak surveillance
systems,and inadequate investment in
laboratory infrastructure, diagnostic
tools, and human resources [30].
Kenya leaders view AMR as an
international health priority and
has ratified the resolutions by
the WHA, WOAH, and FAO
General Assemblies on combating
AMR globally. Using the One
Health approach that embraces
interdisciplinary collaboration and
communication, the government of
Kenya has implemented policies to
safeguard human and animal health
and the environment. The first step
was the Constitution of Kenya 2010,
under the Bill of Rights (Articles
43, 1a and c), which provides for
equitable, affordable, and quality
health care of the highest standard
to all its citizens [31]. In 2015,
leaders at the WHA adopted the
Global Action Plan on Antimicrobial
Resistance, which was ratified by
Kenya [4]. In the same year, the
Ministry of Health and the Ministry
of Agriculture, Livestock, Fisheries
and Cooperatives established the
National Antimicrobial Advisory
Committee to develop the Kenya
National Action Plan on Antimicrobial
Resistance in 2017 [32].
As physicians in Kenya, WAAW
reminds us that the devastating
effects of AMR on society and the
economy threatens to reverse much
of the progress gained in medicine.
The Kenya Medical Association
(KMA) is committed to ongoing
work to increase public awareness and
education on AMR, discourage OTC
antibiotic use, advocate for the One
HealthapproachtocombatAMR,and
encourage antimicrobial stewardship
practices among physicians. As they
collectively promote multisectoral
research collaborations and support
county hospitals to become centres
of excellence for antimicrobial
stewardship, KMA leaders shared
their innovative AMR message for
WAAW 2023 [33].
Malaysia
Malaysian physicians are aware of
the global threat of AMR, especially
due to inappropriate antimicrobial
prescribing practices in the health
care setting and animal production
[34]. However, they became
awakened to the increasing threat
of AMR on communicable diseases
during the post coronavirus disease
2019 (COVID-19) era. In 2020,
the Malaysian Ministry of Health
updated the National Health and
Morbidity Survey to incorporate
a few questions on AMR [35].
Data revealed that despite more
than 95% of individuals who were
prescribed antibiotics from health
care professionals over the previous
year, nearly one-third of respondents
reported that they were poorly
compliant to the recommended usage
[35].
The Government of Malaysia has
led several key milestones to increase
public awareness and combat AMR
across Malaysia.In 2017,the National
Antimicrobial Resistance Committee
of the Malaysian Ministry of Health’s
Infection Prevention and Control
Unit established the National
Coordinating Centre for
Antimicrobial Resistance, as
the responsible body for policy
development and implementation
pertaining to AMR [36]. This
effort brings together all concerned
stakeholders, including the
Ministries of Health, Defense,
Higher Education,and Agriculture as
well as the Departments of Veterinary
Services and Fisheries. Also, the
Malaysian Ministry of Health
prepared and implemented the
MalaysianActionPlanonAntimicrobial
Resistance (MyAP-AMR) 2017-2021.
The plan has four primary objectives
– improve educational and awareness
plans, strengthen surveillance and
research strategies, implement
evidence-based infection prevention
and control measures, and AMR
stewardship programmes in human
and animal health – to reduce the risk
of AMR across the country [36].
In 2021, the Official Malaysia One
Health Antimicrobial Resistance
Portal (MyOHAR) was launched as
a resource to describe the planned
joint activities (https://myohar.moh.
gov.my/). Khairy Jamaluddin, the
then Minister of Health, supported
national efforts to promote WAAW,
including a media blitz to increase
public understanding about AMR
emergence. The leadership team
organised the public display of blue
lights on the Prime Minister’s Office
and the Malaysian Twin Towers at
Kuala Lumpur City Centre, to align
with the WHO’s “Go Blue for AMR”
campaign [37]. Recently, there have
been concerted efforts to intensify
AMR awareness and advocacy
activities, with a special focus on
health care professionals.
As physicians in Malaysia, we urge
our medical community to adhere
to strict guidelines for antibiotic
prescribing as well as lead hospital-
and community-based education
and awareness campaigns [37].
With increasing AMR rates across
Malaysia, as reported by the National
Surveillance of Antibiotic Resistance
Programme, our inaction will affect
our patients’ health and contradicts
our Oath of ‘primum nocere’. Now,
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63
we recognise WAAW 2023 as an
opportune moment for all physicians
to continue to reflect, engage, and
advocate for antibiotic stewardship,
community engagement, and
multisectoral partnerships.
Myanmar
Across Myanmar, a Southeast Asian
country with a population of 53
million residents, health leaders have
observed an increased transmission
of infectious diseases (including
drug-resistant tuberculosis rates) and
widespread irrational antibiotic use.
To support reducing AMR spread,
the Government of Myanmar, led
by State Counsellor Aung San
Suu Kyi, published the National
Action Plan for Containment of
Antimicrobial Resistance, 2017-2022
in 2017 [38]. This strategic research
agenda incorporates systematically
prioritised research areas and
knowledge gaps related to AMR,
which will support the development
of a national policy for research and
innovation. Though national policy
has been initiated together with
animal and human health sector
cooperating with other ministries,
the continual phase was paused
during the pandemic and completely
destroyed by Myanmar Military and
security forces since the military coup.
However, in the midst of the coup,
the military and security forces
in Myanmar have caused severe
disruption in health care system
infrastructure and service delivery,
as medical facilities and workers
are recognised as key targets in
battle [39]. First, physicians are
frequently unable to facilitate
suitable antimicrobial medication
and antibiotic usage methods, due to
meaningful obstruction of access to
medication (including antibiotics) by
the Myanmar Military and Security
forces and high cost of procurement
and logistics from border countries.
