WMJ_2_2018

vol. 64
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 2, August 2018
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
209th
WMA Council Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
WMA Council Resolution on the Prohibition of Nuclear Weapons . . . . . . . . . . . . . . . . . . . . . 13
End of Life Seminars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Junior Doctors Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
World Health Professions Alliance Regulation Conference 2018 . . . . . . . . . . . . . . . . . . . . . . . 15
World Health Assembly Side Events – May 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Intellectual Property: who owns the right to good health?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Physicians’ Role in the Management and Leadership of Health Care . . . . . . . . . . . . . . . . . . . . 22
Policy Analysis Ottawa Declaration on Child Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
CMA Thousand Talents Cultivation Program for County Hospitals . . . . . . . . . . . . . . . . . . . . 28
Universal Medical Esperanto Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Competence Drift in Professional Practice: a Psychological Perspective . . . . . . . . . . . . . . . . . 33
Workforce of Healthcare Professionals in Rural Nigeria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
International Congress on Medical Ethics, a Risk Worth Taking? . . . . . . . . . . . . . . . . . . . . . . 38
Multi-Media Educational Tool Created to Help Children Cope with Cancer. . . . . . . . . . . . . 40
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv, editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
The Latvian Medical Association, “Latvijas Ārstu biedrība”,
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Yoshitake YOKOKURA
WMA President
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,
Tokyo, Japan
Dr. René HÉMAN
WMA Chairperson of the Finance
and Planning Committee
P.O. Box 20051
3502 LB, Utrecht
Netherlands
Prof. Dr. Frank Ulrich
MONTGOMERY
WMA Vice-Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Ketan DESAI
WMA Immediate Past-President
Indian Medical Association
Indraprastha Marg
110 002 New Delhi
India
Dr. Joseph HEYMAN
WMA Chairperson
of the Associate Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. Andrew DEARDEN
WMA Treasurer
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Leonid EIDELMAN
WMA President-Elect
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Heidi STENSMYREN
WMA Chairperson of the Medical
Ethics Committee
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE – 114 86 Stockholm
Sweden
Dr. Miguel Roberto JORGE
WMA Chairperson of the Socio-
Medical Affairs Committee
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Ardis D. HOVEN
WMA Chairperson of Council
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chicago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
1
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Editorial
Editorial
Regular reviewing of rigid assumptions is the prime task of the 21st
century medicine. Undoubtedly, first and foremost it refers to medi-
cations and it is vital to assess anew whether the particular medica-
tion is appropriate for the specific illness or syndrome or the risks
might exceed the expected result; is it really so that polypragmasia –
administration of 6–10 medications to a patient at the same time –
is the best practice for concurrent treatment of several diseases.
It would be purposeful to revise the indications of any medication at
least once in ten years. It would be even better if it were done with-
out involving the pharmaceutical industry. It should be investigated
on what grounds using of a certain medication or applying some
diagnostic or manipulative treatment has been refused now. Quite
often it is because a new, more effective medication has entered the
market, but we are unaware of its real side effects and long-term
impact in a ten year period.
Treatment is vital, however, not the most important part of health
care – there is also prevention,diagnostics,treatment and rehabilita-
tion. Still, treatment includes not only the use of medications, but
also physical medicine (heat, electricity), surgery, psychotherapeutic
treatment, radiation therapy and non-traditional methods of treat-
ment.
During the last 30 years the role of physical therapy and surgery has
diminished due to new medications.
It would also be wise to reconsider an evidence-based opinion that
has been formulated as a result of serious research. For example,
anti-bacterial therapy was developed on the basis of definite find-
ings and it treated easily different infectious diseases. Today, when
we understand that the microbiome is an important part of human
physiology and how it is damaged by antibacterial therapy, it is sen-
sible to review our considerations about treating not so serious and
also very serious infectious diseases.
It is time to review the physician-pharmacist relationship on a global
scale. There is a strong tendency in the world to associate medicine
with doctors, but the pharmaceutical industry – with pharmacists
and druggists. Doctors are often blamed publicly as soon as any-
thing has been done wrong either by the nurse or nurse assistant or
hospital registrar. Pharmacists are made responsible for medications
being expensive,for prescribing them too much and that quite often
medicine seems to be an appendix to the pharmaceutical industry.
Civil service and politics have largely promoted pharmacy to take
the lead position on a global scale.Under the auspices of civil service
the usage of medications is focused on in guidelines, recommenda-
tions and funded health care.There is extensive and fruitful research
worldwide about the beneficial effect of movement (walks, train-
ings) on the progress in treatment, but in the prepared documents it
is substituted by bed regime and a handful of tablets because politi-
cians and financiers are unable to calculate the costs of indirect care,
treatment of psychosomatic disorders, holistic treatment (and even
more incapable of calculating the cost of non-conventional medi-
cine).
Politicians and civil servants are incapable of understanding science;
they cannot perceive man as a whole and they demand to treat a
specific illness, not a patient, moreover, they demand to treat, but
not to heal. Globalization associates with the consumer philosophy
which propagates two slogans – “the more medications, the better
your health” and “expensive medicine is better than cheap medi-
cine”. The consumer philosophy leads to the situation when a sick
man is equated with a broken car.The greatest lobbyists of the con-
sumer philosophy are rich people – politicians and civil servants as
they always manage to get public or insurance funds to pay for the
health care services they have received.
Thus, polypragmasia and bureaucracy poison medicine globally.The
only remedy against this policy and red-tapism is regular revising of
the long-standing assumptions. The World Medical Association is
the structure which is capable of undertaking the leadership in these
activities and, moreover, it will be obliged to do it.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal,
President of the Latvian Medical Association
2
WMA Council Session
The 209th
WMA Council meeting was held
at the Radisson Blu Latvija Conference &
Spa Hotel from April 26–28 in the year of
Latvia’s 100th
anniversary.Around 150 dele-
gates from 40 national medic al associations
attended.
THURSDAY APRIL 26
Council
The proceedings were opened by Dr. Ardis
Hoven, Chair of the WMA, who thanked
the Latvian Medical Association for their
hospitality. She spoke about the importance
of everybody participating in the meeting
and listening to one another.
President’s Report
Dr.  Yoshitake Yokokura, in his Presiden-
tial report, reported on his activities in the
past six months and his mission to advance
the initiative of Universal Health Cover-
age (UHC), as well as to strengthen health
systems around the world. He referred
to the various meetings he had attended.
These included the 2017 Global Health
Forum in November 2017 hosted by the
Taiwan Health Ministry and Foreign Af-
fairs, and the UHC Forum 2017 held in
Tokyo in December organized by the Jap-
anese Government, World Bank, United
Nations, WHO and UNICEF. One of the
highlights of the latter meeting was the
agreement between the WMA and WHO
to agree an official Memorandum of Un-
derstanding on collaboration for establish-
ing the UHC on a global level and for the
strengthening of disaster preparedness.
This Memorandum was signed in Gene-
va on April 5 and he believed this agree-
ment was a milestone and would further
enhance the presence of the WMA in the
global community.
Secretary General’s Report
Dr.  Otmar Kloiber, Secretary General,
tabled a detailed written report, setting
out the Secretariat’s activities since the last
meeting. In his oral report he said that since
the Chicago Assembly further end of life
seminars had been held at the Vatican in
Rome and in Abuja, Nigeria, and a session
with the Arab Medical Union had been ad-
dressed by Dr. Hoven.
Chair’s Report
Dr. Ardis Hoven, in her written report for
Council, mentioned that in writing a fore-
word on Women’s Health in Global Per-
spective, she was reminded of the barriers
to health care and clinical needs that con-
stituted threats to adequate health care for
women. With increasing migrant streams
caused by war, climate change and econom-
ic disruption, women had become targets
of abuse, violence and deprivation. She said
gender based health disparities intensified
the need for the WMA’s role in the Social
Determinants of Health globally.
“As leaders in medicine, we have the op-
portunity and the responsibility to lay aside
our politics and concentrate on the needs of
patients and our health care colleagues. As
we enjoy the hospitality of Riga, I encour-
age honest dialogue around what we might
consider difficult topics. Respect for, and
encouraging, the minority opinion will be
very desirable. We are diverse in many ways
and we must celebrate that diversity”.
Emergency Resolution
An emergency resolution on nuclear weap-
ons was submitted for debate by the Japan
Medical Association and the International
Physicians for the Prevention of Nuclear
War. The Council agreed that this should
be considered by the Socio Medical Affairs
Committee.
The Council meeting was adjourned.
Finance and Planning
Committee
Dr. René Héman (Netherlands) took the
chair.
Financial Statements for 2016 and 2017
Dr. Andrew Dearden,the Treasurer,gave an
oral report on the Association’s financial ac-
counts and interim statement. He said there
were no surprises, but several very good
messages. They had finished 2017 with a
surplus, their equity was good, expenses
were well regulated and membership dues
had increased. These achievements allowed
the Association to increase workload as
necessary. In short, the Association’s financ-
es were in a good position.
The committee recommended that the
Council approve the interim Financial
Statement for 2017, as well as the report on
Membership Dues Payments for 2018
WMA Strategic Plan
Dr. Kloiber gave an oral report on the As-
sociation’s draft Strategic Plan, explaining
that it was being separated into two parts –
one reflecting the principles upon which the
plan was based and a second part articulat-
ing an action plan. The revised draft would
be reported to the Council in October in
Reykjavik.
209th
WMA Council Session,
26–28 April, 2018, Riga
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WMA Council Session
WMA Statutory Meetings
The Committee considered arrangements
for future WMA Statutory Meetings and
heard about offers from three Constituent
Members to host the 2020 General Assem-
bly – the Rwanda Medical Association to
host in Kigali, the British Medical Asso-
ciation to host in London and the Consejo
General de Colegios Médicos de España to
host in Cordova.
The Conseil National de l’Ordre des Méde-
cins (France) also presented an invitation to
host the 2022 Council Session in Paris.
The Committee recommended to Coun-
cil that the 218th
Council session be held
from 22–24 April 2021, that the 72nd
Gen-
eral Assembly be held from 13–16 October
2021 and that the 221st
Council session be
held from 7–9 April 2022.
It recommended that the invitations from
Rwanda, the UK, and Spain be postponed
to the next Council session in Reykjavik and
that the invitation from CNOM France for
Paris to host the 221st
Council Session in
April 2022 be accepted.
WMA Special Meetings
The Committee received an oral report
from the Secretary General, about several
forthcoming events:
• Ethics Conference, Reykjavik, 2–4 Octo-
ber 2018: This year’s scientific session at
the General Assembly would be integrated
on the second day of the three-day Ethics
conference and this could be a model for
future meetings. Dr. Snædal (Iceland) said
the programme would include the Decla-
ration of Helsinki, the Declaration of Lis-
bon, the Declaration of Taipei and other
core WMA policies. External participants
would be invited to join the discussions.
• UNESCO World conference: This meet-
ing would be held in Israel, 27–29 No-
vember 2018.
• World Health Assembly, 21–26 May
2018. The WMA was planning multiple
side events during the WHA.
• The World Health Professions Alliance
Regulation conference would be held before
the WHA, 19–20 May 2018 in Geneva.
Associate Membership
Dr.  Joe Heyman, Chair of the Associate
Members, said that at the end their meet-
ing in Chicago, 85 members had joined a
Google group set up to debate online draft
policy documents. He told the committee
that they now had around 200 members in
what had become a very active group.
Dr. Kloiber thanked Dr. Heyman for his ef-
forts managing the online group. He said it
was a very lively group, involved in a very
high quality discussion about draft policies.
Junior Doctors Network
Dr.  Caline Mattar, Chair of the Junior
Doctors Network, reported on the group’s
work on antimicrobial resistance, UHC and
health workers. They had held a one-day
meeting in Latvia that included a capacity
building and a leadership workshop attend-
ed by some NMAs.
In her written report, she said that there
was now an active group of junior doctors
in Latin America and new members from
the Eastern Mediterranean were joining the
Network.
Past Presidents and Chairs
of Council Network
Dr. Jon Snædal (Iceland) gave a report on the
group’s activities. He thought the title of the
group was rather cumbersome and suggested
that perhaps it might be renamed the Senate
or the House of Lords of the WMA! He told
the committee that the group had started en-
gaging in the dialogue related to the 40th
an-
niversary of Alma-Ata Declaration.
Governance Review
Dr. Mark Porter, Chair of the Review Com-
mittee,gave an oral report.He reminded del-
egates that the committee had been set up to
receive and review proposals for new business
and to assist in considering items for con-
sideration. The committee had made a good
start in helping to improve Council business.
Nominating Process
A proposal to introduce a self-declaration
statement to the nominating process for
WMA Presidency was discussed. It was
explained that this would be an additional
layer of governance.
TheCommitteeagreedtorecommendthatthe
proposal should be circulated for comment.
World Medical Journal
In his written report,the editor in chief of the
Journal, Dr. Peteris Apinis, said the Journal
turned 64 this year and much had changed
during this time. He thanked those who had
assisted him since he took over the editorship
in 2008. He said the Journal was essentially
a newsletter meant for the leaders of medical
associations all over the world,to inform them
about key events, documents, movements and
the direction in which the WMA was going.
The Journal was published four times a year
and for the past two years had also been pub-
lishing in digital form,with printed copies go-
ing to the world’s leading libraries.
Public Relations
The Committee was told that after the Gen-
eral Assembly in Chicago last year, there was
very strong international publicity, including
4
WMA Council Session
on social media, generated by the revision of
the Declaration of Geneva and its immediate
publication in the Journal of the American
Medical Association. Ms Magda Mihaila,
WMA Communications and Information
Manager,was now coordinating social media
on Twitter and Facebook. There had been a
highly successful social media campaign dur-
ing the early part of 2018 in support of the
arrested Turkish doctors.
Socio Medical Affairs
Committee
Dr. Miguel Roberto Jorge (Brazil) took the
chair.
Health and Migration
Dr.  Poonam Dhavan, Migration Health
Programme Coordinator at the Internation-
al Organisation for Migration, gave an oral
report about the work of her organisation.
She emphasized the critical role of health
for migrant populations and referred to the
increasing development of international
policies on migration. She spoke about the
importance of the role of health profession-
als in providing care to all migrants in need,
in line with medical ethics principles. She
concluded by expressing her organisation’s
aspiration to collaborate with the WMA in
the area of health and migration.
Monitoring Report
Dr. Kloiber reported on the new Memoran-
dum of Understanding between the WMA
and the World Health Organisation signed
in April between Dr.  Tedros Adhanom
Ghebreyesus,WHO Director-General, and
WMA President Dr.  Yoshitake Yokokura.
The Memorandum identified four areas for
the organisations to focus on – fostering the
development of Universal Health Coverage
with specific attention on the role of physi-
cians, strengthening the world health work-
force, inequalities in health and emergency
preparedness. Dr. Kloiber said that as a re-
sult of the agreement the WMA would have
to deliver more on how physicians were in-
volved in these processes. One example was
the situation facing African countries of
doctors being imported from Cuba. He said
he had already started by bringing together
various NMAs to discuss this issue.
Health and Environment
The Co-Chair of the Environment Caucus,
Dr. Lujain Al-Qodmani (Kuwait), reported
on the meeting the Caucus had held the pre-
vious day.It had discussed the opportunity to
review and analyze the WMA’s existing envi-
ronmental policies to make them more con-
cise, coherent and current and had decided
to set up an informal working group to look
at those policies and make recommendations
to the Council. The Caucus had also agreed
to set up a green mailing list to facilitate and
promote exchange of information within the
WMA membership on issues related specifi-
cally to health and the environment.The list
would be open to any NMA members and
interested Associate members.
Plastic Bags, Ecological Issues &
Environmental Degradation
The Committee considered a proposed revi-
sion of the WMA Statement on Environ-
mental Degradation and Sound Manage-
ment of Chemicals, originally submitted
by the Latvian Medical Association. It was
argued that the current policy should be
widened to include plastic pollution.
The Committee agreed to recommend that
the draft revision should be circulated to
constituent members for comment.
Medical Tourism
The committee considered the proposed
WMA Statement on Medical Tourism.
Delegates were reminded that the paper
was first brought to the committee two
years ago by the Israel Medical Association.
Concerns were raised then about parts of
the document and the new proposed State-
ment was a revised version, taking into ac-
count those concerns. The argument of the
Israeli Medial Association was that at the
moment this activity was going on and the
WMA did not have a firm policy or any
regulations.
During the debate that followed, several
members expressed continuing concerns
about the definition of medical tourism and
thought that the word “tourism” suggested
something leisurely,when,what it was really
about was cross border medical treatment.
Delegates agreed several amendments.
One called on governments to consider all
the implications of medical tourism to the
healthcare system of a country by develop-
ing comprehensive, coordinated national
protocols and legislation. Another, relating
to confidentiality, made it clear that inter-
preters, and other administrative staff with
access to health information of the medical
tourist should sign confidentiality agree-
ments.
The committee recommended that the pro-
posed Statement, as amended, be approved
by the Council and forwarded to the Gen-
eral Assembly for adoption.
Gender Equality in Medicine
The Israel Medical Association submitted
a revised Statement on Women in Medi-
cine. An earlier draft had been debated,
amended and circulated among members
for comment. The committee was told that
the revised paper attempted to bring to-
gether physicians from different parts of the
world, with different cultures and different
work environments. An attempt had been
made to address all the concerns raised.The
challenge was that in one part of the world,
particularly northern Europe, they were
5
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WMA Council Session
dealing with a quite equal society, where it
might be problematic to talk about special
concerns for women. However, there were
other parts of the world where there was no
equality in the medical workplace and no
equal opportunities.These countries needed
more protection to encourage employers to
allow women to achieve their true potential
in medicine.
A lengthy debate followed, with several
amendments being put forward and debated.
The committee agreed to change the title of
the document from “Women in Medicine”
to “Gender Equality in Medicine”.