Due to interrupted transportation
networks and the destruction of
health care institutions, conflict
conditions make it difficult or
impossible to seek medical support,
resulting in protracted injuries
without treatment that can lead to
infections [40]. The wounds caused
by bombs, shrapnel, and bullets are
sometimes highly polluted (e.g. heavy
metal exposures), increasing the risk
of infection especially in areas lacking
proper sanitary facilities. Secondary
infections and death can result from
inoperable hospitals, relocation to
war-safe zones, and loss of follow-
up cases. Second, military limitations
on humanitarian aid distribution
(including medical treatment)
can seriously impact the health of
internally displaced persons (IDPs)
in Myanmar, restricting access to
health care services [41]. The IDP
camps, which are often overcrowded
and unsanitary, presents a setting that
facilitates increased transmission of
AMR strains between individuals.
The international medical community
(e.g. WHO; World Medical
Association, WMA; Junior Doctors
Network, JDN) should lead efforts
to advocate for prompt solutions
to reduce AMR spread across the
globe. As the Myanmar health
system grapples with the rising tide
of AMR, the international medical
community can help address the
extraordinary health crisis (as a result
of the military coup) by providing
critical humanitarian supplies (e.g.
medicines, antibiotics, vaccines)
through border countries to those who
are in desperate need in Myanmar
and deploying mini-laboratories to
ensure accurate diagnostics. Without
these measures, the Myanmar
health system will continue to be
challenged in providing high-quality
medical services to the populace,
and the spread of infectious diseases
(including AMR) may flourish to
neighboring countries.
Nigeria
In Nigeria, antimicrobials can
be purchased without a doctor’s
prescription and are widely sold on
the streets, motor parks, markets,
and public buses. With easy access
to antimicrobials, which can increase
the risk of incorrect dosage and abuse,
patients seeking primary health
services may have already consumed
several antimicrobials. Over the last
decade, the Nigerian government
and various professional health
organisations have been actively
working together to curb the menace
of antimicrobial abuse and misuse
(including counterfeit agents) and
protect population health for the 195
million residents.
The Nigerian government has
supported the adoption of laws
and regulations that ban the sale of
antimicrobials without a doctor’s
prescription and govern the handling
of medicines in human and animal
populations. In 1990, leaders
established the Poisons and Pharmacy
Act (Cap 366), the Food and Drug Act
(Cap 150), the Counterfeit and Fake
Drugs (miscellaneous provisions) Act
(Cap 73), and the National Essential
Drugs List (EDL) [42]. In 1993, the
Nigerian government adopted the
Drugs and Drug Related (Registration)
DegreeNo.19,whichbansunregistered
medicines and medicine-related
products in Nigeria and outlines the
procedures for registering medicines
and cosmetics. In 2017, the Federal
Ministries of Agriculture and Rural
Development, Environment and
Health and the Nigerian Centre for
Disease Control (NCDC) supported
the launch of the National Action
Plan for Antimicrobial Resistance
2017-2022, which aimed to create
awareness of AMR and implement
strategies to combat its risk and
spread [43]. Simultaneously, the team
conducted a national analysis of AMR
to analyse the situation in Nigeria,
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64
noting that primary gaps included
limited antimicrobial stewardship
across sectors, weak coordination
efforts between human and animal
disease surveillance systems, and few
public and private sector activities to
raise AMR awareness in the general
population [44].
Across Nigerian hospitals, the
Ministry of Health supports WAAW
campaigns and promotes in-hospital
continuous medical education
topics that focus on strengthening
infection, prevention, and control
measures. For WAAW 2020, a
high-panel discussion deliberated
on the challenges and possible
solutions to the misuse and abuse of
antimicrobials in Nigeria [45]. The
team concluded that barriers included
the lack of public awareness, limited
oversight on policy implementation,
easy access and availability of
antimicrobials (including counterfeit
and fake drugs),and fear of worsening
symptoms due to AMR infections.
They commented on possible
solutions such as enforcing doctor’s
prescription for antimicrobials,
implementing appropriate infection
control strategies, and promoting
antimicrobial stewardship [45].
Moving forward, the urgent call for
action in Nigeria is the continuous
sensitization of the populace to desist
from self-medicating practices or
purchasing drugs without a doctor’s
prescription. Physicians should
collaborate with public and private
institutions and organisations to
help educate the wider community
on the importance of adhering to
prescriptions and the harms of self-
medication. They can promote
antimicrobial stewardship measures as
a multisectoral and multidisciplinary
effort across human, animal, and
agricultural sectors.
Pakistan
Pakistan, a lower-middle income
country in South Asia, represents
the fifth most populous country in
the world with 240 million residents.
The rapid emergence of multi-drug
resistanceorganismshasplacedamajor
strain on an already overstretched
health delivery system in the country.
Physicians who diagnose AMR
infections have limited choices of
antimicrobial agents, and at times feel
helpless to manage such complicated
clinical cases. One national concern is
the high prevalence of Mycobacterium
tuberculosis (including drug-resistant
strains), as Pakistan and seven other
countries represent two-third of
emerging tuberculosis cases [46].The
emergence of multi-drug resistance
strains has been associated with
delays in diagnosis, inappropriate
and inadequate drug regimens, poor
follow-up, and lack of social support
programs [47].
Recognising the grave consequences
ofthisglobalthreat,Pakistanendorsed
the GlobalActionPlanonAntimicrobial
Resistance, which was presented at
the 68th WHA in Geneva in 2015,
recognising the need for urgent action
at national, regional, and global levels
[4]. To support this vision, one key
organisation is the National Institutes
of Health (NIH) of Pakistan, which
serves as the national focal point for
the International Health Regulations
and AMR, and forms part of the
Ministry of National Health Services
Regulation and Coordination
(NHSR&C). The NHSR&C is
responsible for the implementation
of technical areas of surveillance and
response (including AMR),workforce
development, and laboratory systems.
In 2015, the NHSR&C formed
an Intersectoral Core Steering
Committee to oversee the process
of developing a national AMR
policy in Pakistan [48]. These efforts
led to the launch of the National
Strategic Framework for Containment
of Antimicrobial Resistance in 2016
and the Antimicrobial Resistance
National Action Plan in 2017. In
2016, the NIH implemented the
GLASS, and in 2018, established the
Pakistan Antimicrobial Resistance
Surveillance System (PASS).Then,in
2021, the Drug Regulatory Authority
of Pakistan (DRAP) published
the Guidelines on Responsible Use of
Antimicrobials in Human Health,
which complement the National
Guidelines for Infection Prevention and
Control 2020, including best practices
to reducing the number of infections
and hence antimicrobial consumption
[49,50].
Over the past decade, the NIH of
Pakistan has led numerous initiatives
(e.g. seminars, photograph and video
competitions) to spread awareness
among health professionals and the
public about the misuse or overuse
of antibiotics as a predominant cause
of AMR. The NIH team publishes
a quarterly Antimicrobial Resistance
Newsletter, highlighting the latest
news, activities, guidelines, and
surveillance reports (https://www.
nih.org.pk/public/antimicrobial-
resistance/antimicrobial-resistance-
amr-newsletter). In 2020, they
launched the AMR Virtual Journal
Club, with 100 participants per
session, to strengthen AMR
knowledge among pathologists,
microbiologists, clinicians, and
laboratory personnel across Pakistan.
In 2021, they collaborated with
the WHO to organise an AMR
international conference, using the
One Health theme, to provide a
platform for medical professionals,
scholars, social and medical scientists
to share innovative ideas regarding
AMR challenges and solutions.
The Pakistan Medical Association
(PMA), the representative body of
medical professionals in Pakistan,
plays a key advisory role as clinical
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65
and research experts during
policymaking processes by the
government of Pakistan. To support
WAAW activities, PMA members
also organise various awareness
activities at local and regional levels,
including printed materials, television
interviews, and social media talks for
the public as well as health seminars
for health professionals. PMA
members and invited experts continue
to discuss the threat of AMR and
stress the importance of the rational
use of antimicrobials in human,
animal, and agriculture sectors.
Philippines
The risk and spread of AMR are
significant concerns in the Asia-
Pacific region, which represents
two-thirds of the global population
[51]. The Philippines, a country of
118 million residents, equivalent to
1.5% of the total world population
[52], has recognised the high level
(31-66%) of self-medication, due
to limited oversight of pharmacies
and easy access to antibiotics [53].
With rural populations relying on
traditional healers, the Filipino
population may be receiving unknown
substances (with or without antibiotic
ingredients) for their illness [54]. To
address the AMR burden, the Inter-
Agency Committee on Antimicrobial
Resistance (ICAMR) was established
in 2014, chaired by the Department
of Health (DOH), and including
the Departments of Agriculture
(DA), Trade and Industry (DTI),
Science and Technology (DOST),
and Interior and Local Government
(DILG). These agencies are tasked
with overseeing the implementation
of the Philippine Action Plan to Combat
Antimicrobial Resistance 2019-2022,
which links actions and interventions
across the human, animal, food, and
environment sectors to combat AMR
[54,55].
The Republic of the Philippines
supports public campaigns and
training opportunities that increase
public awareness of AMR risks and
spread and promote multidisciplinary
and multisectoral collaborations.
First, the ICAMR led the Philippine
Antimicrobial Awareness Week
(PAAW) in 2023 (https://pharma.
doh.gov.ph/paaw-2023/), building
off successes and using the
same “Preventing Antimicrobial
Resistance Together” (“Sama-samang
magtulungan, upang Antimicrobial
Resistance ay mapigilan”) from the
2022 campaign [56]. Second, the
DOH used social media technology
to create the “AMR Champions
Contest”, to encourage health
professionals working in the human
and animal health sectors to make
videos to showcase their institutional
best practices to combat AMR [57].
In partnership with universities,
social media communications (e.g.
Facebook, Twitter) and informative
webinars have widely shared
the importance of antimicrobial
stewardship. Third, the DOH
supported the implementation of the
Antimicrobial Stewardship (AMS)
training program, which is a six-week
blended training course designed to
educate health professionals about
the principles of antimicrobial
stewardship and best practices for
prescribing and using antimicrobial
agents.
National support for the
implementation of key activities that
increase awareness of antimicrobial
stewardship have included reinforcing
the national action plan, developing
continuing education programs for
health professionals,promoting public
health awareness campaigns, using
innovative technology (e.g. social
media) to widely spread accurate
health messages, and establishing
antimicrobial stewardship committees
in health care facilities. By ensuring
political commitment,the Philippines
health system can monitor the
appropriate use of antimicrobial
agents and minimise the risk of
AMR.By working together,all health
professionals can help curb the spread
of AMR and preserve these life-
saving drugs for future generations.
Lastly, the DOH receives support
from the Philippine Medical
Association, the national medical
association of all Filipino physicians,
with all its 121 component societies
in 17 regions nationwide. Together
with the different specialty,
subspecialty, and affiliate societies,
it aims to promote the rational use
of antimicrobials across all relevant
sectors and prevent AMR beyond the
COVID-19 pandemic.