The issues of flexible working hours and
work-life balance were debated. One pro-
posal, to encourage employers to ensure
women were able to access all their rights
and entitlements, and to ensure that men
had equal opportunities to take parental
leave, was rejected.
Delegates debated whether or not to in-
clude a reference to female physicians fac-
ing significant levels of mental illness and
suicide. Some delegates questioned the ac-
curacy of the reference, and many speakers
said that suicide and mental illness affected
both women and men. The committee de-
cided to omit any reference to this issue.
The committee then approved the whole
document as amended.
Professional Autonomy of Physicians
Clarisse Delorme, the WMA’s Advocacy
Adviser, explained that as part of the As-
sociation’s annual policy review process, the
Council had decided that the Statement
on Professional Responsibility for standards
of Medical Care be rescinded and archived,
and that the Declaration of Seoul on Pro-
fessional Autonomy and Clinical Indepen-
dence and the Declaration of Madrid on
Professionally-led Regulation be merged in
a single document. Sections could then be
incorporated into that merged document
from the Statement on Professional Responsi-
bility for standards of Medical Care.However,
the Council later reversed its decision and
decided that the Declarations of Seoul and
Madrid be kept separate and revised indi-
vidually to incorporate the relevant missing
sections from the Statement on Professional
Responsibility for standards of Medical Care,
which would then be rescinded and ar-
chived.
During a debate on the Declaration of
Seoul, the issue was raised of other profes-
sions, particularly in Africa, moving into
areas traditionally undertaken by physi-
cians. It was argued that the document did
not satisfactorily address this. Dr.  Kloiber
responded by saying that other professions
were in fact trying to occupy parts of the
physician’s traditional scope of practice. In
some places there might be a good reason
for this, but in general it was a problem.
There was a big problem in different health
care systems with the density of health
professions. There were parts of the world
where there was no physician and patients
had to rely on health care workers or nurses.
Dr. Kloiber said current WMA documents
did not address this situation and he had
been asked by the Executive Committee to
look into this issue and build alliances with
other groups, such as WoNCA.
The committee went on to recommend to
the Council that the revised Declaration
of Seoul be approved and forwarded to the
Assembly for adoption.
Declaration of Madrid on on
Professionally-led Regulation
The committee then considered the revised
Declaration of Madrid on Professionally-
led Regulation. Members pointed out that
many countries no longer had professional-
ly-led regulation, having moved to statutory
regulation. However, it was pointed out that
in a recent WMA survey of members,it was
shown that 46 countries had professionally-
led regulation.
After a brief debate the committee decided
to recommend to the Council that the re-
vised Declaration be recirculated among
members for comment.
Sustainable Development
The Japan Medical Association introduced
a proposed Statement on Sustainable De-
velopment. It was explained that two years
ago it had been decided to set up a working
group on sustainable development with the
mandate to develop a proposal for a WMA
policy on the topic and to define a proposed
strategy for sustainable development at in-
ternational and national level. The Council
meeting in Chicago decided to circulate the
document among members for comments.
The committee recommended that the re-
vised Statement be approved and forwarded
to the Assembly for adoption.
Avian and Pandemic Influenza
A proposed revision of the WMA State-
ment on Avian and Pandemic Influenza was
considered. Delegates were reminded it had
been decided that this Statement should
undergo a minor revision under the 10-year
review process. Concerns had been raised
about the scientific content of an early revi-
sion of the document. Those concerns had
now been addressed. The committee agreed
to amend the document to say that a new
pandemic virus could develop if a human
became simultaneously infected with avian
and human influenza viruses, resulting in
gene swapping and a new virus strain for
which there may be no immunity.
The committee recommended that the
whole document as amended should be ap-
proved by the Council and forwarded to the
Assembly for adoption.
6
WMA Council Session
Nuclear Weapons
A revised Statement on Nuclear Weapons
was presented jointly by the Japan Medical
Association and the International Physi-
cians for the Prevention of Nuclear War.
Dr.  Bjørn Hilt, chair of board of the
IPPNW, said there were two important
amendments to the previous WMA State-
ment on nuclear weapons. The first was the
so-called modernization of nuclear weap-
ons. Nuclear weapon states wanted to use
a perverse amount of money to modernize
their nuclear arsenals They wanted to use
trillions of US dollars, pounds and roubles
to modernize their nuclear weapons and to
keep them for infinity. This meant making
these weapons more usable and this was
very dangerous and disturbing.
The other amendment was that 122 UN
members on July 7 last year adopted the
text of the Treaty on Nuclear Weapons.The
secretariat of the WMA, ICN and IPPNW
had published a joint statement in Septem-
ber. But to make this statement the official
policy of the WMA it needed the approval
of the Council. They had a common inter-
est to use this new window of opportunity
of the Treaty to educate the public and for
WMA members to put pressure on their
own governments.
He said that critics of the Treaty argued that
the Treaty as such would not eliminate a
single nuclear weapon. But once the Treaty
had been ratified by 50 states it would en-
ter into force and become international law.
That would strengthen the legal and moral
pressure on nuclear states to fulfil their ex-
isting obligations according to the non-pro-
liferation Treaty to negotiate for the elimi-
nation of all nuclear weapons. Dr. Hilt said
they could still prevent another catastrophe
of nuclear weapons happening.
Delegates agreed several minor amend-
ments to the Statement and the committee
agreed to recommend to the Council that
the Statement be forwarded to the General
Assembly for adoption.
The committee also agreed the emergency
resolution on nuclear weapons and recom-
mended to the Council that it be approved.
Maternal and Child Health
The Japanese Medical Association pre-
sented a proposed Statement on the De-
velopment and Promotion of a Maternal
and Child Health Handbook. The State-
ment was based on a booklet developed by
the Japanese Medical Association in 1948.
The committee was told that the booklet
had contributed to improved health for
the mother and child in Japan. Today there
were 40 different versions of the handbook
in various countries.There was also an elec-
tronic format. The Japanese Medical Asso-
ciation said the WMA should be collabo-
rating on this with the WHO, and NMAs
should help in developing and promoting
the handbook globally.
The Committee agreed to recommend to
Council that the booklet be circulated to
constituent members for comment.
Pseudoscience
A proposed Declaration on Pseudoscience,
Pseudotherapies, intrusion and sects in the
field of health was submitted by the Spanish
Medical Association. It argued that there
was concern over the proliferation of these
practices with their negative consequences.
There was a whole group of disciplines of
pseudo practices intruding on the medi-
cal profession and trying to trespass on the
scope of conventional scientific based medi-
cine. But in most countries there was no
regulatory framework.
The committee recommended that the doc-
ument be circulated to constituent members
for comment.
Latvian Reception
During an evening reception, hosted by the
Latvian Medical Association for all WMA
delegates, Dr. Ilze Aizsilniece, Vice Presi-
dent of the LVA, welcomed the WMA, and
talking about the changing weather in Riga
and the change in democracy that had oc-
curred in her country.
‘Nuclear weapons, detention of medical
doctors for expressing publicly their con-
cerns about the impact of war on humans’
health, autonomy of the medical profession,
the way the research is conducted: these are
only a few of problems discussed during the
209th
Council of the WMA.
‘Maybe someone will say that medical
doctors should not be concerned about
such matters, they should only focus on
clinical practice and research. I want to
oppose.
‘I lived in a country where travel to another
country was a dream. We needed special
permission from authorities to cross the
border. Only books approved by the author-
ities were available. Reading other books
was a very dangerous. I lived in a country
where people not agreeing with the system
were imprisoned in psychiatric hospitals.
Can you be a good medical doctor in such
situation? Can you follow the principles
of medical ethics in such circumstances?
I doubt it.
‘I would like to take this opportunity to
thank the World Medical Association for
the courage to tackle inconvenient topics, to
take action in support of the national medi-
cal associations, to discuss internationally
the problems related to environment and
other factors affecting human health.
‘I do believe that working together we
can make this planet peaceful and healthy.
Thank you for the work you are doing ev-
ery day at the national and international
level’
7
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WMA Council Session
FRIDAY APRIL 28
Socio Medical Affairs
Committee (continued)
Classification of Documents
Nine policies that were 10 years old were
considered for review:
–
– The Committee recommended that the
following documents should undergo a
major revision:
–
– Resolution on the Access of Women
and Children to Health Care and the
Role of Women in the Medical Profes-
sion
–
– Statement on Reducing Dietary So-
dium Intake
–
– Statement on Resistance to Antimicro-
bial Drugs
–
– Statement on Violence and Health
–
– The following Statements should un-
dergo a minor revision
–
– Resolution on Collaboration Between
Human and Veterinary Medicine
–
– Statement on Reducing the Global
Burden of Mercury
–
– The following documents should be
rescinded
–
– Resolution on Poppies for Medicine
Project for Afghanistan
–
– Resolution on Economic Crisis: Impli-
cations for Health
–
– The following policy should be reaf-
firmed
–
– Resolution Supporting the Ottawa
Convention on the Prohibition of
the Use, Stockpiling, Production, and
Transfer of Anti-Personnel Mines and
on Their Destruction
Disaster Preparedness
The Japanese Medical Association sub-
mitted a paper on disaster medicine and
raised the issue of whether the WMA
should establish a network for disaster
medicine.
The paper argued that the time had come for
WMA to establish such a disaster-response
and assistance scheme on the global level.
This would involve the WMA in bringing
together UN agencies, international or-
ganizations, governments, military forces,
NGOs and others to work for disaster relief
in a bilateral manner. Medical association
members in each country would actively
participate in such a network.
The Committee agreed to recommend that
the proposal to set up a WMA Network on
Disaster Medicine be approved by Council
and forwarded to the General Assembly for
adoption.
Artificial Intelligence
The American Medical Association pre-
sented a white paper on Artificial/Aug-
mented Intelligence and Considerations for
Use of Health Care. The paper asked how
the WMA should position itself on this is-
sue. Computing power had a broad impact
in many areas of life and would have a great
impact on medicine. This could be posi-
tive, but there needed to be a dialogue with
other stakeholders. Clinical decision mak-
ing could be enhanced by this, not replaced
by it. However, there were downsides, for
instance on liability issues and protection
of health data. The AMA said it would be
discussing this topic at its meeting in June
and might return with proposals at a future
WMA meeting.
Autonomy of Doctor’s work
The Finnish Medical Association made
a presentation to the Committee on ethi-
cal guidelines it had drawn up to support
doctors acting in unclear situations. The
guidelines were thought necessary because
it was felt that professional autonomy was
not clear to all doctors and particularly to
junior doctors. Yet the pressure on the pro-
fession was very strong,from politicians,the
media, patients and the pharmaceutical in-
dustry. So the Finnish Medical Association
had collected what it called “10 Command-
ments” from WMA policy documents and
its own policies to help doctors understand
what their obligations were.
Medical Ethics Committee
Dr.  Heidi Stensmyren (Sweden) took the
chair.
Dr.  Kloiber, the Secretary General, high-
lighted two important emerging issues
that impacted on the medical profession.
The first was artificial/augmented intelli-
gence. In many countries ethical questions
were being discussed.The WMA needed to
have an ethical position on this and would
be helped by knowing more about what
NMAs were doing in this area.
The second issue was nano-technology,
where more questions were being asked. It
was being widely introduced in many ar-
eas of our lives, and regulatory authorities
with whom the WMA worked were already
working on these issues. This would have
regulatory consequence and there would
be ethical ramifications. The WMA should
look into this and he invited NMAs to
share their work with the Association.
Finally, he said that the Pontifical Acad-
emy for Life had issued a White Paper on
Global Palliative Care Advocacy, and the
WMA had been invited to participate in
this process.
Turkey
The Committee heard a report on the situ-
ation in Turkey and, in particular, how it
affected the Turkish Medical Association.
They were reminded that the Turkish Med-
ical Association had no ties to any Govern-
ment bodies and received no financial sup-
port from Government. It had authority to
8
take disciplinary action over violations of
professional conduct and was on the side
of prioritising disadvantageous groups and
the oppressed. It also tried to keep channels
of dialogue open with the government. On
January 24,after Turkish armed forces start-
ed a military campaign in Afrin, the Turk-
ish Medical Association had issued a press
release saying that war was a public health
problem. After this press release, Turkish
authorities accused the TMA of assisting
terrorists. A criminal complaint was filed
against TMA leaders for making propa-
ganda in favour of a terrorist organisation.
The Ministry of Health filed another law
suit saying that the TMA engaged in activi-
ties incompatible with its mandate. Central
committee members of the TMA were
then detained for a week. Delegates were
told that the TMA had fulfilled the pro-
fessional duty of physicians and the WMA
and NMAs around world had responded in
support.
Dr. Kloiber said the WMA had organised a
highly successful social media campaign in
defence of the TMA.
Istanbul Protocol
Clarisse Delorme, WMA Advocacy Advi-
sor, reported that the WMA had been in-
vited to participate in the development of
a supplement to the Manual on Effective
Investigation and Documentation of Tor-
ture and Other Cruel, Inhuman or Degrad-
ing Treatment or Punishment, commonly
called the Istanbul Protocol.
Therapeutic Abortion
As part of the annual policy review process,
the Committee continued its revision of the
WMA Declaration on Therapeutic Abor-
tion. It considered a draft document that
had been circulated among members, and
received an oral report from the workgroup
set up to work on the document.
In the debate that followed it was argued
that it should be made clear in the preamble
what this document was not about. It was
proposed that the following wording be
added: “This Declaration does not include
or imply any views on termination of preg-
nancy carried out for any reason other than
medical indication”. This wording was ap-
proved.
It was also suggested that the document
should be renamed WMA Statement on
Medically-Indicated Termination of Preg-
nancy.This was also approved.
After a further debate, during which other
amendments were approved, the Commit-
tee recommended that the Statement, as
amended, be approved by Council and for-
warded to the General Assembly for adop-
tion.
Ethics of Telemedicine
The revised WMA Statement on the Ethics
of Telemedicine was considered. It had been
agreed that the document should undergo
a major revision and the South African
Medical Association volunteered to under-
take that work. The document before the
committee explained that telemedicine was
the practice of medicine over a distance, in
which interventions, diagnoses, therapeu-
tic decisions, and subsequent treatment
recommendations were based on patient
data, documents and other information
transmitted through telecommunication
systems. The committee was told that the
document addressed a number of issues,
including cross border regulation. However,
the Statement as revised still highlighted
the importance of face to face medicine and
doctors’ autonomy in their responsibilities
in telemedicine.
A brief debate followed about the phrase in
the document that “the patient-physician
relationship must be based on a prior per-
sonal examination”. The committee agreed
that this should be amended, along with
other changes.
The committee then recommended that the
proposed Statement, as amended, be ap-
proved by the Council and forwarded to the
General Assembly for adoption.
Fleeing Physicians
The committee considered the proposed re-
vision of the WMA Statement on Licensing
of Physicians Fleeing Prosecution for Seri-
ous Criminal Offences. During the debate
that followed, a number of questions were
raised. It was explained that this document
was about physicians fleeing prosecution.
But what was meant by serious offences?
Some people talked about serious allega-
tions, some about offences and some about
crimes. Should they be talking about phy-
sicians who had not yet been prosecuted?
And what was meant by serious offences?
Should it be up to the host country to de-
cide?
The committee approved one amendment,
making it clear that physicians who had
been convicted of serious criminal offenc-
es, in particular of genocide, war crimes or
crimes against humanity,should be denied a
licence to practice medicine elsewhere.
However, speakers argued that further con-
sideration should be given to the definition
of serious or outrageous offences and it was
agreed to recommend to Council that the
document be recirculated to members for
comment.
End of Life Questions
The committee heard reports about the four
regional end of life conferences that had
been held around the world, as part of the
WMA’s review of its policy on physician as-
sisted suicide and euthanasia. Four written
reports were submitted (see p. 13) and oral
WMA Council Session
9
BACK TO CONTENTS
reports were also given about the discus-
sions in Nigeria and in Rome.
Dr. Kloiber explained that this issue would
be brought back into an international dis-
cussion to be started in Reykjavik at the
medical ethics conference before the Gen-
eral Assembly in October.
A brief debate took place about how to
reconcile current WMA policy that eutha-
nasia was unethical with the fact that in
some countries euthanasia was now legal.
The committee was told that there would
be ample time to discuss this matter fur-
ther at the medical ethics conference in
Reykjavik.
The Canadian Medical Association gave
notice that together with the Royal Dutch
Medical Association it would be bringing a
draft revised paper for consideration in Oc-
tober, to see if they could accommodate all
the divergent views among members.
Dr. Kloiber said that one message he took
from the regional conferences was that
there was a very strong need for the WMA
to look again at its policies relating to end-
ing futile treatment, respecting patient will
and the use of living wills, as well as pallia-
tive care.
Genetics and Medicine
The Danish Medical Association proposed
that the WMA initiate a major revision of
its Statement on Genetics and Medicine.
The main reason for this was that the cur-
rent version of the Statement did not deal
sufficiently with the ethical issues that
arose through the development and use
of next-generation sequencing in person-
alized medicine. It was proposed that a
working group be set up to carry out the
revision.
The committee agreed to recommend to
Council that a major revision take place and
that a working group be set up to do this,
with the aim of producing a revised State-
ment to be considered by the meeting in
Reykjavik.
Biosimilar Medicinal Products
The Israeli Medical Association proposed a
Statement on Biosimilar Medicinal Prod-
ucts. Delegates were told that biological
pharmaceuticals had been around for some
time. This had allowed new methods of
treatment, but these were extremely costly
and were hard to access. The high pricing
was because of the complexity of manu-
facturing and production, but also because
these pharmaceuticals were under patent.
Now some of these patents were starting to
expire. This would reduce prices consider-
ably, allowing more patients and countries
to access these therapies. But identical ac-
tive substances could not be created because
there might be a difference in the dosages.