Poland
In Poland, a country of 37 million
residents, antibiotic consumption was
reported to be among the highest
in the European region [58]. Over
the past two decades, health leaders
have collectively worked to monitor
AMR rates through the national
establishment of the National
Reference Centre for Antimicrobial
Susceptibility Testing (NRCAST) in
1997 and the National Programme
for the Protection of Antibiotics
(NPPA) in 2004 [58].The NRCAST
prepares annual reports on the rates
of drug resistance through two
national reference centres: National
Reference Center for Antimicrobial
Susceptibility (Krajowy Ośrodek
Referencyjny ds. Lekowrażliwości
Drobnoustrojów, KORLD) focused
on hospital-acquired infections and
KOROUN targeting community-
acquired pathogens. The KORLD
collects information on drug
resistance of invasive bacterial
isolates (S. pneumoniae, S. aureus,
E. coli, K. pneumoniae, P. aeruginosa,
Enterococcus faecalis, Enterococcus
faecium, Salmonella sp., Acinetobacter
sp.) in hospitalised patients (https://
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66
korld.nil.gov.pl/). One recent report
highlightedonesignificantthreatwith
drug resistance of carbapenemase-
producing Enterobacterales bacilli
(https://korld.nil.gov.pl/odpornosc-
na-antybiotyki-2/czesto-zadawane-
pytania/) [59]. The National
Reference Center for Diagnostics of
Bacterial Infections of the Central
Nervous System (Krajowy Ośrodek
Referencyjny ds. Diagnostyki
Bakteryjnych Zakażeń Ośrodkowego
Układu Nerwowego, KOROUN),
which was part of the RESPI-NET
(formerly, Aleksander), compiles data
on drug susceptibility of community-
acquired respiratory pathogens
(e.g. S. pneumoniae, Streptococcus
pyogenes, Haemophilus influenzae)
(https://koroun.nil.gov.pl/koroun/
projekt-aleksander/). Also, the Chief
Sanitary Inspectorate (GIS) collects
data and publishes annual reports
on risk factors (including drug-
resistant bacteria) from hospitalised
patients across provincial and district
epidemiological stations (https://
www.gov.pl/web/gis/raport—stan-
sanitarny-kraju). These surveillance
data are submitted to the European
Centre for Disease Prevention and
Control and included in the European
annual surveillance reports on AMR
[60].
Diverse educational campaigns
and formal coursework have been
developed for health professionals in
Poland.First,the European Antibiotic
Awareness Day (EDWA) has been
recognised annually on 18 November,
where physicians organise a medical
conference and various campaign
materials promoting knowledge
about the proper use of antibiotics
are available for the general public
and especially for doctors (https://
antybiotyki.edu.pl/edwa/info.php).
Second, the Clinical Microbiology
Centre Foundation has coordinated
scientific symposia for over 25 years,
including the Advances in Infection
Medicine for Medical Employees
event that targets physicians and
microbiologists, devoted to discussing
microbial drug resistance and
infection prevention, diagnosis, and
treatment (https://fundacjacmk.
pl/). Third, the National Antibiotic
Protection Program (NPOA), which
is financed by the Ministry of Health
of Poland, has prepared evidence-
based guidelines to promote rational
antibiotic therapy and strengthen
infection prevention and control
for health care professionals. The
program also organises an extensive
educational campaign (including
training workshops) to increase
awareness of AMR risk among health
professionals(https://antybiotyki.edu.
pl/). Fourth, the Polish Chamber of
Physicians and Dentists also provides
online training courses on AMR risk
and recommended evidence-based
practices for physicians in primary
care and specialty disciplines. Finally,
to support this need, the Jagiellonian
University’s Collegium Medicum
has offered a one-year postgraduate
degree entitled, “Antibiotics and
Antimicrobial Stewardship,” for
health care employees, where
graduates are encouraged to assume
leadership positions responsible for
rational antibiotic therapy in their
hospitals.
Republic of Korea
The Republic of Korea is a country
in East Asia with a population of 51
million, where half of the population
resides in the Seoul metropolitan
area. With the increased use of
antibiotics, antifungal agents, and
anti-tuberculosis drugs across the
nation, elevated AMR prevalence
raises concerns among national
health leaders [61]. According to
the Organisation for Economic Co-
operation and Development, the
national antibiotic consumption
rates have remained stable between
2005 and 2014, and were reported
highest among Turkey (40%), Greece
(33%), and Republic of Korea (30%),
surpassing the estimated average of
20% [62].
Over the past two decades, the
Ministry of Health of the Republic
of Korea has increasingly focused
on AMR management. First, the
National Antimicrobial Resistance
Safety Management Project (2003-
2012) aimed at reducing antibiotic
use and resistance rates, leading
to a notable decrease in hospital-
acquired infections and antibiotics
[63]. Second, prompted by the WHO
Global Action Plan on Antimicrobial
Resistance in 2015, the Korean
government established the First
National Antimicrobial Resistance
Management Plan (2016-2020),
which introduced a surveillance
system for resistant bacteria,
promoted research and development
on human,animal,and environmental
resistance, and implemented the
One Health approach [64]. As the
plan reported a remarkable 18%
decrease in overall antibiotic usage
and prescribing rates for respiratory
diseases, including two strategies:
1) implementation of an infection
prevention and control fee within the
National Health Insurance, requiring
the installation of isolation rooms
and fee allocation for employing
isolation rooms; and 2) establishment
of Korea Global Antimicrobial
Resistance Surveillance System
(Kor-GLASS), which follows
WHO’s recommendations related
to standardised data collection,
molecular epidemiological evaluation,
and compiled clinical information
associated with bacterial isolates
[63,65].
Furthermore, in 2021, the Korean
Society of Infectious Diseases and
the Korea Disease Control and
Prevention Agency (KDCA)
established the Korea National
Antibiotic Use Analysis and
Surveillance System (KONAS),
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67
to reduce inappropriate antibiotic
prescription by measuring and
reporting the antibiotic use in each
hospital. As of 2023, the Second
National Antimicrobial Resistance
Management Plan (2021-2025) is
being implemented, and the Republic
of Korea is actively participating in
the global AMR surveillance system,
especially with the designation of the
Korea National Institute of Health
(KNIH) as a WHO Collaborating
Centre for Antimicrobial Resistance.
Notably, while the first national plan
(2016-2020) focused on improving
AMR rates and infection prevention,
the second national plan (2021-2025)
emphasises improving the current
system, managing the use of broad-
spectrum antibiotics, and adapting
the plan to small- and medium-sized
hospitals and long-term care facilities
[63].
Despite significant policy
achievements, national health leaders
face limitations to strengthen efforts
to review antibiotic prescribing
practices, improve surveillance
systems, and broaden the scope of
AMR interventions in all health
care settings [62,65]. Antibiotic
stewardship is widely promoted, but
financial and educational support
for human resources (e.g. doctors,
pharmacists, nurses) and leadership
to facilitate stewardship activities
should be expanded across all
hospitals, especially small centres
[66,67]. Broadening participation in
the KONAS system for monitoring
antibiotic use in medical institutions,
establishing a continuous evaluation
system for appropriate antibiotic
prescribing, and strengthening the
Kor-GLASS surveillance system
through regional expansion are
essential to identify the most
important antibiotic-resistant
bacteria nationally [63,65]. National
and global AMR efforts require
robust collaborations to monitor
and share data on antibiotic use and
resistance and respond promptly to
disease outbreaks [63].
Rwanda
AMR remains a global health threat,
especially across low-and middle-
incomeAfricannations(likeRwanda),
where there is limited understanding
and evidence-based data on the
AMR burden [68]. In Rwanda,
the alarming increase of AMR
resistance, driven by weak health
surveillance systems, poor adherence
to infection prevention and control
measures, and inappropriate use and
misuse of antimicrobials, undermine
recent considerable improvements
on health. Two recent studies
conducted at the Kigali University
Teaching Hospital reported antibiotic
sensitivity to bacteria – specifically,
E. coli and Klebsiella isolates – in
biological samples collected from
patients admitted to neonatal and
medical wards [69,70]. Hence, there
is an urgent need to conduct scientific
research to identify the real-time
burden of AMR and reframe national
guidelines to mitigate risk and spread
of AMR.
In response to this AMR challenge,
the Government of Rwanda has
instituted stringent regulations
governing the responsible use of
antimicrobials in both human
and animal health, marking a
pivotal stride towards mitigating
AMR. First, Rwandan leaders
adopted the National Antimicrobial
Resistance Action Plan 2020-2024, a
comprehensive framework that spans
across human, animal, agriculture,
and environmental sectors [71].
These efforts highlight Rwanda’s
embrace of a holistic One Health
perspective, building upon the One
Health Strategic Plan (2014-2018),
adopted by the Government of
Rwanda in 2015, recognising the
necessity for collaborative action in
effectively addressing AMR [72].
Second, a robust surveillance system
was established to vigilantly monitor
the emergence and proliferation of
AMR, enabling prompt intervention
and evidence-based decision-making
within the health system. Third, the
Rwandanhealthsystemhasintegrated
antimicrobial stewardship programs,
beginning with neonatal centres and
critical care units, which advocate
for prudent antimicrobial usage to
minimise the risk of resistance.Finally,
leaders launched capacity-building
initiatives for human and animal
health professionals to reinforce
antibiotic prescribing and infection
prevention and control practices.
Despite instituted stringent
regulations governing the responsible
use of antimicrobials in both human
and animal health in Rwanda,
integrating strong antimicrobial
stewardship programs in health care
institutions, marking a pivotal stride
towards mitigating AMR is far from
over. As effective AMR management
is intrinsic to comprehensive health
care enhancement, the implemented
measures should be integrated
into the broader health system
with sustained commitment from
the government, its development
partners, and multiple community
stakeholders. Furthermore, through
active research collaborations with
international partners, Rwanda can
significantly contribute to the global
understanding of AMR dynamics,
thereby enriching the collective
knowledge base.
Spain
In line with other European countries,
health authorities and professionals
across Spain remain extremely
concerned about untreatable
infections due to AMR. Over the
past three decades, the Spanish
Society of Hospital Preventive
Medicine, Public Health and Health
Management (Sociedad Española de
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68
Medicina Preventiva, Salud Pública
y Gestión Sanitaria, SEMPSPGS)
has supported the Prevalence Study
of Nosocomial Infections in Spain
(EstudiodePrevalenciadeInfecciones
Nosocomiales en España, EPINE),
to examine the AMR burden in
Spain [73,74]. The EPINE 2022
(not published yet) reported ARM in
a sample of S. aureus (26% resistant
to methicillin), E. coli (16% resistant
to third generation cephalosporins),
and K. pneumoniae (7% resistant to
carbapenems) in health care related
infections.
At the national level, Ministry
of Health leaders are prepared to
maintain high-quality standards in
laboratory diagnostics and clinical
care. The Carlos III Health Institute
(Instituto de Salud Carlos III,
ISCIII) was established in 1986, after
the adoption of Law 14, to provide
scientific services and promote
research applications aligned with
the National Health System. As the
National Centre of Microbiology
(Centro Nacional de Microbiología,
CNM) forms part of the ISCIII,
this centre focuses on clinical
diagnostics, AMR monitoring and
surveillance (National Antimicrobial
Resistance Surveillance 2020 or
Vigilancia Nacional de la Resistencia
a Antimicrobianos 2020), references
services, and research (including
biosafety level 3 laboratory) for
infectious diseases [75]. Also, the
Spanish Agency of Medicines
and Medical Devices (Agencia
Española de Medicamentos y
Productos Sanitarios, AEMPS)
(ht t ps://w w w.aemps.gob.es/ )
guarantees high-quality and safe
products as well as accurate health
information to protect human,
animal, and environmental health.
Other national initiatives are based
on the National Plan against Antibiotic
Resistance (Plan Nacional frente a la
Resistencia a los Antibióticos, PRAN)
(https://www.resistenciaantibioticos.
es/es), which was approved by
the Interterritorial Council of
the National Health System and
the Intersectoral Conference on
Agriculture in 2014 [76].The PRAN,
which published three action plans
(2014-2018, 2019-2021, 2022-2024),
is guided by the One Health concept
and contains six strategic lines
(surveillance, control, prevention,
research, training, communication).
As a major consensus-building effort
between autonomous communities,
federal ministries, scientific societies,
professional organisations, and
experts, it aims to increase awareness
among health professionals and the
public about AMR risks as well as
offer tools and recommendations.
One milestone event was the creation
of the Programmes for Optimizing
Antibiotic Use (Programas de
Optimización de Uso de los
Antibióticos, PROA) across Spanish
hospitals, which aim to rationalise the
use of antibiotics to improve health
outcomes, reduce costs, and minimise
contributions to AMR [77].