The challenge was to know when a drug was
a biosimilar or not. In Europe biosimilars
had been regulated since 2005. In the US
they had only allowed this in 2015. In Israel
they were not allowing it, but difficult regu-
latory issues were involved. One of the ethi-
cal challenges to be faced was that insurers,
employers and maybe governments might
be inclined to encourage or demand phy-
sicians to switch to biosimilars because of
lower prices, posing a risk to patients. It was
therefore thought important for the WMA
to have some guidance on this issue.
The committee agreed to recommend to
Council that the proposed Statement be
circulated to members for comment.
Classification of 2008 Policies
The committee recommended that the
Resolution on Physician Participation in
Capital Punishment and the Resolution on
the Prohibition of Physician Participation
in Capital Punishment be merged.
It also recommended to Council that the
Resolution on the Responsibility of Physi-
cians in the Denunciation of Acts of Torture
or Cruel,Inhuman or Degrading Treatment
of Which They are Aware should undergo a
major revision and that a workgroup be set
up to undertake this.
The committee recommended that the In-
ternational Code of Medical Ethics should
undergo a long-term major revision and
that a working group be set up to undertake
this.
Female Foeticide
The committee was informed that the Swiss
Medical Association, with the support of
the Swedish Medical Association, would
submit a revision of the WMA Resolution
on Female Foeticide at the General Assem-
bly in Reykjavik in October.
SATURDAY APRIL 29
Council (continued)
Dr.  Hoven took the chair for the recon-
vened meeting of the Council and delegates
stood to recite the Physicians’ Pledge.
The Council considered reports from the
three committees that had met on the pre-
vious two days.
Report of the Medical
Ethics Committee
Medically-Indicated
Termination of Pregnancy
A proposal was put forward to amend the
proposed Declaration to add to the pre-
amble the words: “The medical profession
retains its respect for all human life, born
and unborn”. However, after a brief debate,
WMA Council Session
10
the proposed amendment was defeated,
and the Council agreed that the Declara-
tion as submitted should be approved and
forwarded to the General Assembly for
adoption.
Telemedicine
The Council agreed to forward to the Gen-
eral Assembly the Statement on the Ethics
of Telemedicine.
Fleeing Physicians
The Council agreed to recirculate the pro-
posed Statement on Licensing of Physicians
Fleeing Prosecution for Serious Criminal
Offences for comment.
Genetics and Medicine
The Council agreed to set up a work group
to develop a Statement on Genetics and
Medicine and to circulate the document
for comment, with the aim of producing a
revised Statement to be considered by the
meeting in Reykjavik.
Biosimilar Medicinal Products
The Council agreed to circulate the pro-
posed Statement on Biosimilar Medicinal
Products for comment.
Classification of Documents
The Council agreed:
• that the Resolution on Physician Partici-
pation in Capital Punishment be merged
with the WMA Resolution to Reaffirm
the WMA’s Prohibition of Physician Par-
ticipation in Capital Punishment, which
will constitute a minor revision as there is
no change to the content of either docu-
ment
• that the resolution on the Responsibility
of Physicians in the Denunciation of Acts
of Torture or Cruel, Inhuman or Degrad-
ing Treatment of Which They are Aware
undergo a major revision
• that a workgroup be set up to undertake
a long term major review of the Interna-
tional Code of Medical Ethics
Report of the Finance and
Planning Committee
Financial Statement
The Council approved the interim Financial
Statement for 2017.
Future Meetings
It agreed the following dates for future
meetings:
• the 218th
Council session to be held from
22–24 April 2021
• the 72nd
General Assembly to be held
from 13–16 October 2021
• the 221st
Council session to be held from
7–9 April 2022
• that no additional invitations be accepted
for the 2020 General Assembly, 2021
Council Session, and 2023 Council Ses-
sion and General Assembly, and that the
decision regarding the existing invita-
tions from Rwanda, the UK, and Spain
be postponed to the next Council session
in Reykjavik.
• the invitation from CNOM France to
host the 221st
Council Session in Paris in
April 2022 be accepted.
Nominating process for
WMA Presidency
The Council agreed that the proposal to
introduce a self-declaration statement to
the nominating process for WMA Presi-
dency be circulated to members for com-
ment and for further discussion at the next
meeting.
Report of the Socio-Medical
Affairs Committee
Plastic Bags, Ecological
Issues & Environmental
Degradation
The Council agreed to circulate for com-
ment the proposed Statement on Environ-
mental Degradation and Sound Manage-
ment of Chemicals
Policies for Adoption
The Council agreed that the following doc-
uments be approved and forwarded to the
General Assembly for adoption:
–
– Statement on Medical Tourism
–
– Statement on Gender Equality in
Medicine
–
– Declaration of Seoul on Professional Au-
tonomy and Clinical Independence
–
– Statement on Sustainable Develop-
ment
–
– Statement on Avian and Pandemic In-
fluenza
–
– Statement on Nuclear Weapons
Emergency Resolution
It was agreed that the proposed emergency
Resolution on the Prohibition of Nuclear
Weapons be approved for immediate release
(see p. 13).
Documents to be Circulated
The Council agreed that three documents
be circulated among members for com-
ments:
–
– Declaration of Madrid on Professionally-
led Regulation
WMA Council Session
11
BACK TO CONTENTS
–
– Statement on the Development and
Promotion of a Maternal and Child
Health Handbook
–
– Declaration on Pseudoscience, Pseudo
therapies, Intrusion and Sects in the
field of health
Classification of Documents
The Council agreed that the following poli-
cies should undergo major revision:
–
– Resolution on Access of Women and
Children to Health Care and the Role
of Women in the Medical Profession
–
– Statement on Reducing Dietary So-
dium Intake
–
– Statement on Resistance to Antimicro-
bial Drugs
–
– Statement on Violence and Health
It was agreed that the Resolution on Col-
laboration Between Human and Veterinary
Medicine and the Statement on Reducing
the Global Burden of Mercury be reaffirmed
with minor revision and that the Resolution
Supporting the Ottawa Convention on the
Prohibition of the Use,Stockpiling,Produc-
tion, and Transfer of Anti-Personnel Mines
and on Their Destruction be reaffirmed.
Finally, it was agreed that the Resolu-
tions on Poppies for Medicine Project for
Afghanistan and on the Economic Crisis:
Implications for Health be rescinded and
archived.
Disaster Medicine
The Council agreed that the proposal to set
up a WMA Network on Disaster Medicine
be approved.
Advocacy Panel
Dr.  Ashok Paul, Chair of the Advocacy
Panel, presented an oral report from the
group. He said that despite the fact that the
WMA had a very small permanent staff,
the Association had a fairly wide reach and
high brand name recognition, well above
what might be expected based on size
alone. He said the prime focus of increasing
the WMA’s visibility, reach and influence
should be concentrated on NMAs. He sug-
gested that briefings should be arranged for
new participants to WMA meetings to in-
form them about available WMA resources.
Another way to raise the Association’s pro-
file would be to consider relaxing the rule
that matters under discussion should not be
discussed in public fora. And he said that
there could be more engagement with non-
member NMAs.
World Health Organisation
The Council heard reports on the WMA’s
work with the WHO on a number of is-
sues, including supporting the development
of Universal Health Coverage, engagement
on the health workforce and emergency
preparedness.
The 71st
World Health Assembly, in May,
was due to discuss two high level meetings
on NCDs and TB arranged for later in the
year.
Together with the other health professions
in the World Health Professions Alliance,
the WMA was holding the 5th Regulation
Conference. And there was also due to be a
side event during the World Health Assem-
bly on the 100th anniversary of the Spanish
flu outbreak.
The WMA would be sponsoring a lunch-
time event during the week on Healthcare
in Danger and the issue of strengthening
national frameworks for the protection of
health care.
Dr. Kloiber then spoke about some of the
political undercurrents currently going on
about the 40th
anniversary of the Alma Ata
Declaration. This Declaration had put the
focus on primary care and this had led to
Health for All for 2000.But the Declaration
had had only a limited success. However, a
2008 report on primary care had emphasised
the value of primary care as the core part of
comprehensive health care and the necessity
for family physicians as part of it.
He said there was a clear role for the physi-
cian as a leading part of the primary care
team. But in a further document that was
currently being discussed as part of the fol-
low up to Alma Ata, the focus had been put
on other health professionals and not on
family physicians. There was a strong trend
to change the scope of practice towards
nurse specialists and pharmacists, not only
concerning prescribing rights, but also to
be the first point of contact in primary care
provision. This was something about which
the WMA was extremely critical. Howev-
er, it was no longer enough to simply say
“no” to this development. The WMA had
to have scientific evidence. So it was now
building a coalition of organisations with
the same views and was looking for what
evidence there was to support its case on
family physicians. It was important that
those NMAs that had already done work
on scope of practice came forward with the
necessary material to help the WMA’s case.
Dr.  Kloiber’s report led to a lengthy and
wide-ranging debate, that turned out to be
one of the most important discussions of
the meeting.
Speakers from Israel, Denmark, India and
South Africa were among those who sup-
ported Dr.  Kloiber and reported about
similar pressures in their countries. In Isra-
el, these pressures were leading to tensions
between physicians and nurses. There was
agreement that the WMA needed to work
on its arguments about the importance
of family physicians. It needed to counter
the argument that nurse practitioners were
more cost effective. Some speakers talked
about patients preferring to see family phy-
sicians, while others referred to the risk to
WMA Council Session
12
patient safety and quality of care by moving
away from family physicians. What was re-
quired was less complexity in delivering pri-
mary care, not more complexity from more
independent contractors.
It was reported that in India this issue was
a huge problem.Thousands of medical cen-
tres were being opened by the Government,
manned by non-doctors. The medical pro-
fession was fighting this, but it needed evi-
dence to bring the community onside.
It was argued that this was essentially a
political problem, in part caused by a lack
of doctors, encouraging other professions
to trespass on the medical profession. In
France they referred not to doctors but to
health professionals. One speaker said doc-
tors should not talk about delegating tasks
to nurses, but about collaborating with
nurses.
Several speakers said there was a need to
recognise that the delivery of health care
had changed with time and the role of doc-
tors was changing as well. This required
thinking about who was the most appro-
priate person to deliver a particular type of
care.But it was also said that patients would
always need medical practitioners and non-
medical practitioners should be augmenting
physicians’ job and not replacing them.
Speakers from Brazil, France, Britain, Ger-
many, Canada and Malaysia, all referred to
similar problems in their own countries.
There was general agreement that this was
an extremely important issue and that the
WMA needed to engage with governments
as well as with the community as a whole.
The Council approved a proposal for the
secretariat to prepare urgently an advocacy
plan for the Council Executive on how to
respond to this issue.
The meeting ended with a round of thanks
from Dr. Kloiber for all those who had con-
tributed towards a highly successful meet-
ing.
Mr. Nigel Duncan,
Public Relations Consultant, WMA
E-mail: nduncan@ndcommunications.co.uk
WMA Council Session
13
BACK TO CONTENTS
WMA Council Resolution
on the Prohibition of Nuclear
Weapons
Adopted by the 209th
Session of the Council, Riga, April 2018
The duties of physicians are to preserve life and safeguard the
health of the patient and to dedicate themselves to the service of
humanity.
Concerned about current global discussions on nuclear proliferation
and given the catastrophic consequences of these weapons on hu-
man health and the environment, the World Medical Association
(WMA) and its Constituent Members consider that they have a re-
sponsibility to work for the elimination of nuclear weapons world-
wide.
The WMA is deeply concerned by plans to retain indefinitely and
modernize nuclear arsenals; the absence of progress in nuclear
disarmament by nuclear-armed states; and the growing threat of
nuclear war.
The WMA welcomes the Treaty on the Prohibition of Nuclear
Weapons, and joins with others in the international community,
including the Red Cross and Red Crescent movement, Interna-
tional Physicians for the Prevention of Nuclear War, the Interna-
tional Campaign to Abolish Nuclear Weapons, and a large majority
of UN member states. Consistent with our mission as physicians,
the WMA calls on all states to promptly sign, ratify or accede to,
and faithfully implement the Treaty on the Prohibition of Nuclear
Weapons;
Emphasizing the devastating long-term health consequences, the
WMA and its Constituent Members urge governments to work
immediately to prohibit and eliminate nuclear weapons.
End of Life Seminars
The Socio Medical Affairs Committee received reports about the
four end of life conferences that had been held in Latin America,
Asia, Europe and Africa, as part of the WMA’s review of its policy
on physician assisted suicide. Four written reports were submitted
and oral reports were also given on each conference. A summary of
the written reports follows.
Brazil Symposium
A written report was submitted by the Brazilian Medical Associa-
tion about the Symposium it hosted in Rio de Janeiro in March
2017. This referred to the advances in medicine as well as the in-
crease in life expectancy which had led to times of suffering, useless
treatments and the solitude of patients. Against this background,
palliative care must be a right or at least an attainable service for all
patients.The report spoke about the need to protect patients’dignity
and added ‘if the doctor is prepared not only to cure but also to kill,
the ethics of medical practice and the trust that the patient must
have in his doctor will be very battered’.
The report referred to the pressure that some patients might face if
euthanasia was allowed and the fact that the request for euthanasia
might be reduced by improved training of professionals in palliative
care. It said societies should be aware of the ‘slippery slope’ risks of
legislation allowing euthanasia.
It concluded: ‘The sick at the end of life need a helping hand not to
precipitate their death, nor to prolong their agony with the thera-
peutic obstinacy,but to be with them and relieve their suffering with
palliative care while their death arrives’.
Japan Symposium
The meeting on End-of-Life Questions in Japan was held on Sep-
tember 14 and 15,2017,with the participation of the Confederation
of Medical Associations in Asia and Oceania members,the Chinese
Medical Association and the Israel Medical Association. A report,
prepared by Professor Tatsuo Kuroyanagi,the legal adviser of the Ja-
pan Medical Association, said the main purpose of the symposium
was to investigate different opinions that existed among the WMA
Asia-Pacific members and their home countries/jurisdictions with
regard to the three WMA policies, namely WMA Declaration on
Euthanasia, WMA Statement on Physician-Assisted Suicide, and
WMA Resolution on Euthanasia.
A questionnaire survey was sent to 21 NMAs, and 19 submitted
their answers. At the symposium, 17 NMAs presented their reports
by further elaborating or partially modifying their answers. At the
meeting NMAs were divided into four groups based on the simi-
larities in legal systems and religions.
Based on the survey and the group discussions,all of the NMAs op-
posed euthanasia and physician assisted suicide.With the exception
of Australia and New Zealand, there was no significant desire in the
civil society of the Asia/Oceania region to discuss the concept of eu-
thanasia and PAS. However, all the NMAs supported the creation
of Advanced Directives and advanced care planning with physicians
for the terminally-ill patients.
WMA Council Session
14
Rome Symposium
The WMA together with the German Medical Association and the
Pontifical Academy for Life organized a two-day Conference at the
Vatican’s Aula Vecchia del Sinodo on 16 and 17 November 2017.
The meeting was attended by around 150 participants, including
WMA leaders and members, experts in palliative care, ethicists,
lawyers and religious leaders. The presentations and the views ex-
pressed covered the full spectrum of opinion.
In an address prepared by Pope Francis and read by Cardinal Pe-
ter Turkson, the Pope said it was clear that not adopting, or else
suspending, disproportionate measures, meant avoiding overzealous
treatment. From an ethical standpoint, this was completely differ-
ent from euthanasia, which was always wrong, in that the intent of
euthanasia was to end life and cause death.
Throughout the meeting, proponents of right-to-die policies empha-
sised that their intention was to protect physicians in their own coun-
tries who are acting within the law,not to change or influence policies
in other countries. They based their arguments on the concepts of
patient self-determination, dignity and compassion. Those who were
opposed to euthanasia and PAS, representing the majority of attend-
ees, rejected these procedures as being diametrically opposed to the
ethical principles of medicine and expressed concern that they could
lead to misuse or abuse, e.g. in the case of mentally or psychologically
incapacitated people. They also expressed concern that these proce-
dures could cause damage to the complete trust which characterises
the patient-physician relationship or lead to social pressure for the
elderly or those with chronic illness to end their lives.
The majority of attendees ultimately advocated for the retention of
the existing policies of the WMA on euthanasia and PAS.
But participants were united in their support for high-quality, ac-
cessible palliative care and their belief that PAS and euthanasia
should never be seen as a cost-saving measure.
Nigeria Symposium
The African Symposium was hosted by the Nigerian Medical As-
sociation in Abuja, Nigeria on February 1 and 2 2018.
Attendees included Presidents and delegates of National Medi-
cal Associations from Nigeria, Zambia, Kenya, South Africa, Cote
D’Ivoire and Botswana.
Among the resolutions at the conclusion of the meeting were that
NMAs in Africa are unanimously opposed to euthanasia and physi-
cian assisted suicide in any form. They supported policies and leg-
islations permitting and strengthening palliative care. There was a
need for improved political will and commitment to palliative care
by African Governments. There was agreement on the need to ori-
entate governments, policy makers and the public on the impor-
tance and availability of palliative care.
And there was great need for the strengthening of African health-
care systems, universal health coverage, improved budgetary alloca-
tion to health, and integration of palliative care and other chronic
medical conditions into the health care financing/health insurance
schemes of African countries.
Junior Doctors Meeting
The Junior Doctors Network held a meeting prior to the 209th
WMA Council Meeting. This brought together 20 young doctors
from across the world to discuss issues important to the WMA’s
work and to gain skills important for their work and future roles
as health leaders. The event served as an opportunity to meet with
a number of Latvian junior doctors as well a representative from the
European Junior Doctors Association.
The day started with a meeting with the WMA leadership – Dr. Yo-
shitake Yokokura, WMA President, Dr. Ardis Hoven, WMA Chair
of Council, and Dr. Otmar Kloiber, WMA Secretary General. There
were discussions on leadership within the WMA and within National
Medical Associations,as well as current issues important to the WMA.
The morning session included important internal work for the
JDN reviewing the proposed terms of reference for JDN Working
Groups, and a discussion on the structure of JDN meetings and ap-
proaches to membership of the network.
Concluding the morning, a scientific workshop on climate change
policy and health summarized WMA work in this field at the inter-
national level It highlighted future opportunities for JDN involve-
ment and familiarized participants with how national commitments
are defined. This allowed them to reflect how they could contrib-
ute to the implementation of the WMA Declaration of Delhi on
Health and Climate Change in their own contexts.
During the afternoon, selected JDN working groups were discussed
with important advances made with respect to planning the work of
the recently created group on Working Conditions. Finally, for the
first time at any JDN meeting, there was a leadership training sec-
tion, led by two external speakers, Drs Paul Jones and Greg Radu.
This elaborated on different leadership theories and their applica-
tion in the healthcare context.
Yassen Tcholakov
JDN Socio-Medical Affairs Officer
WMA Council Session
15
BACK TO CONTENTS
The Fifth World Health Professions Regu-
lation Conference was held at the Crowne
Plaza Hotel, Geneva on May 19 and 20.
An audience of almost 150 attended from
36 countries.They included members of the
five professions that make up the World
Health Professions Alliance  – physicians,
nurses, pharmacists, dentists and physical
therapists, as well as a number of econo-
mists and regulators. Over the two days,
20 expert speakers addressed the theme of
the conference, ‘Facing challenges to acting
in the public interest’, and engaged in high
level debates with participants.
Dr. Ardis Hoven, Chair of the WMA, who
chaired the first day’s debates, said in ad-
vance of the conference, that regulation of
the health professions was increasingly per-
ceived as an economic issue or as a question
of power.Some professionals saw regulation
as a means to limit their professional free-
dom. Others, such as insurers and managed
care companies, viewed it as an unwelcome
expense, since obeying rules costs time and
money.
‘Regulation necessarily means … setting
limits and demanding checks and balances,’
she said. ‘Striking a balance between per-
sonal choices … and obligations towards
safety, highest quality and equity is difficult
and requires justification’. Dr. Hoven added
‘Standards can help to provide a level play-
ing field for all involved, including both fair
and appropriate processes’.
The first session of the conference looked
at the barriers to implementing regulatory
standards. Dr.  Hoven said such barriers
included political and commercial interfer-
ence, inadequate understanding of profes-
sional autonomy and regulation and a high
degree of resistance to change.
Three speakers addressed different aspects
of professional autonomy and regulation.
Professor Zubin Austen, Professor of the
Koffler Chair in Management at the Uni-
versity of Toronto, spoke about setting
standards and how these could be got right.
He gave a history of the word ’competence’
and looked at what competency assessment
models had been tried  – including the se-
cret shopper methodology involving actors
disguised as patients visiting clinicians. He
emphasised the importance, when creating
assessment models, of getting ‘buy in’ from
both the public and the profession.
Andrew Gray, from South Africa, vice Presi-
dent of the International Pharmaceutical
Federation, talked about autonomy, with ref-
erence to the WMA’s Declaration of Seoul
on Professional Autonomy and Clinical In-
dependence. He said that as the working en-
vironment had changed for many health pro-
fessionals, so professional autonomy had also
been seen as under threat, or at least subject
to change. On the positive side, collaborative
practice had blurred the boundaries between
professions and between professionals.How-
ever, health professionals needed to guard
against the negative consequence of dual and
divided loyalties.
David Benton, CEO at the National
Council of State Boards of Nursing, asked
who regulated the regulators. He said there
was currently a lot of critical commentary
about regulation. However, it was right that
regulators should be held to account, and
they were already being held to account in
various ways. But which of the ways was
effective and had the biggest impact – the
external ones or the self imposed ones? The
formal processes or the informal processes?
He concluded that they needed to get bet-
ter in managing the performance of regula-
tors.
During the following panel discussion, par-
ticipants debated whether there was too
strong an alignment between the professions
and the regulators. It was said that regulators
in many parts of the world were enriched by
their interaction with the professions. More
than one speaker warned about the risk of
politicians leaning on regulators.
An example of the barriers to implementing
the right standards was given by Dr. Andrew
Wetende, President of the Kenyan Dental
Association, who spoke about Kenya’s ex-
perience with the Minamata Convention on
Mercury, the international treaty designed to
protect human health and the environment
from the releases of mercury and mercury
compounds. Barriers to success in imple-
menting this included lack of resources and
involvement of key stakeholders, profession-
als who refused to embrace the regulations
and a lack of operational guidelines.
Dr.  Barry Dolman, President of the In-
ternational Society of Dental Regulators,
World Health Professions Alliance Regulation Conference 2018
Geneva 19–20 May
Nigel Duncan
WMA News
16
WMA News
from Montreal, talked about the impor-
tance of regulation to ensure evidence-
based care. He spoke about four trends
impacting regulation – from governments,
the new patient, social media and disrup-
tive technology.
He said new patients were more educated,
looking at ways where they wanted to direct
treatment rather than relying on physicians
and others. They had now trained patients
to find their own answers.
He said that regulators also had no ability to
control social media information.They were
facing catch up and were powerless to stop
this this phenomenon. But hopefully they
could moderate its impact.
Agnes Waudo, a director of Emory Uni-
versity Kenya Projects, continued on the
theme of barriers to implementation of
regulatory standards as they affected Africa.
These included a lack of resources to sup-
port implementation and enforcement, a
lack of capacity building, political influence
subverting standards, conflicting mandates
and non-compliance. Finally, there was the
problem of the shortage of health work-
force.
During the panel discussion, Dr.  Mark
Sonderup from the South African Medical
Association, said that in South Africa the
medical profession felt isolated from regula-
tors. He asked what role regulators should
have in the world of social media, where
professionals were pushing out information.
The answer he received was that there was a
major role for regulators to play.
Dr.  Otmar Kloiber, Secretary General of
the WMA, said that in his view people
were turning more and more to regulators
to ask questions and get advice. He said
that almost half of the WMA’s national
medical association members were also
regulators. He questioned the perception
that physician regulators were less tough
on the profession and thought the oppo-
site might be the case and that they were in
fact tougher. He also said that the profes-
sion was not lagging behind governments
on the issue of regulation. It was ahead of
governments in thinking about regulation.
He was particularly critical of governments
that blamed the health profession when
things went wrong because of a failure of
the legal system, adding to applause ‘We
are not the sheriffs’.
The second day’s proceedings opened with
a warning that the health professions were
facing many challenges on regulation.
The meeting was told that today’s skills
and culture needed to change to be fit for
­
tomorrow.The professions were standing on
shifting sands.
Dr.  Jacques de Haller, President of the
Standing Committee of European Doctors
(CPME), in his presentation, spoke about
global standards and how much local adap-
tation was needed. The medical profession
was a profession that loved to travel,to learn
and to practice. It needed to travel. But al-
though it was a truly global profession,there
was no global regulation or global rules with
legal effect about the health professions.
He spoke about the situation in Europe,
where there were some supra-national
regulations. The Professional Qualifications
Directive set rules about what was to be
recognised by different member countries.
It dealt with rules for temporary mobility,
introduced a system of mutual recognition
of diplomas and defined minimum edu-
cational requirements, although it did not
harmonise education requirements.
A survey carried out by the CPME showed
that regulations to practice and the imple-
mentation of regulations to practice were
different in each country. His conclusion
was that although the global profession
did not have global regulation, it probably
did not need it because the current systems
worked well. They shared a common goal,
providing safe and high quality care.
He said it was commonly thought that a
doctor should be ‘the same’ anywhere. How-
ever, such a concept, if considered desirable,
could only be achieved with bottom up edu-
cational initiatives by the medical profession
itself and sharing best regulatory practice ex-
amples, enabling regulators to select require-
ments best suited to their local needs.
Luke Slawomirski, an OECD economist,
delivered a presentation on patient re-
ported outcome measurements. These were
based on the question ‘What was the goal
of health care?’. If it was to improve the
wellbeing of individuals and society, health
systems knew very little about whether or
not they were successful in this endeavour.
He spoke about how the OECD was mea-
suring health outcomes. There was an in-
formation gap they were trying to fill and
collecting patient reported indicators would
improve policy and practice.
Emmanuel Jo,Manager Analytics at Health
Workforce New Zealand Ministry of
Health said big data analysis improved care
and patient safety. We were now living in a
big data environment with electronic health
records, electronic human resources data,
registration data for regulated health work-
ers and claims data. He talked about how
analytics were now being used in New Zea-
land, in both primary and secondary care.
Dr. Margot Skinner, vice President of the
World Confederation for Physical Therapy,
talked about her experiences of the Trans-
Tasman Mutual Recognition Arrangement
that had allowed health professionals in
Australia and New Zealand to practise in
either country without the need for further
study or assessment. The agreement en-
abled each country’s professional workforce
to come from a bigger pool. Professionals
were also able to undertake courses and post
graduate qualifications without the usual
barriers. The arrangements had generally
worked well for Australia and New Zealand
because the two countries had similar stan-
dards for health and wellbeing.
17
BACK TO CONTENTS
WMA News
‘The bigger challenge is for countries where
standards for education of health profes-
sionals are not the same’, she said.
In the panel discussion that followed there
was a lively discussion, when one partici-
pant asked whether regulation had lost its
identity. Panellists were quick to emphasise
the importance of the patient in the process.
The primary purpose of regulation, it was
said, was to secure protection for the public,
to ensure that practice did meet require-
ments. Regulators had to be effective, effi-
cient and ethical.But there was a big danger
when regulation lost the human touch.
The last session of the conference looked at
continuing professional development, what
it meant and how it served patients. This
led to a debate about whether measure-
ments and accreditation were useful tools.
Dr.  Kloiber said it was political pressure
that had driven medical associations and
regulators to accreditation.
One of the final panel discussions related to
the WHPA’s slogan ‘Teaming up for better
health’. What did it mean? Panellists said
this had to start within the professions. Key
players needed to team up, and this was
happening. But Janet Grant, an educational
psychologist, said that the evidence on inter
professional education was not good. The
evidence was it was a waste of time unless
teams learned together in practice.
Dr.  Kloiber said that in a lot of circum-
stances a non-team approach to learning
was not constructive.
He explained that the phrase started with
the global organisations working together
as the WHPA. He said the five health pro-
fessions were not far apart in what they had
to say. But each group on its own was not
being heard. So they had come together as
the WHPA , as they thought they could
contribute to better health.They could pro-
duce more together than apart, and he had
not seen any evidence to the contrary.
The conference ended with a closing sum-
mary from Ema Paulino, Interim CEO of
the International Pharmaceutical Federa-
tion. She reminded the meeting that these
WHPA conferences aimed to shape the fu-
ture of health professional regulation within
the context of global health systems via
multi-disciplinary and multi-stakeholder
approaches. She said that regulation should
be an enabler and a facilitator of the practice
of all healthcare professionals, with a prime
objective of ensuring the safety of the deliv-
ery of healthcare services.
‘Too often, there is a lack of knowledge
about systems of regulations and only a few
comparisons are available to describe such
systems internationally. We observed that
although globalization is rapidly advancing
in all spheres of human endeavour, regula-
tory systems controlling the health profes-
sions are very disparate.’
She said the conference had illustrated that
health professional regulation faced many
challenges in a world characterised by po-
litical, social, economic and technologi-
cal change. Widespread reform of health
professional regulation reflected policy
initiatives by many governments to ensure
sustainable, efficient and effective health
service delivery. But what were the implica-
tions, and how did they ensure the public’s
best interests were met?
‘Health professional regulation is high on
the global agenda. Increasing numbers of
trade agreements, a push for greater har-
monisation and ease of mobility, economic
pressures, privatisation and corporatisation
of health and education services and health
human resource challenges are all impacting
the regulatory environment globally.’
She said these trends would influence the
shape of regulation. The conference had
noted that public scrutiny of professional
work was higher than ever and that the de-
sign,implementation and execution of com-
petence assessment were essential. Speakers
had emphasised that the central element of
professional autonomy was the assurance
that individual healthcare professionals had
the freedom to exercise professional judg-
ment in the care and treatment of patients
without undue influence by outside parties
or individuals.
The conference had agreed that professions
evolved and that regulations, standards and
assessment schemes should follow.They had
talked about safety, quality and compliance
to benefit patients, communities and popu-
lations and how right-touch regulation was
targeted, transparent, agile, accountable,
consistent and proportionate. They had
considered migration challenges, whether
adaptation to local needs was necessary,
and how new ways of looking at perfor-
mance and population data was changing
the health landscape and how regulators
ensured patient safety and quality of care.
Finally, on supporting the quality of life-
long learning, Ema Paulino said that dif-
ferent views had been presented on what
constituted the roles and responsibilities of
regulators associated with continuing pro-
fessional development, and how they could
ultimately ensure competency in a sector
where information asymmetry was preva-
lent.
‘I believe we can conclude by stressing
the importance of collaboration amongst
healthcare professionals, the true value of
working together in practice for the benefit
of the patient. This can also be enhanced
and translated from us looking at regula-
tory systems together, in these forums. In
addition, I believe we can also conclude that
there is a significant advantage of looking
at regulation from an interprofessional per-
spective, given that similar challenges are
met by the various professions throughout
the world.’
Mr. Nigel Duncan,
Public Relations Consultant, WMA
E-mail: nduncan@ndcommunications.co.uk
18
World Health Assembly
During the week of the World Health As-
sembly in May, Geneva was hive of activ-
ity, with breakfast meetings, lunchtime side
events and evening conferences.WMA lead-
ers were involved in a large number of these
events. Among them were the following.
International Symposium on
Universal Health Coverage
On Tuesday May 22, the second day of the
Assembly, the WMA, together with the
Taiwan Medical Association, hosted the
International Symposium on Universal
Health Coverage.
The packed meeting was addressed by both
the President and the Chair of the WMA.
Dr.  Yoshitake Yokokura, President of the
WMA and President of the Japan Medical
Association, spoke about borderless-ness in
a world of globalization. He said the cross-
border unity of physicians worldwide was
increasingly important to prepare for the
spread of infectious diseases and the occur-
rence of natural disasters.
‘The WMA is concerned about the eco-
nomic and social influence of the preva-
lence of rapidly expanding NCDs. The
WMA also recognizes the importance of
measures to be taken beyond the fields and
departments at the national and global
­levels.’
He said the new Memorandum of Under-
standing with the WHO aimed to promote
UHC and strengthen the emergency di-
saster preparedness and he added that the
medical profession should return to the ba-
sis of health care, create a healthy longevity
society, and continue to support it.
‘I am convinced that the system which leads
Japan’s aging society, unprecedented in the
world, to “the society of peace of mind”
should be also supported by the “Universal
health insurance”.I think that it is ideal that
because of extended healthy life expectancy,
the elderly people can help to create a basis
of the nation as “the people who support
a society”. In this sense, the significance
of promoting UHC is extremely high to
realize such a society. As President of the
WMA, I  am determined to make utmost
efforts toward global promotion of the
UHC.’
Dr. Ardis Hoven, Chair of the WMA, said
the concept of UHC was very close to the
ideas of the WMA. She said there was ma-
jor inequality in health in the world and
those regions with the highest need – south
east Asia and Africa – had the lowest share
of the health work force. It was the same
with resources, which were mainly available
in regions with a moderate or low burden of
disease. This inequality was reflected in the
life expectancy at birth. And all these in-
equalities existed within countries, whether
they were affluent or not.
Dr.  Hoven referred to the WMA’s policy
on patients’ rights and UHC with its state-
ment that every person was entitled, with-
out discrimination, to appropriate medical
care.The WMA was firmly of the view that
every patient should have a chance to be
seen by a physician. But there was a clear
disparity between countries in the numbers
of physicians per thousand people, and this
had to be recognized. So the WMA had
policy that where countries had a critical
shortage of physicians, task shifting should
be viewed as an interim strategy. But task
shifting should not replace the development
of sustainable, fully functioning health care
systems. If they wanted to achieve equitable
access to care, political action was necessary.
Dr.  Hoven concluded with these words:
‘To make Universal Health Coverage a re-
ality will require huge investments. It will
require investments in people and, let me
emphasize, this includes the education of
physicians. It will require investment in fa-
cilities, in safety, and quality. But there is no
doubt that these investments will pay off –
for healthier living, for a better society and
form a stronger economy’.
A recorded video message was sent to the
meeting by Ms Tsai Ing-wen, President of
Taiwan. She said that Universal Health
Coverage was the most unifying theme in
global health. She talked about Taiwan’s in-
troduction of National Health Insurance in
1995, under which all nationals, regardless
of gender, age or wealth were equally cov-
ered for their whole life.The NHI premium
accounted for less than five per cent of the
individual monthly pay roll and the total na-
tional health care expenditure was less than
seven per cent of GDP.The scheme was very
comprehensive, covering everything from
the common cold to organ transplants. The
public satisfaction approval rate was recently
found to be 85 per cent. The scheme safe-
guarded not only people’s access to health
care, but also ensured financial protection.
Ever since the implementation of NHI, no-
one had gone broke because of medical bills.
The scheme was a model to achieve UHC
and she said she believed Taiwan’s experi-
ence could serve as a paradigm for the world.
Strengthening National
Frameworks for the
Protection of Health Care
The following day, the WMA was one of
the coordinating organisations for an ICRC
Health Care in Danger event.The meeting’s
theme was ‘Strengthening National Frame-
works for the Protection of Health Care’.
World Health Assembly Side Events –
May 2018
19
BACK TO CONTENTS
World Health Assembly
The two-hour forum was hosted by Maciej
Polkowski, ICRC Head of the HCiD Ini-
tiative, who emphasised how important this
project was for the ICRC.
Two keynote speakers outlined the scale
of the problem of violence. Dr. Esperanza
Martinez, Head of Health at the ICRC’s
Health Unit, spoke about the consequences
of attacks on hospital and health profession-
als, and said the problem was not confined
to war zones. However, he said there was
now a very strong community of concern
with a common voice that was going to be
heard. Raphael Gorgea, Deputy Director of
Operations from Médecins Sans Frontières,
talked about the attacks that had been made
on MSF hospitals and staff, and the impact
this had had on patients and the delivery of
health care. Among the ways to combat this
was to advocate for the respect of interna-
tional law and to promote health care as a
common good.