As the Spanish General Medical
Council (CGCOM), we promote
professional acts of excellence to
master competencies in infectious
disease epidemiology and cautiously
adhere to the optimal therapeutic
guidelines for infection control. We
define a high-quality physician as
a clinician who adheres to ethical
principles and practices in the health
care setting. Our ethical commitment
to patients – namely, the first ethical
principle of our practice, “primum
non nocere”– obliges us to collectively
follow the recommendations of the
PRAN and other clinical protocols in
order to combat AMR.
Taiwan
Taiwan stands at the forefront of
combattingAMR,andhashistorically
united its efforts in both infection
control and judicious antibiotic usage.
In the realm of infection control,
Taiwan started official data collection
for nosocomial infections in the
late 1990s, and then established the
Taiwan Nosocomial Infections
Surveillance System (TNIS System)
in 2007, overseen by the Taiwan
Centers of Disease Control and
Prevention (https://www.cdc.gov.tw/
En) [78,79].Evolving into theTaiwan
Healthcare-associated Infection
and Antimicrobial Resistance
Surveillance System (THAS System)
in 2020, this system actively monitors
health care associated infections
(HAIs) in medical centres and
regional hospitals [80]. The latest
report from 2021 revealed alarming
statistics, with high proportions of
various resistant strains in intensive
care units. Notably, the surveillance
highlights concerning trends,
like the increase in carbapenem-
resistant Enterobacterales (CRE)
from 5.2% in 2016 to 7.6% in 2023,
calling for urgent collaborative
strategies to curb these escalating
figures [81]. The Taiwan Centers
of Disease Control and Prevention
has responded by issuing guidance
on preventing carbapenem-resistant
Enterobacterales transmission within
health care facilities, underscoring the
gravity of the situation.
In the medical domain, Taiwan’s
universal National Health Insurance
system, covering 99.6% of the
population and extending to 93%
of hospitals and clinics, ensures
widespread access to health care.
Policies, such as the discouragement
of antibiotics usage for upper
respiratory tract infections during
outpatient visits and the integration
of antibiotic stewardship into hospital
Global Efforts to Combat Antimicrobial Resistance
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69
accreditation, have led to a notable
reduction in unnecessary antibiotic
prescriptions [82]. Moreover,
the Infectious Disease Society of
Taiwan’s guidelines for treating
infections caused by multidrug-
resistant organisms underscore the
commitment to proper management
of AMR infections within the
medical community.
Taiwan health leaders acknowledge
AMR as a global public health
concern that requires cross-sector
collaboration and global campaigns
(like WAAW) to address the prudent
use of antimicrobial agents. Using the
WAAW 2023 theme, “Preventing
Antimicrobial Resistance Together,”
Taiwan Centers of Disease Control
and Prevention spearheaded the
“2023 World Antibiotics Week” to
unify efforts across public and private
sectors. Embracing the One Health
concept, a collective commitment
was made to implement antibiotic
management and infection control
measures, urging public engagement
to thwart AMR. Taiwan’s approach
to prevent drug-resistant infections
includesencouraginghealthylifestyles
and hand hygiene, vaccination
adherence, and responsible antibiotic
usage.
Trinidad and Tobago
Although AMR is a growing threat
to global communities, antimicrobial
consumption rates in the Caribbean
are unknown, as few regional
survey responses were received
upon data collection [83]. To propel
collaborative discussion on AMR
policies and guidelines,the Caribbean
Public Health Agency and Public
Health England organised a two-
day meeting in 2014, highlighting
the need to adopt a strategy that
can enhance laboratory capacity
to combat AMR [84]. A former
Minister of Health of the Republic
of Trinidad and Tobago, commented
that “Physicians are the gatekeepers
of antibiotic use,” marking the need
for health professionals training and
community education campaigns
[84].
Over the past decade, the Trinidad
and Tobago Medical Association
(T&TMA) and other national leaders
have demonstrated remarkable
leadership to combat AMR, as
they have collaborated to build a
sustainable future for the 1.3 million
residents. First, national leaders
have supported the development
of a Multisectoral Coordinating
Committee to Combat AMR, which
collectively works in alignment with
the five strategic objectives of the
Global Action Plan on Antimicrobial
Resistance [85]. Using mainstream
media, this committee has promoted
multimodal interventions (including
hand hygiene) as cost-effective
approaches to stop the spread of
infectious pathogens in human,
animal, and agricultural production
[86]. Second, as the first Caribbean
nation to join the WHO GLASS in
2020, health leaders contribute freely
available data on AMR surveillance
[87]. Finally, health leaders have also
independently explored antibiotic
misuse and prescribing practices
in humans and animals, including
evaluating the knowledge, attitudes,
and practices of pharmacists related
to antibiotic dispensing, to improve
and enforce AMR guidelines and
policies [88].
As our global community recognises
WAAW 2023, the T&TMA urges
all health professionals across human
and animal health sectors to promote
infection prevention and control or
biosecurity measures and antibiotic
stewardship within human and
livestock populations. By applying
the One Health concept, global
physicians have a moral obligation to
educate the public about the dangers
of misusing antimicrobial agents in
humans, livestock, and agriculture,
and advocate for stronger national
AMR guidelines and policies.
Additional local, regional, and
international efforts should include
strengthening connections between
physician-laboratory networks,
developing innovative messaging
for health education materials, and
expanding community outreach to
health professionals and the general
public. With 13 sovereign countries
and other territories in the Caribbean
region, we can collectively improve
our AMR response and develop
robust regional initiatives that support
strict antibiotic prescribing practices
across sectors, which can strengthen
population health and health system
resilience.
Turkey
Health leaders of the Turkey Ministry
of Health, supporting an estimated
population of 82 million residents,
have become increasingly aware of the
high rates of AMR and antimicrobial
consumption, when compared to
other nations [89]. According to
2022 surveillance data, carbapenem
resistance was reported in A.
baumannii (92.2%), K. pneumoniae
(66.6%), P. aeruginosa (67.6%), and
E. coli (17.1%) isolates [90]. Also,
resistance to methicillin was observed
in S. aureus (MRSA) (50.0%) and
coagulase-negative staphylococci
(MRCoNS) (85.7%),and vancomycin
resistance was reported in E. faecium
(VRE) (23.2%) [90].