The meeting went on to hear speakers from
three countries  – Nigeria, Pakistan and
Peru – about how the problem of violence
against the health sector was being tackled.
This ranged from round table talks to en-
gage all those involved to practical interven-
tions for raising awareness locally, improved
reporting of incidents, policies of zero tol-
erance and crowd control measures. The
meeting concluded with general agreement
that health care was a common good, that it
could not be taken as a given and that it had
to be promoted.
100 Years After the
Spanish Flu Pandemic
The third event, on Wednesday May 23,
was held to mark the 100th anniversary of
the Spanish Flu Pandemic and was hosted
by the WMA, the International Federation
of Red Cross and Red Crescent Societies
(IFRC) and the International Federation of
Pharmaceutical Manufacturers & Associa-
tions (IFPMA).
The event was opened by Thomas Cueni,
Director General of the IFPMA, who said
it was estimated that Spanish flu killed more
people in 24 weeks than Aids had killed in
24 years. In fact, the pandemic killed up to
100 million people,more people than all the
wars of the 20th
century combined. In 1918
this amounted to nearly five per cent of the
world’s population. It served as a poignant
reminder of the importance of preparedness.
If a highly contagious and lethal pathogen
like the 1918 influenza were to take hold
today, nearly 33 million people worldwide
would die in just six months. More than
ever they were exposed to new biological
threats, many of them yet undiscovered.
He said that in today’s extremely inter-
connected world, with people travelling at
unprecedented rates, global health security
had never been more fragile or more urgent.
Previous epidemics had shown that when the
global health community came together,they
were able to tackle infectious diseases.Going
forward, they needed to design and imple-
ment pro-active preparedness, to further im-
prove their capacity to prevent and control
unpredictable disease outbreaks. Sample and
data sharing were key and he said they all
recognized the importance of the WHO’s
global influenza surveillance system.
The first of two keynote speakers was Alex
Azar, US Secretary of Health and Human
Services, who said that at the time of the
outbreak of Spanish flu, the United States
and the world were ill-prepared to combat
a pandemic. Influenza viruses had not yet
been discovered, there were no vaccines to
prevent infection and no medicines to treat
it, and the field of public health was in its
infancy.
‘Today, influenza pandemics remain one of
our top infectious disease threats. We have
a growing set of increasingly advanced tools
to detect the emergence of a new strain of
influenza virus domestically and abroad,
but much work remains to be done. When
it comes to the threat of pandemic flu, as
well as other infectious threats, prepared-
ness cannot be confined within borders.The
world must work together to focus on the
prevention and mitigation of pandemics
that pay no mind to borders and focus the
work of institutions like the World Health
Organization on that threat.’
He said the Trump Administration strong-
ly supported the Global Health Security
Agenda to prevent, detect and respond to
infectious disease threats in collaboration
with their partner countries. It also sup-
ported reforms to the WHO to ensure that
future epidemics were handled more effec-
tively than Ebola was.He outlined the work
of the Centers for Disease Control and Pre-
vention in building global flu surveillance
networks with partner countries that helped
to detect and respond to new and known
influenza viruses. And he talked about the
way in which the US was putting in place
preparedness plans for responding in the
event of a flu pandemic.
The country’s vaccine manufacturing capac-
ity had increased ten-fold since the 2000s.
At the same time they had worked to reduce
the time it took to develop a new flu vac-
cine in the event of a pandemic and they
had invested in research toward a universal
flu vaccine.
Mr. Azar concluded with these words: ‘The
world has come a long way since 1918, but
we are still vulnerable, not just to the flu but
a range of infectious threats. The United
States will continue to work with our part-
ners around the globe to build preparedness
for these threats and to strengthen our pre-
paredness at home.
Infectious diseases remain a serious threat,
but with the right level of cooperation and
focus, we can look forward to marking
many more World Health Days before we
see another pandemic like the Spanish flu’.
The second keynote speaker was Elhadj As
Sy, Secretary General of the International
20
Intellectual Property Rights
The 71st
World Health Assembly (WHA),
which represents the highest decision-
making body of the World Health Organ-
isation (WHO), took place in Geneva this
May. The World Medical Association was
represented by a diverse delegation of both
members of the Junior Doctors Networks
and representatives from National Medical
Associations working under the coordina-
tion of the WMA Secretariat. Amongst
the many issues followed by the WMA, an
inherently contentious part of the WHA
agenda was the review of the global strat-
egy and plan of action (GSPoA) on public
health, innovation and intellectual proper-
ty1
. Indeed, the potential barriers of medi-
1 
World Health Organization. “Global Strategy
and Plan of Action on Public Health, Innova-
tion and Intellectual Property” 2011. Available
at: http://www.who.int/phi/publications/Global_
Strategy_Plan_Action.pdf
cines costs and procurement are central ele-
ments for achieving the ambitious goals of
the SDGs Agenda by 2030 especially at this
WHA focused on Universal Health Cov-
erage. While these negotiations have taken
place over previous decades, progress has
been slow and there is still a long way to go
before accomplishing the vision behind the
work on access to medicines.
Discussion around intellectual property
and access to medicines have been taking
place at WHO ever since the adoption of
The Agreement on Trade-Related Aspects
of Intellectual Property Rights (TRIPS)
agreement in 1994. Being party to this
treaty was mandatory for participation in
Federation of Red Cross and Red Crescent
Societies. He said that over the last few
years the world had experienced a number
of epidemics, including Ebola, which had
killed around 11,000 people in three west
African countries. He asked if they were
really ready and prepared for another epi-
demic or pandemic. Had they learned the
lessons of the first Ebola outbreak? He said
it did not matter how far away outbreaks
occurred, adding ‘They are only one hand
shake away from many of us. They are only
one plane ride away for many of us’.
He said there were many factors involved
in determining the levels of vulnerability in
epidemics. But none of them would be safe
until all of them were safe. The only way to
contain these epidemics and outbreaks was
where they were happening, right in the
communities. They needed international
regulations and preventive measures, but
they also needed to make the necessary
investment in those areas where these out-
breaks were occurring.Too often they had to
return to the same communities to respond
to the same outbreaks. He emphasized how
important it was to get the acceptance of lo-
cal communities to take preventive action.
Partnerships were essential and health sys-
tem strengthening was vital.
There was then a panel discussion conducted
by the moderator, ex-BBC journalist Claire
Doole. The panel consisted of Dr.  Ardis
Hoven, Chair of the WMA, Dr.  Marie
Mazur, Vice President of Response Solu-
tions at Seqirus, Dr. Sylvie Briand, Direc-
tor of Infectious Hazards Management at
the WHO and Dr. Julie Hall, Chief of Staff
from the Office of the Secretary General at
the IFRC.The first querstioin the panellists
were asked was whether the world was pre-
pared for another pandemic. Dr. Hoven re-
plied bluntly ‘No’. She and the other panel-
lists agreed that there was much more work
to be done.
They went on to talk about vaccines.
Dr. Hoven spoke about the scepticism sur-
rounding vaccines, saying that the challenge
was to counter the reluctance to accept im-
munisation of any kind. They had barriers
to confront. There was information going
round that was not scientific and that was
discouraging individuals from being immu-
nized. So they had to have systems in place
that accelerated the way people could get
immunized. She said that when physicians
said they had been immunized, it was much
more likely that their patients and families
would be immunized. She also spoke about
the WMA’s influenza campaign which had
been running for five years in partnership
with others.
In a discussion about Ebola, Dr.  Hoven
stressed the importance of strengthening
health care systems and addressing the work
force issue. ‘If we don’t have people to take
care of people, it all falls apart’, she said.The
Ebola outbreak of two years ago had illus-
trated cracks in the health infrastructure.
On a more general issue, she added that
health care professions and their national
organisations should be ‘looped in’ with
governments, so that they were part of the
planning work that needed to be done, not
just when there was an emergency, but on
an everyday basis. She also said that there
should be a removal of barriers between
agencies in order to communicate better.
They had to remove the silos of information
and knowledge between them.
As the meeting ended,the moderator Claire
Doole tweeted: ‘I had great panelists – so
rare to have an all woman panel! They were
a joy to moderate – succinct clear and com-
pelling – the perfect panelists’.
Mr. Nigel Duncan,
Public Relations Consultant, WMA
E-mail: nduncan@ndcommunications.co.uk
Intellectual Property: who owns the right to
good health?
21
BACK TO CONTENTS
Intellectual Property Rights
Yassen Tcholakov Lisa Murphy
the World Trade Organization (WTO)
and thus countries were inherently forced
to adhere to it. TRIPS set down regulation
on Intellectual Property (IP) into the inter-
national trading system, which has namely
impacted access to newly developed medi-
cines. While TRIPS contains provision for
a number of flexibility mechanisms2
(in-
cluding patent exceptions, compulsory li-
censing and limits on data protection) their
use has been rare. Indeed, countries who
have utilised them have had to face politi-
cal pressure and retaliatory action. In that
context, the WHO proposed the GSPoA in
2008 which was fully adopted in 2009.This
year marks the 10th
anniversary of GSPoA’s
creation, and member states were reflective
on what had been achieved.
The GSPoA focuses on the 8 elements:
• prioritizing research and development
needs;
• promoting research and development;
• building and improving innovative capac-
ity;
• transfer of technology;
2 
Nicol D. Owoeye O.“Using TRIPS flexibilities
to facilitate access to medicines” WHO Bulletin.
April 2013.Available at: http://www.who.int/bul-
letin/volumes/91/7/12-115865/en/
• application and management of intellec-
tual property to contribute to innovation
and promote public health;
• improving delivery and access;
• promoting sustainable financing mecha-
nisms;
• establishing and monitoring reporting
systems.3
This GSPoA review4
highlighted the slow
and uneven progress in the various areas
of work and some of the funding gaps. It’s
recommendations include WHO support
for member states to utilise the aforemen-
tioned TRIPS flexibilities1
, increased trans-
parency in the pricing of medicines, and the
strengthening of non-profit based innova-
tion models through delinkage5
(the process
3 
World Health Organization.“The Global Strat-
egy and Plan of Action on Public Health, In-
novation and Intellectual Property”. Available at:
http://www.who.int/phi/implementation/phi_glob-
stat_action/en/
4 
World Health Organization. “Overall pro-
gramme review of the global strategy and plan
of action on public health, innovation and intel-
lectual property” November 2017. Available at:
http://www.who.int/medicines/areas/policy/GSPA-
PHI3011rev.pdf?ua=1
5 
Love J. “Inside Views: Delinkage Of R&D
Costs From Product Prices” Intellectual ­
Property
through which pharmaceutical research is
financed through means other than medi-
cation sales).
However the review neglected some im-
portant issues, such as the creation of a
research and development (R&D) treaty.
Many members expressed frustration dur-
ing WHA with the lack of progress on
implementation and funding for this area of
work. The current finance gaps are largely
a reflection of WHO’s wider funding chal-
lenges, with a large proportion of its money
firmly earmarked according to donor inter-
ests. During these R&D discussions there
was a noticeable equatorial difference in
opinion. While the global south empha-
sized the importance of WHO facilitat-
ing the use of TRIPS flexibilities and new
non-profit based innovation models, the
north focused on patent driven innovation.
There were calls from many low and middle
income countries for international coopera-
tion and financing to increase their R&D
capacities, with support sought from WHO
for country led action.
Many member states from within the
high income bracket endorsed the estab-
lishment of public-private partnerships as
key to driving creation of quality medi-
cines. There was also push back against the
GSPoA’s recommendations for transpar-
ency of research and development costs,
which is a crucial measure for preventing
industry manipulation of drug costs and
ensuring fair medicine pricing.This, along-
side a move to a fixed price model for med-
icines from a market driven system, could
greatly enhance medicines availability and
procurement. The perceived threat to prof-
its for the pharmaceutical industry make
those recommendations contentious. The
question of how much implementation the
WHO will be able to drive has yet to be
answered.
Watch. September 2016. Available at: http://
www.ip-watch.org/2016/09/15/delinkage-of-rd-
costs-from-product-prices/
22
Health Care
On the agenda item on the GSPoA review,
the WMA presented a statement support-
ing opening the GSPoA to newer essential
health products, encompassing medicines,
vaccines, diagnostics or biologicals and to
call for intellectual property which serve the
people and contribute to sustainable devel-
opment.6
Additionally, the WMA also de-
livered an intervention on a different agen-
da item calling for the WHO to help with
filling the gap in the current R&D system
and address global challenges such as anti-
6 
World Medical Association. “71st World Health
Assembly 11.6 Global strategy and plan of action
on public health,innovation and intellectual prop-
erty” May 2018. Available at: https://www.wma.
net/wp-content/uploads/2018/05/11.6-WHA71-
Global-strategy-public-health-innovation-and-
intellectual-property-WMA.pdf
microbial resistance and the lack of effective
treatment for dementia.7
Now that the review panel for priority ac-
tions have identified a number of key ob-
jectives8
to be achieved by 2022, it remains
to be seen what achievements the global
health community will be celebrating in
5 years time.In a globalized economy,inter-
7 
World Medical Association. “71st World Health
Assembly 11.5 Addressing the global shortage of,
and access to, medicines and vaccines” May 2018.
Available at: https://www.wma.net/wp-content/
uploads/2018/05/WMA-11.5-access-to-medicine.
pdf
8 
World Health Organization. “Global strategy
and plan of action on public health, innovation
and intellectual property” March 2018. Avail-
able at: http://apps.who.int/gb/ebwha/pdf_files/
WHA71/A71_13-en.pdf
national law, including intellectual property
regulations, should always serve the people.
If it fails to do so, the global community has
a moral obligation to redress its mistakes.
The current IP system has failed to deliver
on its promises and it is unjustified to award
corporations the privileges of a monopoly
at the expense of the wellbeing of millions
who still lack access to essential medica-
tions.
Yassen Tcholakov, MD MIH CCFP,
McGill University (Canada)
Lisa Murphy, MBChB BSc, Barts
and The London NHS Trust
E-mail: yassentch@gmail.com
The Demographic Challenge
Long-term forecasts on demographics are
similar in most rich welfare states, in the
sense that as populations are ageing and
wealth is increasing, more and better health
care is demanded. Since many countries
finance health care largely through taxes,
finding solutions to finance the welfare
will put the public systems under pressure.
As the workforce will consist of a smaller
part of the population, either taxes or out-
of-pocket payments will have to increase,
the quantity or quality of publicly delivered
health care will have to decrease, or a com-
bination of the above. Any solution that
simplifies the equation and releases some
of the pressure on the health care system
should be taken into consideration. The
Swedish Medical Association sees physi-
cians taking a more active role in the leader-
ship of health care as crucial in making the
health care more efficient.
The scarce resources would most likely be
used more efficiently if the decisions on
resource allocations were always based on
the medical and clinical knowledge about
what creates the most substantial impact on
health outcomes.
In 2017 the Swedish Medical Associa-
tion commissioned a report on physicians’
engagement in leadership in health care,
and the effects thereof. The report, Physi-
cians’ role in the management and leadership
of health care1
, examined the published sci-
entific literature and found several positive
effects of getting more medical doctors to
engage in leadership.
The report found, among other things, that
physician leadership can improve hospital
performance in terms of quality of care,
1 
Physicians’ role in the management and lead-
ership of health care. A scoping review.
Stockholm,February 2017. Mairi Savage, MPH
Pamela Mazzocato, PhD Carl Savage, PhD Mats
Brommels, MD, PhD, Professor
Physicians’ Role in the Management and Leadership of
Health Care
Heidi Stensmyren
SWEDEN
23
BACK TO CONTENTS
Health Care
management of financial resources and staff
satisfaction. All these factors are vital to
meet the increasing demands of heath care
for a long time to come.
The report also identified some mechanisms
that seem to have a role in mediating the
positive relationship between physician
leadership and performance outcomes. For
instance,having a medical background gives
physician leaders increased credibility com-
pared to managers without medical train-
ing. Clinical knowledge seems also to be
essential for improved decision making.The
knowledge acquired from a long medical
education and years of working experience
is obviously helpful for creating an under-
standing between different levels of man-
agement and performance.
While the quality of medical decisions im-
proves, the risk of complications decreases,
and costs are lowered. This might explain
why there are indications that financial re-
sources are managed in a better way when
physicians are assuming a managing role.
Few doctors in management
Why then, aren’t physicians more engaged
in management? One reason could be that
most physicians already make a good earn-
ing.The financial gain from taking on more
responsibility does not often add up to the
amount of workload from managerial tasks.
A managing role in health care is associated
with a lot of responsibility and potential ex-
pressions of dissatisfaction from both em-
ployees and superiors. This is of course the
case in most sectors, but certainly no less in
the medical profession where decisions are
literally about life and death.
In contrast, for nurses in Sweden, the wage
difference between being a regular employ-
ee and a manager can be much larger, which
partly could explain why many nurses are
keener on engaging in management. Still,
according to the Swedish Medical Asso-
Picture 1
Picture 2
SWEDEN
24
ciation it should be the genuine interest for
leadership and management, not financial
benefits, that should motivate doctors to
pursue a career in leadership and manage-
ment in health care. If medical doctors, de-
spite being interested, choose not to seek
the managerial roles, it will benefit no one
in the health care system.
Virtuous and vicious cycles
Picture 1 shows a possible virtuous cycle
that can arise from better physician leader-
ship.Medical doctors as leaders and manag-
ers create a culture and an atmosphere that
invites and engages staff to participate in
improving health care. The catalyst in such
a process is not obvious but formal recruit-
ment as a starting point is probably where
policy makers can influence the process.
Formal recruitment can lead to positive as-
pects in the leadership, such as creating a
broader recruitment base. It may very well
be the case that persons who would not have
considered becoming a leader can be made
aware of the opportunity if the process is
formal, and if the responsible for human re-
sources actively seek out to those individu-
als. Since there is no reason to expect that
persons who previously haven´t considered
leadership are less likely to be successful at
it, such actions are likely to lead to better
management in the long run.
These positive effects can hopefully be self-
sustaining, giving a positive spiral upwards.
On the other hand, picture 2 illustrates the
outcome if the recruitment process is done
informally.
Informal recruitment can lead to a narrow
base of recruitment, placing wrong persons
in important management positions. Such
discrepancy in the workplace is likely to lead
to internal conflicts and impaired commu-
nication between the managerial level and
employees.
Thus,it is obvious how important it is to en-
gage the right persons in management and
to make sure that recruitment is formal and
organised.
Strong leadership for
improved communication
An aspect that is sometimes overlooked is
the leadership as a link from health care
policies to delivering good health care. In
this context, it means that effective leader-
ship easily can communicate the intentions
of upper-level decision makers to floor-level
staffers. If the economic incentives points in
a certain direction, but solutions to accom-
plish these incentives are perceived to be
technical or difficult to understand, a leader
with good understanding of the whole sys-
tem can create an atmosphere of commit-
ment among the staff. For this to hold, the
economic incentives must of course steer
towards improving health outcomes.
Policies for improved leadership
Even after finding good and promising
leaders for management, the process is not
nearly completed.There is a need for support
throughout the career, and learning leader-
ship skills must begin already in the early
stages of education. Mandatory courses in
leadership in medical schools are important
in order to establish a culture where medi-
cal professionals are encouraged to consider
making a managerial career in addition to a
clinical career. Better possibilities to com-
bine clinical and managerial positions are
important, not only to make management
more attractive but to strengthen the con-
nection between staff and managerial levels.
Such courses can include both traditional
leadership education and more hands-on
procedures such as catastrophe simulation,
depending on the focus.
Putting it all together
To insure a sustainable programme for ef-
fective management and leadership in
health care all the steps in different levels
must be connected.
• Medical schools must supply the basic
foundation of leadership knowledge
• Incentives must be in place for enough
physicians to pursue this alternative ca-
reer
• Recruitment processes must aim to find
the most suitable candidates
• Support in place for those who choose to
become managers.
If all these factors are in place there is rea-
son to believe that physicians’ leadership
will provide better use of the resources in
healthcare.
Heidi Stensmyren, MD
President of the Swedish Medical Association
Chairperson of the WMA
Medical Ethics Committee
E-mail: ordforande@slf.se
Health Care SWEDEN
25
BACK TO CONTENTS
Child Health
1. Introduction
The World Medical Association (WMA)
Ottawa Declaration was adopted by 50th
WMA Assembly October 1998 and later
substantially revised by the 60th
WMA As-
sembly October 20091
, According to the
WMA revision cycle, the document is up
for revision next year. This analysis pro-
vides an overview of the development of
the declaration, its elements and their oc-
currence in the original and the amended
version.
The Declaration of Ottawa originally aimed
at improving the rights of children to health
care2
throughout the world. In this article
we analyze and compare the above two doc-
1 
World medical association, published 22nd
.
March. 2017, https://www.wma.net/policies-post/
wma-declaration-of-ottawa-on-child-health/
2 
See World Medical Association Web page
published 20.October.1998, https://www.wma.
net/news-post/declaration-of-ottawa-on-the-right-
of-the-child-to-health-care/
uments looking for the new points added in
the new version and the important points
left out while amending as well as points to
emphasize on.
2. Analysis
The initiative, entitled the Declaration of
Ottawa, was building on the WMA Dec-
laration of Lisbon on the Rights of the Pa-
tient (1981) and the 1989 United Nations
Convention on the Rights of the Child.
Among other rights3
, the Declaration of
Ottawa stated that:
• Parents whose children are admitted to
hospital should, wherever possible, be
provided with appropriate accommoda-
tion in or near the hospital at minimal or
no cost. In addition parents should be al-
lowed time off work without prejudice to
their continued employment;
3 
UNICEF. convention on the rights of the child ,
New York, 20 November 1989.
• parents,guardians or children of sufficient
maturity should be free to change their
physician or to seek a second opinion;
• the wishes of children should be taken into
account in decisions involving their care;
• a competent child patient, their par-
ents or guardians should be entitled to
withhold consent to any procedure or
therapy;
• the child patient is entitled to be fully in-
formed about their medical condition.
Dr. James Appleyard himself Pediatrician
who was the President of WMA by then,
said at the time “that the Ottawa Declara-
tion provides an international bench mark
for children’s health care and a bench mark
that many governments fail to reach.
This bench mark will empower national
medical associations throughout the world
to persuade their governments to value
their children and improve the health of the
world’s children”4
.
Dr. Appleyard continued “The rights of
children to health care need to be at the
centre of our health policies and investment
in the health care of children is the most
cost effective measure for any government
to take”4
.
The amended Ottawa Declaration of 2009
sent a clear demand towards governments,
care providers, communities and parents
regarding their responsibilities by asking
them to have the Ottawa principles ful-
filled without any constraints. However,
with the revision of 2009, the WMA split
the content of the original document as
well as additional, new items and informa-
tion into two documents: The revised policy
document5
, the (then) new Declaration of
4 
World Medical Association, pub 20 October
1998, https://www.wma.net/news-post/decla-
ration-of-ottawa-on-the-right-of-the-child-to-
health-care/
5 https://www.wma.net/policies-post/wma-declara-
tion-of-ottawa-on-child-health/
Policy Analysis Ottawa Declaration
on Child Health
Elicien Ishimwe Otmar Kloiber
26
Child Health
­
Ottawa and a background document6
, giv-
ing explanation to the policy revision, but
not being part of the policy.
In addition, the amended Ottawa declara-
tion7
stated clearly seven new important
principles, which are:
1. Clean water, air and soil with a safe en-
vironment
2. Protection from injury,exploitation,dis-
crimination
3. Health Families, homes and communi-
ties
4. Healthy Nutrition
5. Early Learning opportunities
6. Availability of drugs & immunization and
7. Research
However, there are other Principles which
have been left out from the original Ottawa
declaration such as,
1. Child abuse which could have been a du-
plication to the WMA Statement on Child
Abuse and Neglect revised by 68th
WMA as-
sembly of 2017:There it is noted that the wel-
fare of children is of paramount importance
and that child abuse in all its forms8
is one of
the most destructive manifestations of fam-
ily violence. Moreover the United Nations
convention on the rights (1989) of a child in
its article 9,19 and 39 state that all forms of
child abuse should be taken into consider-
ation by states parties to prevent them9
.
6 
h t t p s : / / w w w . w m a . n e t / w p – c o n t e n t /
uploads/2017/02/Background_Ottawa_
Declaration-Oct2009.pdf
7 
See WMA, Current policies. 2017 https://www.
wma.net/policies-post/wma-declaration-of-ottawa-
on-child-health/
8 
WMA statement on child abuse and neglect,
15th
October 2017
https://www.wma.net/policies-post/wma-
statement-on-child-abuse-and-neglect/
9 
Adopted and opened for signature, ratification
and accession by General Assembly resolution
44/25 of 20 November 1989, available at:
http://www.ohchr.org/EN/ProfessionalInterest/
Pages/CRC.aspx
The amended policy mentions “protection
from the child’s exploitation”however given
the definition of the UNHCR in the report
entitled “action for the rights of children”
UNHCR10
defines abuse as “the process
of making bad or improper use, or violat-
ing or injuring, or to take bad advantage of,
or maltreat, the person,” while exploitation
literally means “using for one’s own profit or
for selfish purposes”10
.
Child abuse includes the physical, emo-
tional, or sexual mistreatment of a child, or
the neglect of a child, in the context of a
relationship of responsibility, trust or power,
resulting in actual or potential harm to the
child’s physical and emotional health, sur-
vival and development11
.
Exploitation of a child on the other hand
refers to the use of the child in work or
other activities for the benefit of others and
to the detriment of the child’s physical or
mental health, development, and education.
Exploitation includes, but is not limited to,
child labor and child prostitution; therefore
child abuse should be one the principles not
be left out8
.
During Human Rights Council 2018, pre-
senting her report, Ms. Santos Pais said
that half of the world’s countries had ad-
opted a comprehensive policy agenda on
violence against children. Nevertheless,
half of the world’s children experienced
violence. Children were disciplined by
violent means, bullied, sexually assaulted
in their circle of trust, groomed online,
and abused in detention centers. The 2030
Agenda provided a historic opportunity
to end violence12
. In 2019 there would be
an in-depth review of goal 16, including
10 
UNHCR report “action for the rights of chil-
dren” ttp://www.unhcr.org/3bb825cd2.pdf
11 
UNHCR, Critical issues Abuse and Ex-
ploitation. March 1999, http://www.unhcr.
org/3bb81aea4.pdf
12 
http://srsg.violenceagainstchildren.org/page/1229
target 16.2 to end all forms of violence
against children.
2.Religious assistance: this principle is also
in the original document13
while amending,
it was left behind. However, The Declara-
tion of Lisbon states clearly that one has the
right to receive or to decline spiritual and
moral comfort including the help of a min-
ister of his/her chosen religion14
.
3. Freedom of choice: This principle is not
mentioned in the amended policy5
as well
although in the background document of
the amended policy it no longer part of the
policy.
4. Emergency Consent: The original docu-
ments explain that if the child is uncon-
scious, or otherwise incapable of giving
consent, and a parent or legally entitled
representative is not available, but a medical
intervention is needed urgently,then specif-
ic consent to the intervention may be pre-
sumed, unless it is obvious and beyond any
reasonable doubt on the basis of a previous
firm expression or conviction that consent
would be refused in particular situation; it is
not stated in the new polic13
.
The UN convention on the rights of child15
deems the “the right to develop a healthy
attachment to a parent, legal guardian, or
caregiver” as necessary for its social and
emotional wellbeing. And finally and in dif-
ference to the UN convention children with
13 
world medical association. declaration of Ot-
tawa on the right of the child to health care,
adopted by the 50th
WMA general assembly Ot-
tawa, Canada, October 1998, https://www.wma.
net/policies-post/wma-declaration-of-ottawa-on-
child-health
14 
WMA declaration of Lisbon on the rights of
the patient. 2015, https://www.wma.net/policies-
post/wma-declaration-of-lisbon-on-the-rights-of-
the-patient/
15 http://www.ohchr.org/en/professionalinterest/
pages/crc.aspx
27
BACK TO CONTENTS
Child Health
Table 1. Summary of the comparison of the original and amended policy
No Item Old Policy New Policy
Background document of the
new policy
1 Clean water, air and soil Left out Present
Children shall have access to
the mentioned items adequately
and environments free of toxins
and microbes known to harm
2 Protection from injury, exploitation, discrimination Left out Present Mentioned
3 Child Abuse Present Left out
Item was pointed out as a sub
line of the previous item
4 Health Families, homes and communities Left out Present Mentioned
5 Best Possible Health at Birth Present Present Mentioned
6 Health nutrition Left out Present Mentioned
7 Early Learning Left out Present Mentioned
8 Physical Activity Present Present Mentioned
9 Education Present Present Mentioned
10 Eradicate traditional practices prejudicial to health of the child Present Left out Present under the item No 2
11 Health Resources Available to All
Present but renamed
as Quality of care
Present Mentioned
12 Drugs & immunization Left out Present Mentioned
13
Hospitalization Present
Present with follow-
ing details missing
Present with all the details
1. A child should be admitted to hospital only if the care
cannot be provided at home
Present present
2. A child in the hospital should be provided a suitable
environment
Present Left out
3. Every effort should be made to allow a child admitted to
be accompanied
Present Left out
4. A child should be allowed as much outside contact and
visiting as possible
Present Left out
13
5. With relevant age a mother should not be denied the
opportunity to breastfeed except if there is a medical
contraindication
Present Left out
Present with all the details
6. A child should be afforded every opportunity and facility
appropriate to play, recreation and continue Education
Present Left out
14 Rehabilitation
Mentioned in the
general principal
Present Mentioned
15 Freedom of choice Present Left out Mentioned in the background
16 Dignity of the Patient Present Present Mentioned in the background
17 Access to Information Present Left out Mentioned
18 Consent Present Present Mentioned
19 Confidentiality Present Present Mentioned
20 Research Left out Present Mentioned
21 Freedom of choice Present Left out Present
22 No discrimination of any kind Present Present Present
23
Emergency Consent (child unconscious and no guardian
available)
Present Left out Left out
24 Health Education Present Left out Mentioned
25 Religious, assistance Present Left out Mentioned
Note that the background document is not part of the policy.
28
Health Care
As a social organization of science and
technology on the national level, the Chi-
nese Medical Association (CMA) responds
actively to the task and requirements of
health poverty alleviation put forward by
the Chinese government, attaches great im-
portance to the health poverty alleviation
work, and gives full play to its advantages
of having extensive connections with vari-
ous industries and with all walks of life, as
well as to the advantages of the experts and
the active roles of scientific and technologi-
cal communities in poverty alleviation work.
With a view to boosting the development of
medical and health services in China’s pov-
erty-stricken areas, CMA’s health poverty
alleviation leading group thoroughly carries
out the essence of poverty alleviation docu-
ments adopted at the 19th
National Con-
gress of the Communist Party of China, re-
duces or exempts registration fees through
academic conferences for doctors in China’s
west region, at the grassroots level and in
poverty-stricken areas, grants transporta-
tion and accommodation subsidies to grass-
roots doctors, intensively patronizes clinical
scientific research projects of west region,
donates much-needed materials such as
medical equipment to impoverished regions
and counties and medical periodicals to
grassroots hospitals, and launches activities
such as CMA Thousand Talents Cultiva-
tion Program for county hospitals, etc.
As a typical case of the health poverty al-
leviation work conducted by CMA, the
Thousand Talents Cultivation Program for
county hospitals (abbreviated to “Thou-
sand Talents Program”) adopts approaches
of “going down to grassroots to offer help”
and “ushering in grassroots medical staffs
for training” to improve grassroots doctors’
abilities in diagnosis and medical treatment
and to favour the health of impoverished
masses.The following is the brief.
with disability were not given much atten-
tion in this policy.
3. Conclusion and
Recommendation
As expected there are many similarities be-
tween the original Declaration of Ottawa
on Child Health in 1998 and the amended
policy of the 60th
WMA assembly in 2009.
Both list items to be considered for the good
of child health, however, in the new policy
which is currently being used as guidance to
physicians worldwide is lacking some im-
portant principles. Some have been lost in
the revision,some moved to the background
document (which is not part of the policy)
and some were not mentioned in the origi-
nal and the revised version.
The child health was at the center of the
United Nation Millennium Development
Goals (MDGs)16
and it is still a of the pri-
ority in Sustainable Development Goal 3
which emphasizes among others the re-
duction of child mortality. Child health
goes beyond SDG 3 to SDG4 (child needs
a healthy diet), SDG5 (be free of any dis-
crimination or violence) and SDG6 (clean
water and hygiene)17
. The above highlights
the critical importance of collaboration and
coordinated action across multisector to
achieve improvement in chil health. There-
16 
United Nations, MDG4 at: http://www.un.org/
millenniumgoals/pdf/Goal_4_fs.pdf
17 
United Nations, Sustainable Development
Goals, 2017 available at: https://www.un.org/
sustainabledevelopment/sustainable-development-
goals/
fore The Ottawa Declaration is one of the
key documents together with the Declara-
tion of Oslo on the Social Determinants
of Health to guide actions, regulations and
attitudes to improve the rights of children
to health and health care throughout the
world. Under the light of the fulfillment of
the United Nations’s Sustainable Develop-
ment goals the revision of the Ottawa Dec-
laration deserves highest attention.
Elicien Ishimwe,
Medical Doctor,
Ministry of Health, Rwanda
E-mail : ielicien@gmail.com
Otmar Kloiber,
General Secretary,
World Medical Association
E-mail: otmar.kloiber@wma.net
Keqin Rao Yongmao Jiang Weili Zhao
CMA Thousand Talents Cultivation
Program for County Hospitals
CHINA
29
BACK TO CONTENTS
Health Care
I. Going Down to
Grassroots to Offer Help –
Popularization of Medical
Sciences and Technologies
In 2017, the “Thousand Talents Program”
invited a total of 223 experts (205 associate
seniors or higher and 18 PhDs) to popu-
larize sciences and technologies in 7 prov-
inces, 13 prefecture-level municipalities,
13  counties and 34 hospitals, with ward-
round teaching, surgery teaching and gra-
tuitous treatment for the rank and file serv-
ing as a platform for study, communication
and sharing among grassroots doctors. In
this way, the “Thousand Talents Program”
set up a bridge of partnership between
grassroots hospitals and major hospitals.
8 events conducted in the year attracted a
total of 4914 participators, with 4800 cop-
ies of data compilations issued gratuitously
and downloads of the electronic version
reaching 7149.
In addition, some CMA branches secured
funds from other sources or used their own
funds to conduct special training courses
much needed by grassroots units or pover-
ty-stricken areas. In 2017, CMA’s pathol-
ogy branch conducted the “West Bound”
pathology training course in 2017 to teach
165 trainees gratuitously; the anaesthesiol-
ogy branch offered the clinical anaesthesia
guide training course; and the paediatrics
branch launched the 11th
Paediatricians’
Lecture Tour in West China, etc.
II. Ushering in Grassroots
Medical Staffs for Training –
Further Education and Training
for Grassroots Doctors
In 2017, CMA organized two batches of
core-member doctors totalling 207 from
county hospitals in 10 provinces to receive
a 5-month professional training at 37 pro-
vincial Class-A tertiary comprehensive hos-
pitals with a view to improving their abili-
ties in standard diagnosis and treatment of
common and frequent diseases, which pro-
vided a personnel support for reducing the
referral rates from counties.