To combat AMR risk across the
nation, health leaders implemented
a national active surveillance system
for health care associated infections
and AMR with antibiotic restriction
policies for antimicrobial use in
health care [91]. They established
the first national antimicrobial
stewardship program (National
Hospital Antimicrobial Restriction
Program, NARP) in 2003, and
Global Efforts to Combat Antimicrobial Resistance
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70
subsequently the second national
program in 2014 [91]. As a result of
this second national program (2014-
2017), one report noted that the
antibiotic prescription rate decreased
from 35% to 25%, and that the total
antibiotic expenditure to whole drug
expendituredecreasedfrom14%to4%
[92]. Furthermore, infectious disease
specialty associations have continued
to organise AMR awareness activities
with web conferences, local and
national symposiums and meetings,
podcasts, and video broadcasts to
increase awareness among health
professionals to lead efforts to prevent
health care associated infections
and reduce antibiotic consumption.
Aligned with these actions, the
Turkish Society of Infectious
Disease and Clinical Microbiology
(KLIMIK) (https://www.klimik.
org.tr) is currently developing a
national evidence-based guideline
on the diagnosis and treatment of
carbapenem-resistant gram-negative
bacterial infections.
As physicians of the Turkish
Medical Association, we urge health
professionals to urgently accelerate
national actions to prevent health
care associated infections and reduce
the risk of AMR spread. First,
antibiotic consumption monitoring
systems with feedback mechanisms
should be implemented into national
antimicrobial restriction programs
and monitored by local antimicrobial
stewardship programs [93]. Second,
the Ministry of Health can activate
health care associated infection
surveillance programs, establish local
antimicrobial stewardship programs,
and reactivate the second national
program that was halted due to
the COVID-19 pandemic. They
can also initiate communication
between relevant stakeholders in
the human, animal, and agricultural
sectors, especially infectious disease
specialty societies. Finally, as a global
community, we can collectively
organise public awareness campaigns
and evaluation studies that can assess
the rational use of antibiotics across
the wider society.
Uganda
Over the past decade, the Ministry
of Health of Uganda, a country of
approximately42millionresidents,has
reported alarming rates of mortality
due to AMR. One national study
identified the three most common
resistant strains of bacterial infections
as S. aureus, E. coli, and Salmonella
typhi [94]. Significant challenges
have included limited funding for
diagnostic testing, absence of strict
federal policies for pharmaceutical
regulation, sale of substandard
drugs by unlicensed pharmacies and
underutilization of epidemiological
surveillance data to monitor real-
time trends and prepare for potential
disease outbreaks [94,95].
Health leaders in Uganda recognise
the need to form multi-sectoral
collaborations and take immediate
action to combat AMR across the
country and continent. In 2018,
they developed the Antimicrobial
Resistance National Action Plan
(AMR-NAP) 2018-2023, to help
strengthen the national response to
AMR by encouraging stakeholders
to prepare plans that help monitor
and control the spread of AMR [96].
Next, they developed the Uganda
One Health Strategic Plan 2018-2022,
which focused on the three priority
actions of AMR, zoonotic diseases,
and biosecurity [97]. Finally, they
established the National One Health
Platform, which aimed to connect
four federal ministries – Ministry
of Agriculture, Animal Industries,
and Fisheries, Uganda Wildlife
Authority, Ministry of Water and
Environment,and Ministry of Health
– as well as identify synergies in One
Health and improve communication
across sectors and disciplines for
collaborative initiatives [98].
As physicians of the Uganda Medical
Association (UMA), we call upon
all stakeholders to optimise the use
of antimicrobial agents in humans,
regulate antibiotics use in livestock,
and encourage research on examining
drug resistance to anti-fungal and
anti-viral agents, especially in rural
settings.As health leaders,we can help
advocate for the implementation of
stricter laws on antibiotic prescribing
practices and educate health
practitioners and the general public
about the global threat of AMR.
Without strict oversight and political
commitment, our global community
will not be ready to manage AMR as
the next pandemic.
United Arab Emirates
In the United Arab Emirates (UAE),
a country of nine million residents,the
growing awareness of AMR has led
the government and private sector to
actively prioritise measures to combat
AMR. As part of ongoing efforts,
the UAE Ministry of Health and
Prevention have assigned infectious
disease specialists across hospitals
and other health care facilities to
identify drug sensitivity and support
antimicrobial stewardship [99]. To
strengthen the collective efforts of
the health system, the Government
adopted Federal Law No. 14 of 2014
(Combating Communicable Diseases)
and Federal Law No. 13 of 2020
(Public Health) [100].
To support current AMR initiatives,
the Government of UAE prepared
two key guidance documents that
outline the established procedures
that health stakeholders should follow
in their clinical management and
health education activities. In 2019,
health leaders adopted the National
Strategy and Action Plan for Combating
Antimicrobial Resistance (NAP-AMR)
2019-2023, as a roadmap for the
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71
UAE to tackle AMR by applying
the One Health approach [101].
These efforts also include promoting
behavioural changes among health
professionals and the public. In 2022,
they launched the UAE Surveillance
of Antimicrobial Resistance Annual
Report 2022, which will be used as a
guidance tool for creating national
AMR control policies [102]. The
report highlights the evidence-based
guidelines for antibiotic prescribing
practices and promotes academic
research in pharmaceutical discovery
[102].
Each year, government institutions
and hospitals host educational
seminars throughout the country
alongside the global WAAW
campaigns. Health professionals,
governments, academic professors,
and relevant stakeholders actively
lead AMR awareness campaigns and
training sessions. For example, the
Gulf Medical University’s College of
Pharmacy Antimicrobial Stewardship
Workshop in 2018, helped students
from graduate programs in clinical
pharmacy (PharmD and Master
in Clinical Pharmacy) as well as
pharmacy practitioners from the
Thumbay Hospital in Ajman,
to update their knowledge on
AMR burden and how to address
AMR infections within their role
as pharmacy practitioners [103].