10 provinces, including Guizhou, Sichuan,
Gansu, Qinghai, Jiangxi, Shaanxi, Hubei,
Yunnan, Henan and Hunan, were chosen
for the pilot project. The provinces were
a linked aggregation of destitute areas as
listed by Poverty Relief Office of the State
Council, highlighting the requirement of
improving health conditions for poverty-
stricken areas.
The trainees came from 177 hospitals,
91.7% of which were county hospitals or
hospitals at the county level (trainees from
impoverished counties made up 32.27%,
and those from poor cities accounted for
7.73%) while 5.8% were prefecture-level
hospitals. The trainees were all honoured
with the professional title of attending doc-
tor or higher and had an educational back-
ground of college degree or above. Two-
thirds of the trainees were less than 40 years
old and signed the letter of commitment to
promise return to their original units after
training to serve continuously at the grass-
roots level. The pilot project accorded with
the sanitation and health work guideline of
the new era and observed the “Enhancing
Grassroots”spirit stressed in the medical re-
form and complied with the requirements
of establishing and perfecting the mecha-
nism for conducting further education
among grassroots health workers as well
as training among core-member doctors of
county hospitals as are put forward in the
National Health and Family PlanningTalents
Development Plan for the 13th
Five-Year Plan
and the National Health and Family Plan-
ning Professionals Training Plan for the 13th
Five-Year Plan.
The training related to 12 specialties, of
which 76% were about gynaecology and
obstetrics, paediatrics, intensive care medi-
cine, emergency medicine, anaesthesiology,
psychiatric medicine, etc., which are much-
needed specialties underscored in the Na-
tional Health and Family Planning Talents
Development Plan for the 13th Five-Year
Plan.
To ensure the quality of the further educa-
tion and training, CMA signed entrusted
orientation training agreements with the
said 37 Class-A tertiary comprehensive
hospitals and appropriated training funds
directly to the hospitals to entrust them to
cultivate the trainees and issue qualification
certificates to the eligible after the training.
Apart from entrusting provincial medi-
cal associations to guide and appraise the
training work in their provinces, CMA also
organized a supervising team composed of
10 famous experts in paediatrics,gynaecolo-
gy,intensive care medicine,ultrasonic medi-
cine and medical pedagogy to launch inten-
sified inspections from Sep. 21st
through
22nd
, 2017 in Sichuan where trainees were
relatively concentrated. The experts went to
Sichuan Maternal and Child Health Hos-
pital and Chengdu First People’s Hospital,
where they made on-site inspection over
the implementation of the training system
by the hospitals. In the meantime, the ex-
perts offered ward-round guidance and
conducted case discussion and academic
lectures, etc. CMA also invited representa-
tives of medical associations of other 9 pilot
provinces to constitute a research group to
watch live demonstrations and make work
discussions to enhance the implementation
of the training quality requirements and the
overall progress in the provinces.
CMA has formulated its “2018–2020 Work
Plan for Health Poverty Alleviation Proj-
ects”. In the future, CMA will conduct its
health poverty alleviation work more ac-
curately, give more play to its advantages,
adhere to the problem-oriented and de-
mand-oriented principles, improve its par-
ticipation and input efficiency and effective-
ness in poverty alleviation work, and make
its due contributions to the construction of
a “Health China”.
CHINA
30
Medical Esperanto
Esperanto
Ludwik Lejzer Zamenhof (1859–1917),
a Polish ophthalmologist, descendant of
a family of language teachers, published
his first book about the international lan-
guage after years of diligent preparation in
1887 [1]. He did so under the pseudonym
Doctor Esperanto – the doctor who hopes,
and Esperanto was soon adopted as the
name of the constructed language itself.
Esperanto,Bridge of Words [2],was designed
to be easily learned in much less time than
ethnic languages. Word roots are taken
from European languages; so many learners
will recognize them. There are no irregular
forms, and an appropriate word can easily
be created from a known stem by using a
logical set of prefixes and suffixes. Given
its regularity, no exceptions, language pro-
ficiency in Esperanto can be achieved via
the internet or smartphone app. There is a
well-established method of teaching Espe-
ranto to groups of people who do not have a
language in common, the so called Czech-
method [3].
Background Information:
A brief introduction to the
Chinese Medical Association
The Chinese Medical Association (CMA)
is a non-profit national academic organi-
zation in China. It is an important social
force in the development of medical science
and technology and a linkage between the
government and the medical professionals.
Established in 1915, the CMA now has
88 specialty societies and 667,000 members
in China.
Major Functions of the CMA include: de-
veloping domestic and international medi-
cal academic exchange activities; discover-
ing, recommending and cultivating medical
talents; editing and publishing 184 medical
and popular science journals including print
and electronic, books and over 2,000 audio-
visual products; carrying out continuing
medical education projects and training
specialists; implementing medical project
evaluation and review and as well as science
and technology decision-making demon-
stration; selecting and presenting awards for
outstanding achievements in medical sci-
ence and technology; promoting transfor-
mation and practical application of medical
research results; disseminating medical and
health knowledge for the general public; or-
ganizing technical appraisement on medi-
cal malpractice and AEFI (Adverse Events
Following Immunization); undertaking the
functions and missions entrusted by the
government, and relaying suggestions and
requests from the medical professionals to
the government.
The current 25th
CMA council was elected
in December 2015, with HAN Qide and
CHEN Zhu as CMA Honorary Presi-
dents, ZHONG Nanshan and BA Denian
as CMA Consultant, and MA Xiaowei as
CMA President. The Vice President and
Secretary General is Dr. RAO Keqin.
Keqin Rao, Vice President & Secretary
General, Chinese Medical Association
Yongmao Jiang, Director, Dept. of
International Relations & Publishing
House, Chinese Medical Association
Weili Zhao, Program Manager,
Dept. of International Relations,
Chinese Medical Association
E-mail: cmazhaoweili@163.com
Universal Medical Esperanto Association
31
BACK TO CONTENTS
Medical Esperanto
According to reasonable estimates, there are
about 2 million Esperanto speakers today
[4]. They are well connected via interna-
tional networks and the Universal Esperan-
to Association (UEA),founded in 1908,has
a network of 1669 delegates in 102 coun-
tries [5]. The traditional close connection
of Esperanto speakers is enhanced by the
internet and there is a Smartphone app that
locates nearby Esperanto speakers [6].
The UNESCO resolution of Montevideo in
1954 (Resolution IV. 4. 422-4224) recom-
mended that the Director-General of UNES-
CO follow current developments in the use of
Esperanto.In 1977,the Director-General vis-
ited the World Esperanto Congress in Reyk-
javík,Iceland,and in 1985 UNESCO passed a
resolution recommending that member coun-
tries encourage the teaching of Esperanto.
In the 130 years of its history, Esperanto has
produced a rich culture and extensive,diverse
literature. The language is pleasantly sound-
ing and can express intricate thoughts and
feelings with structural simplicity. Its exten-
sive literature includes poetry, novels, history,
science, including dramas and films original-
ly produced in Esperanto. The language has
proved to be suitable for scientific exchange
as well. The Red Cross supported the use of
Esperanto in its humanitarian missions [7].
Brief History of the Universal
Medical Esperanto Association
Doctor Ludwig Zamenhof was followed by
many other physician-pioneers in the bur-
geoning Esperanto movement. At the 4th
Esperanto World Congress, 1908, Wilhelm
Róbin, a Polish doctor, proposed a medical
association, subsequently founded as the
Tutmonda Esperantista Kuracista Asocio
(TEKA: Worldwide Association of Espe-
ranto-speaking Physicians). Róbin edited
the medical Esperanto journal Kuracisto
(Physician) and gained the support of sev-
eral influential opinion leaders.
Róbin also helped prepare the Encyclopaedia
of Esperanto and was an important figure in
his country. As early as 1893 in Warsaw he
founded one of the first Esperanto groups.
The first president of TEKA was Dr. Henri
Dor (1835–1912), a famous Swiss oph-
thalmologist. He spoke eleven languages
fluently and propagated Esperanto among
scientists. The first yearbook of TEKA was
published in 1909 with a preface by Za-
menhof himself. It contained the addresses
of 19 national delegates, 41 representatives
in big cities and 428 members.
During the great international medical con-
gress in Budapest (1910) TEKA organized
a successful Esperanto session. World War
I considerably disrupted the activities of
TEKA, but by 1923 they were effectively
resumed. Hungarian
colleagues took the
initiative (Kalocsay,
Mezei, Sós, and later
Bulyovszky). Other
notables included
Prof. Dr. Odo Bu-
jwid (1857–1942),
a Polish bacteri-
ologist who studied
with Koch in Berlin
(1885) and Pasteur
in Paris (1886), an
honorary member of
TEKA since 1927.
Prof.Dr.J.Vanverts,a French gynaecologist,
was editor-in-chief of the Internacia Medic-
ina Revuo (International Medical Review)
for many years. This journal has been pub-
lished in Esperanto from 1923 on.
Dr. Paul Kempeneers (1895–1979), a Bel-
gian physician, orthopaedic surgeon, worked
selflessly forTEKA as a chief secretary.Max-
imilian Blassberg, a Polish doctor (1875–
1939), was an outstanding activist in the
medical Esperanto movement and president
of TEKA for two years. An important mile-
stone was the first comprehensive Esperanto
Dictionary of Medical Technical Terms, edited
by Maurice Briquet (1865–1953), a French
physician, in 1932. Briquet was also the edi-
tor of the TEKA-Review for several years.
After World War II, the centre of Espe-
ranto medical activities shifted to Japan. Dr.
Suzuki, professor at the University of Tiba,
became the editor of the Review. Before
and after the 40th World Congress of Espe-
ranto (1955) the Japanese gynaecologist and
Esperantist Dr. Hideo Shinoda presented
his recently developed surgical techniques
in the United States and several European
countries; Esperanto was used for interpre-
tation. Following the proposal of Dr. Shi-
noda at the World Congress of Esperanto
in 1961, TEKA members unanimously de-
cided to change the name of the association
to Universala Medicina Esperanto Asocio
(UMEA, Universal Medical Esperanto
Christoph Klawe
Participants of the TEKA founding convention in 1908
32
­
Association).UMEA subsequently was lead
by Japanese professors Hideo Yagi, Masao
Suzuki, Hideo Shinoda and Seiji Kato.
The Hungarian physician Imre Ferenczy took
over the presidency from Seiji Kato in 1984
and, in office until 2012, substantially shaped
the character of the association [8]. The
Czech Dr. Eva Kopecna had served as presi-
dent of the UMEA for two years, when the
author of these lines succeeded her and the
head office was transferred to Trier,Germany.
Medical International Review
UMEA started publishing its own journal
in 1923. It contained medical research and
case reports written entirely in Esperanto.In
1964 the journal was renamed Medicina In-
ternacia Revuo (MIR, Medical International
Review). After moving from Budapest to
Lille and Tiba,from 1994 on,MIR has been
published in Krakow, Poland, in print and as
an open access biannual journal [9].
As the number of authors able to submit
worthy articles in Esperanto has diminished
over the years due to the changing fate of
the Esperanto movement itself, the editors
decided to accept articles in other languages
as well. If the article is not in Esperanto, the
editors either provide an abstract in Espe-
ranto or, on demand, translate the whole
article. With his language policy MIR can
give a voice to those who lack access to the
English speaking medical community.
In December 2015, MIR was included in
the list of scientific B-journals according to
the ranking system of the Polish Ministry
of Science and Higher Education. Publica-
tions in B-journals are acknowledged for
the academic careers of Polish scientists
[10]. MIR is not listed in the indexes of
the US National Library of Medicine or
Scopus, not so much because of the lack of
quality but because the peculiar language
policy did not seem appealing to the re-
viewers. The contents of MIR can easily be
found, however, in Google Scholar.
The Universal Medical
Esperanto Association today
UMEA now has members in 19 countries
and special chapters of general medicine,
rehabilitation, neurology, ophthalmology,
psychiatry, psychotherapy, endocrinology,
paediatrics, cardiology, infectious diseases,
physiotherapy, Traditional Chinese Medi-
cine, neuropsychology, pharmacology, even
veterinary medicine, and the traditional
Japanese massage technique Yumeiho.
Since 1977 UMEA has held a conference
of Esperanto speaking physicians every sec-
ond year (IMEK, Internacia Medicinista
Esperanto-Konferenco), which usually at-
tracts 30–200 participants, and less formal
international Skype-conferences for Espe-
ranto speaking doctors now and then.
UMEA honors outstanding protagonists in
the sphere of Esperanto in medicine with the
prestigious UMEA-
Shinoda-Award.
UMEA uses the
Twitter-account @
UMEAeo to be ac-
tive in social media.
UMEA can support
all who need to estab-
lish a common means
of communication in
multinational groups
rapidly, as may happen with humanitarian
crises.
UMEA continually proves that Espe-
ranto can be effectively used in medicine.
Thanks to excellent networking between
international Esperanto speakers, UMEA
can effectively convey important medi-
cal information to the Esperanto speaking
community, as happened on the occasion of
the Ebola and Zika epidemics. UMEA has
ready access to the estimated two million
Esperanto speakers and is willing to sup-
port such international health organizations
as WMA and WHO.
References
1. Zamenhof L L. Internationale Sprache. Vorrede
und vollständiges Lehrbuch. Warschau: Ge-
bethner et Wolff; 1887
2. Schor E. A Bridge of Words. New York: Metro-
politan Books, Henry Holt and Company; 2016
3. Internacia Esperanto-Instituto, editors. Baza
Cseh-Kurso kun metodikaj konsiloj. Den Haag:
Internacia Esperanto-Instituto; 1992
4. Wandel A. How many people speak Esperanto?
Or: Esperanto on the web Interdisciplinary
Description of Complex Systems, 2015;13 (2),
318-321.
5. Universala Esperanto Asocio, editors. Jarlibro
2017, 109-249.
6. Wikipedia. https://en.m.wikipedia.org/wiki/Amikumu
7. The Esperantist Movement’s humanitarian ac-
tivities in the two World Wars and its relation-
ship with the International Red Cross. https://
www.icrc.org/eng/resources/documents/article/
other/57jn53.htm
8. Ferenczy I: Esperanto kaj medicino. In: Blanke
D, Lins U, editors. La arto labori kune. Rotter-
dam: Universala Esperanto-Asocio; 2012.
9. Homepage of the Journal of UMEA. http://in-
terrev.com/mir/index.php/mir
10. Journal Ranking of the Polish Ministry of Educa-
tion.http://www.nauka.gov.pl/g2/oryginal/2015_
12/6a011a7e5df2bc88abdea880d7f3a863.pdf
Dr. Christoph Klawe,
President of the Universal Medical
Esperanto-Association
Department of Neurology
and Neurophysiology
Hospital of the Brothers of Charity, Germany
E-mail: umea@uea.org
Participants of the 20th
IMEK, Nitra, Slovakia, 2016
Medical Esperanto
33
BACK TO CONTENTS
Professional Competence
Background
Across the health professions, there is sig-
nificant interest in maintenance of com-
petence [1]. It is an issue for regulators,
practitioners, educators, employers, policy
makers – and most of all, for the patients
who rely upon the knowledge and skills of
their care providers [1, 2, 3 ]. While there
are no universally applicable definitions for
“competence”, most stakeholders agree that
facets of competence include an ability to
remain up-to-date with developments in
one’s profession, and a fitness-to-practice
at a level commensurate with one’s peers
[3, 4]. In attempt to systematize thinking
about competence many regulators and ed-
ucators have turned to the use of standards
of practice or competence statements as a
vehicle for articulating a profession’s base-
line minimum competence expectations of
practitioners in the field [5]. In many ju-
risdictions, there are requirements in place
for practitioners to complete a minimum
number of continuing education hours
or units each year as a proxy measure for
demonstrating maintenance of competence
in the field (despite the fact that there is
no compelling evidence supporting this
approach as an effective tool for this pur-
pose) [4. 5]. The measurement of compe-
tence through standardized metrics (such
as the use of objective structured clinical
examinations or well-constructed multiple
choice questions) has become a mainstay
of professional education and regulation –
yet concerns exists as to whether the time,
effort and money invested in these ap-
proaches actually supports maintenance of
competence or simply encourages practi-
tioners to jump through regulatory hoops
on a semi-regular basis [4, 5, 6]. In some
fields, there is increasing use of self- and
peer-assessment models, triangulated with
practitioner-specific outcomes data that
have shown promising results in terms of
professional development; this “360 degree
review” approach may be effective, but is
logistically cumbersome and very costly,
limiting its applicability in most health care
professions [7, 8].
Framing Competence
Historically, our understanding of compe-
tence has been as a binary: one is EITHER
competent or incompetent. Only these two
states exist, and practitioners must dem-
onstrate they belong to the former, rather
than the latter, category [9]. Measurement
of competence through standardized test-
ing further reinforces this binary view of
competence: one either “passes” tests or
“meets” standards, or one “fails” them or
“falls below” standards [6]. While such
binary thinking may be marginally more
acceptable within an educational context
in which students are proving their bona
fides, it becomes problematic when applied
to practitioners who may have had years
or decades of experience delivering care to
patients and communities. A binary model
when applied to an experienced practitio-
ner suggests there is a bright line between
the two states of “competent” and “incom-
petent”that may be confidently articulated,
measured, and defended.
Hodges and Lingard, quoting Burke, have
noted that “every way of seeing is also a
way of not seeing” [6]. If we define prac-
ticing physicians and other health care
professionals using binary terms such as
“competent and “incompetent” what are
the consequences, and what opportunities
may we be missing? From the perspective
of most practitioners, competence is not an
either-or phenomenon, and labelling it as
such can be profoundly counterproductive
in motivating individuals to maintain and
enhance their professional skills over a life
time of practice. Simply put, how can we
understand the process by which a physi-
cian – who has worked hard her whole life
to first gain entry to a highly competitive
medical school, who then sacrificed greatly
to get through the gruelling 8–10 years of
undergraduate and post-graduate education
and training, and then who chooses to take
one of the most demanding jobs in soci-
ety – would allow herself to become incom-
petent? Framing competence as a binary
suggests this physician made bad choices
and decisions that led to her current state…
and most of what we understand about
human psychology and motivation sug-
gests that this simply does not make sense.