Also, the 7th UAE International
Conference on Antimicrobial
Resistance (ICAMR) will be held
on 23-24 February 2024, under the
patronage of H.E. Abdul Rahman
Mohammed Al Owais and the
Ministry of Health and Prevention
(https://www.icamr-uae.com/), as
an opportunity to share the latest
scientific and academic advances
through interactive case reports,
presentations, open discussions, and
networking opportunities. These
prominent activities to increase
awareness and understanding of
AMR extend across public and
private hospitals in the UAE.
As physicians, we must uphold
practices for combating AMR,
which include limiting rampant use
of antimicrobial agents, adhering
to judicial prescribing practices,
and increasing AMR awareness
across communities. It is important
to provide junior doctors with a
platform to raise their concerns to
ensure meaningful youth engagement
on AMR efforts. As we collaborate
to improve national surveillance
programs and promote antimicrobial
stewardship,we can establish working
relationships with government sector
representatives to strengthen existing
laws based on the scientific literature.
Globally, countries can collaborate
to expand knowledge and share
resources, and health ministers can
identify common goals and pathways
within the geographic region to
prevent the spread of resistant strains.
Uruguay
The Uruguay Ministry of Health,
supporting 3.5 million residents,
recognises the current and future
challenges facing AMR, including
antimicrobial treatments that are
unavailable in the country, high costs
for managing AMR infections, and
epidemiological changes related to
AMR resistance patterns that lead
to complex clinical management.
Between 2010 and 2017,the Ministry
of Health’s National Surveillance
System of Hospital-acquired
Infections reported an increased
number of AMR infections,including
carbapenemase-producing and
extended-spectrum beta-lactamase-
producing Enterobacteriaceae, P.
aeruginosa, A. baumannii complex,
and colistin-resistant E. coli (https://
www.gub.uy/salud). Health leaders
have also recognised pathogen
adaptation and the global spread
of these diverse strains, as colistin
resistance in gram-negative bacteria
(type mrc-1) was reported in China
in 2015 and subsequently in Uruguay
in 2017 [104].
For more than two decades,
governmental and academic
institutions in Uruguay have
led efforts to strengthen AMR
surveillance across health centres,
including reports of hospital-acquired
infections. In 1997, Ministry of
Health adopted the Decree 437/997
(Decreto No. 437/997), which ensured
that hospital infection control
committees (Comités de Prevención y
Control de Infecciones Hospitalarias,
CIH) would be created across the
country’s hospitals [105]. Additional
actions have included Decree No.
098/2011 for the prohibition of
the use of antibiotics in production
chains since 2011, and Decree No.
141/019 for the prohibition of the use
of colistin in veterinary health. Since
2016, the Ministry of Livestock,
Agriculture and Fisheries (Ministerio
de Ganadería, Agricultura y Pesca,
MGAP) and the Ministry of Public
Health (Ministerio de Salud Pública,
MSP) have developed the National
Plan for Containment of Antimicrobial
Resistance and the National Action
Plan to Combat Antimicrobial
Resistance, as efforts to guide health
leaders and stakeholders in reducing
risk and spread of AMR [106,107].
In November 2018, the Government
of Uruguay reconfirmed their
commitment to the National Action
Plan to Combat Antimicrobial
Resistance, support of the One
Health objective, and collaboration
with three ministries (MGAP, MSP,
Ministry of Environment) [108].
This single national plan, comprised
of five thematic sections, incorporates
key strategic objectives and actions
to protect human, animal, and
environment health and reduce risk
and spread of AMR. Health leaders
are currently updating the National
Action Plan to Combat Antimicrobial
Global Efforts to Combat Antimicrobial Resistance
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72
Resistance for an expected publication
in 2024.
Conclusion
The WAAW 2023 opens a global
forum to recognise the AMR
burden across all countries, examine
the driving factors that propel the
spread of drug-resistant strains,
identify knowledge and practice gaps
related to inconsistent adherence
to infection control practices, and
develop key policies and agendas to
protect population health. As global
leaders prepare for the UN General
Assembly High-Level Meeting on
AMR in September 2024, two recent
AMR guidance documents can
help guide leaders in the revision of
national action plans on AMR and
the implementation of additional
local and national interventions
to strengthen health system
preparedness.First,theGlobalResearch
Agenda for Antimicrobial Resistance,
which was launched in July 2023,
highlighted 40 research topics that call
for appraisals of the evidence-based
literature (spanning the epidemiology
of AMR infections to cost-effective
community interventions) to help
inform policies aligned with the 2030
Agenda for Sustainable Development
[109]. Second, the WHO Core Package
of Interventions to Support National
Action Plans, which was published in
October 2023, incorporated a people-
centred approach into 13 AMR
interventions and actions linked two
four pillars (infection prevention,
health care service access, prompt
diagnosis, high-quality treatment)
and two foundational steps (effective
awareness and oversight, evidence-
based surveillance and research), to
help national health systems eliminate
barriers related to AMR response and
health services [110].
Representing diverse clinical and
surgical disciplines, WMA members
are poised with a strategic leadership
role to help national leaders refine
the national action plans to combat
AMR,including strengthening AMR
surveillance reporting, enhancing
appropriate antibiotic prescribing
practices and use, and identifying best
clinical and community interventions.
As this collective article provides a
comprehensive overview of relevant
policies, capacity building activities,
and community initiatives across 20
countries, our global community can
gaininsightandinspirationfromthese
reports, increase global awareness
of the AMR burden and impacts
on the economy and health systems,
and advocate for urgent collective
actions to combat AMR through
a One Health framework. These
multidisciplinary and multisectoral
collaborations highlight robust
regional leadership and political
commitment across the African,
Americas, East Mediterranean,
European, South-East Asian, and
Western Pacific regions, recognising
a promising future to collectively
promote antimicrobial stewardship
and combat AMR across human,
animal, and agricultural sectors.
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