The vast majority of physicians are smart,
well-intentioned, caring individuals who
selected this profession to apply their skills
and talents in a way that would help their
societies and communities. By what process
would such smart, well-intentioned, caring
individuals “allow” themselves to become
incompetent? And does the threat of being
labelled incompetent, the use of standard-
ized testing mechanisms, or the require-
ment for compulsory continuing education
actually change an individual’s choices and
behaviours?
Zubin Austin
Competence Drift in Professional Practice:
a Psychological Perspective
CANADA
34
Professional Competence
Alternatives to either-or
models of competence
Recently, there has been interest in “see-
ing” competence in a different way – not as
a psychometric or measurement issue, but
instead as a psychological issue reflective of
lived human experience [6, 9]. While there
is an abundance of literature examining the
reliability and validity of competence assess-
ment instruments and approaches (5)(6)(9),
there is very limited literature examining the
experiences of physicians who have failed:
individuals who have been labelled by their
profession as “incompetent” or who have
had their registrations suspended or revoked.
How did these smart, well-intentioned and
caring individuals end up this way? Beyond
caricatures of predatory individuals or sub-
stance-abuse problems, how does one move
from competence to incompetence without
first drifting through an intermediary state (a
middle ground) of being somewhat compe-
tent? And what is in place to support indi-
viduals who (for whatever reason) find them-
selves in this intermediary state to help them
regain their fullest competence?
Competence Drift in the
Health Professions
Recently, we published a study examining
the psychological dimensions of competence
within the context of another profession  –
pharmacy [10].This study explored the lived
experiences and deterioration experienced
by pharmacists who had been labelled by
their regulatory body as “incompetent”.
Longitudinal interviews [11, 12] with these
individuals highlighted that, from their per-
spective, competence is not a binary: they
did not wake up one day and suddenly find
themselves incompetent, nor did they (for
the most part) maliciously or intentionally
choose to become incompetent. Instead, for
participants in this study, the voyage from
competence to incompetence was character-
ized as a slow drift, a series of imperceptibly
small problems which over time became im-
possible for them to address by themselves.
While in some cases, incompetence was the
result of wilful decisions (e.g. choosing to
defraud an insurance plan), the majority of
participants were labelled as incompetent be-
cause of their performance on a compulsory,
standardized assessment that was part of the
annual registration/licensure renewal process
for pharmacists. These practitioners – with a
mean of 26 years clinical experience (range of
9–33 years) were deemed psychometrically
incompetent due to their performance on a
required and standardized objective struc-
tured clinical examination and a case-based
multiple choice test [13], not because of a
complaint or disciplinary procedure.
The competence drift experienced by these
individuals had several important char-
acteristics. First, there were demographic
factors that may highlight who is a risk for
competence drift: those in practice 25 years
or more, those who worked in sole practice
settings without benefit of peers, and those
who were internationally educated (i.e. re-
ceived their formative education and clini-
cal training outside the United States or
Canada) appeared to have a higher risk for
being labelled incompetent by their regula-
tory body [10,13].Second,the vast majority
of these individuals had no prior history of
complaints or disciplinary issues with the
regulator; their competence drift was only
identified through the test that was admin-
istered as a compulsory requirement as part
of an annual license/registration renewal
process [13]. Third – and perhaps most rel-
evant – all of the individuals interviewed for
this study highlighted the impact of pro-
fessional isolation on deterioration of their
skills,even though the majority of them had
complied with relevant continuing educa-
tion or other requirements.
A common denominator for participants in
this study was the notion of isolation and
disengagement from their profession. Those
who were internationally educated individu-
als noted that they never felt they truly “fit
in” the professional community as they were,
from the start of their careers, outsiders to
the schools and pre-existing professional and
alumni networks that characterize profes-
sional life. Those who worked in sole-prac-
titioner settings noted that they were in the
unenviable position of never actually seeing
a peer do their job, and never having the op-
portunity to actually benchmark themselves
against a colleague. Those who had been in
practice 25 years or longer noted how much
the foundations of practice had changed in
those years, particularly society’s and pa-
tient’s expectations of what a professional
is and should be – the professional was no
longer a trusted expert, but instead simply a
vehicle to do whatever the patient wanted (as
opposed to actually needed).
The Psychological Dimensions
of Competence Drift
Competence does not switch on and off
quickly – instead, participants in this study
reported increasing anxiety, decreasing self-
confidence,and diminishing interest in their
job as a slow-and-steady precursor to finally
being labelled incompetent by their regula-
tor. With professional isolation, there was
no obvious person they could ask for help,
without disclosing their deficits. Without
a person or organization to reach out to,
these individuals felt further marginalized
and disengaged from their profession. This
study highlighted that competence drift
may be a decade`s long process or deterio-
ration, one with early warning signs that, if
addressed, perhaps could have led to a dif-
ferent outcome for these individuals.Rather
than “see” competence as a binary defined
by psychometric properties related to tests
and assessment methods, if we view com-
petence as a psychological process in which
individuals are unconsciously decoupling
from their professional community, perhaps
there are opportunities to prevent this drift
from becoming permanent.
Across all participants interviewed, a com-
mon theme emerged: disengagement as
CANADA
35
BACK TO CONTENTS
Professional Competence
the root cause of competence drift [14, 15].
A psychological unfettering from one’s pro-
fession, one’s professional colleagues and
community and ultimately one’s patients
were characteristics shared by all those who
were ultimately found to be incompetent.
Importantly, for most of these individu-
als there was no actual documented harm
cause to patients: there were no complaints,
no discipline or legal cases, and no evidence
that they had done anything wrong. Yet
when it came time to actually “prove” con-
tinuing competence using psychometric
standardized tests, they were unable to do
so. Interestingly, after the fact, most of the
participants admitted they’d known for years
they were sub- or incompetent, but were so
psychologically disengaged by this point
they had insufficient energy to overcome
the inertia of simply carrying on doing what
they’d always done.Many participants noted
that bureaucratic regulatory requirements –
ranging from compulsory continuing educa-
tion attendance to maintenance of a learn-
ing portfolio, to completion of standardized
competence assessment tests – all contrib-
uted to this competence drift, as they were
seen as simply hurdles to be cleared and not
valuable opportunities to reengage profes-
sionally with their field or their community.
While this study in one profession may
have limited direct applicability to other
fields because of the unique way in which
“incompetence” was measured and defined,
there may be lessons that could be of rel-
evance to all health care professions. First,
competence is not an either-or state,it is not
a binary. Competence is a continuum and
competence drift is a years- or decades-long
process. Along this continuum there may
be warning indicators and red flags  – for
example, demographic risk factors; rather
than focus on maintenance of competence
as a series of proxy requirements (e.g. com-
pulsory continuing education), we would be
advised to focus on these early warning in-
dicators and intervene in a supportive way
sooner.Second,a core feature of competence
drift appears to be disengagement  – from
colleagues, from the profession itself, and
ultimately from patients. Psychological dis-
engagement deprives an individual of the
energy and motivation required to actually
address competence drift on his/her own.
At a certain point, a disengaged individual
simply cannot see the problem or help him/
herself and will require some external sup-
port to see them through to a more positive
outcome. Unfortunately, after graduation
and registration as a health care professional,
there are few opportunities for a practitioner
in competence drift to actually reach out to
find such help; to whom can a disengaged,
disconnected physician turn if s/he sus-
pects s/he is experiencing competence drift?
Regulators are not to be trusted due to their
obligations to protect the public; disengaged
individuals likely do not have peers or con-
fidantes within the profession they can turn
to and admit the need for help [15]. Con-
tinuing education has been demonstrated
to have very limited value (if any) in lead-
ing to practice change. Third, psychological
disengagement becomes a vicious down-
ward spiral [15]; as competence continues
to deteriorate, disengagement becomes even
more of a survival and coping mechanism.
Fourth  – and perhaps most importantly  –
this vicious downward spiral is rarely if
ever a conscious choice or decision made by
the practitioner, and it may accelerate over
time, making it even more difficult to stop
the descent. Fifth, our current practices and
approaches within medical regulation and
education  – while well-intentioned  – may
actually be paradoxically contributing to this
downward spiral. In the name of public pro-
tection, we may be using concepts, tools and
approaches that actually further irritate, iso-
late, and ultimately disengage practitioners
from their profession. For example, fram-
ing competence as a binary concept (as we
currently do) deprives practitioners of a vo-
cabulary to describe their lived experience of
competence drift. Requiring practitioners to
“prove” they are competent may not actually
improve practice and enhance competence
if it is interpreted as simply a hoop to be
jumped through and bureaucratic require-
ment enforced by those who do not realize
how challenging day-to-day patient facing
work actually is in today’s environment.
Conclusions
We need to “see” competence in a different
way, one that is more psychologically nu-
anced and recognizes that physicians and
other health care professionals are actually
like all other human beings. By seeing com-
petence as a continuum,not a binary, and by
recognizing that the psychological energy
required to maintain competence comes
from engagement with one’s profession, not
mandatory continuing education, we may
have opportunities to prevent small prob-
lems from becoming bigger ones. When
we see competence drift as a psychological,
rather than psychometric, issue, new oppor-
tunities open for providing support and re-
mediation in a more targeted and more nur-
turing manner. Psychological engagement
in one’s profession  – a feeling of positive,
energized connection to colleagues,the field
itself, and the patients we serve [15] – needs
to be researched further as an inoculation
to competence drift. In so doing, perhaps
we will find alternative ways to intervene
in competence drift before small problems
become big ones.
References
1. Epstein R and Hundert E. Defining and as-
sessing professional competence (review). J Am
Med Assoc. 2002;287(2): 226–236.
2. Ibrahim J. Continuing professional develop-
ment: a burden lacking educational outcomes
or a marker of professionalism? Med Educ.
2015;49(3):240-242.
3. Kane M.The assessment of professional compe-
tence, Eval Health Prof. 1992;15 (2):163-182.
4. Kogan J, Holmboe E and Hauer K.Tools for di-
rect observation and assessment of clinical skills
of medical trainees: a systematic review. JAMA
2009;302(12):1316-1326.
5. Accreditation Council for Graduate Medical
Education (ACGME) and American Board
of Medical Specialties (ABMS).  Toolbox
of Assessment Methods v1.1 – September
2000.  Accessed at:    https://www.slideshare.
CANADA
36
Health Care
Healthcare is essential in the growth of any
country though with its challenges. This article
examines healthcare services and workforce in
rural communities in Nigeria. This is a review
article. Search for previous articles written on
health care in rural Nigeria was done using
Google, PubMed and Medline to search for
articles on healthcare in rural areas, develop-
ing countries and Nigeria. There is dearth of
health care in Nigerian rural areas due to lack
of career opportunities, lack of basic amenities,
lack of training opportunities and fate in tra-
ditional medicine.
Health is the most significant ingredient
to life [1] and the quality of health in any
state or country is the fundamental right of
its citizens [2].This means that a healthy na-
tion is made up of healthy citizens. In Ni-
geria a large percentage of the population
reside in rural communities hence they are
also entitled to good healthcare facilities [3].
Providing equitable access to healthcare be-
comes an indispensable imperative to achiev-
ing wellbeing [4] . Compared to inhabitants
in Nigerian urban areas, people that dwell in
rural and remote areas experience a lower life
expectancy and poor health status [5]. Gen-
erally, Nigeria has a high population density
but a weak healthcare system [6]. Therefore,
access to healthcare should be near to where
the people live as much as possible [7]. The
health sector is labour intensive as it requires
different professionals and precise applica-
tion of knowledge to deliver quality service
[8]. Good public health is vital in any coun-
try not only for the purpose of maintaining a
healthy populace but also as a matter of na-
tional security [1].
Healthcare in Nigeria
Healthcare in Nigeria is provided by both
the government and private health facilities
though some individuals still practice tradi-
tional medicine in the use of herbs and oth-
er traditional materials. The practitioners
of this traditional medicine are herbalists,
traditional bone setters, traditional birth at-
tendants, spiritualists and faith healers. The
spiritualist and faith healers use religion and
conduct sacrifices as part of administering
traditional healthcare to people that patron-
ize them. In Nigeria today, the provision of
healthcare facilities seems to be at low ebb
as many Nigerians are vulnerably exposed to
death [1]. The healthcare facilities in Nige-
ria are three-tier,the primary,secondary and
tertiary healthcare facilities [9].The primary
healthcare centres and health posts provide
primary health care services, the general,
district and cottage hospitals provide sec-
ondary healthcare services while the teach-
ing hospitals, federal medical centres and
specialists’hospitals provide tertiary health-
care services [9]. The tertiary health care
providers receive referrals from the primary
and secondary healthcare providers.
Workforce of Healthcare Professionals
in Rural Nigeria
Buowari, Dabota Yvonne
net/pedgishih/toolbox-of-acgme-assessment-
methods on August 8 2018.
6. Hodges B and Lingard L, (Eds.) (2012). The
Question of Competence: Reconsidering Medi-
cal Education in the Twenty-first century. ILR
Press; Ithaca NY.
7. Sargeant J, Mann K, Sinclair D, van der Vleuten
C and J. Metsemarkers J. Challenges in multi-
source feedback: intended and unintended out-
comes. Med Educ. 2008; 42 (10): 1107-1113.
8. Smither J, London M and Reilly R. Does per-
formance improve following multisource feed-
back? A theoretical model, meta-analysis, and
review of empirical findings, Person Psychol.
2005; 58:33-66.
9. Eva K and Regehr G. “I’ll never play professional
football” and other fallacies of self-assessment, J
Continuing Educ Health Prof.2008;28 (1):14–19.
10. Austin Z and Gregory PAM. The role of disen-
gagement in the psychology of competence drift.
Res Social Admin Pharm 2018 Feb 27.Accessed
at: https://www.sciencedirect.com/science/arti-
cle/pii/S1551741117307775?via%3Dihub
11. Kratochwill T and Levin J (2014). Single-case
Intervention Research: Methodological and
Statistical Advances. American Psychological
Association Press.
12. Kratochwill T and Levin J. Enhancing the sci-
entific credibility of single-case intervention
research: randomization to the rescue. Psychol
Meth. 2010; 15 (2): 124–144.
13. Austin Z, Marini A, Croteau D and Violato C.
Assessment of pharmacists’ patient care compe-
tencies: validity evidence from Ontario (Cana-
da’s) quality assurance and peer review process.
Pharm Educ. 2004;4 (1);23–32.
14. Csikszentmihalyi M (2008). Flow: The Psychol-
ogy of Optimal Experience. Harper Perennial
Modern Classics New York NY.
15. Schon D (1983). The Reflective Practitioner:
How Professionals Think in Action. Basic Books
New York NY.
Zubin Austin, BScPhm, MBA,
MISc, PhD, FCAHS
Professor and Koffler Chair in Management,
Leslie Dan Faculty of Pharmacy,
University of Toronto Canada
Paul AM Gregory, BA, MLS
Research Associate, Leslie Dan Faculty of
Pharmacy, University of Toronto Canada
NIGERIA
37
BACK TO CONTENTS
Health Care
The Nigerian government has made nu-
merous great efforts in providing health-
care facilities for its citizens especially in
the establishment of primary healthcare
centres in Nigerian rural communities [10].
The private hospitals are usually expensive
and mostly located in the urban areas hence
individuals use their digression to choose
which health facility they wish to receive
healthcare.
In a study conducted in rural communi-
ties in Kogi State, Nigeria, results from
the study suggested that distance to im-
proved health facilities and the total costs
of seeking healthcare needs to be reduced
to enhance accessibility to improved health
services by various socioeconomic groups
[10]. Many countries are striving to keep
pace with healthcare delivery because the
sustainability and viability of any country’s
economic and social growth depends on the
healthcare sector as a nation of sick people
would certainly not live up to its basic re-
sponsibilities [1].
Healthcare Professionals
in Nigeria
The healthcare workforce is made up of
health workers which include all the people
involved in the promotion, protection or
improvement of the health of the popula-
tion which play a very important role in
achieving an effective healthcare delivery
system [11] The healthcare system requires
a large number of health workers [8] to ad-
dress the health needs such as the doctors,
nurses, laboratory scientists, physiothera-
pists, medical technologists, medical tech-
nicians and others. The healthcare work-
force is an important guide and indicator
of the strength of the health system and
also the quality of healthcare in a coun-
try. Though there is shortage of healthcare
workers in Nigeria [11], there is too much
concentration of medical personnel in the
urban areas than in the rural communities
[2]. Generally graduates both in medical
and non-medical professions prefer to work
in the urban cities [7] where there are better
amenities such as pipe borne water, electric-
ity, telecommunication, career advancement
opportunities, good schools, accommoda-
tion and communication problems if they
do not understand the local language.
Therefore retention of healthcare workers in
these rural communities is a challenge [13].
The inadequacy of medical doctors, nurses
and midwives across Nigeria in 2016–2030
is not likely to change and this would not
likely affect the health indicators over the
same period since healthcare workers force
play a critical role in strengthening health
system of any country [11].
Healthcare in Rural
Areas in Nigeria
A healthy country is a wealthy country as
its citizens are useful resources that will
be involved in useful investments in order
to move the nation to greater heights [1].
Most rural Nigerian communities do not
have access to healthcare. Sometimes there
are health facilities either primary or sec-
ondary healthcare facilities but the service
is not utilized by the inhabitants. There are
different reasons for this. While primary
healthcare centres (PHC) are relatively
uniformly distributed throughout the local
government areas (LGA) in Nigeria, the
rural people tend to underuse the service
[2]. The availability of basic health services
provided by the primary healthcare centres
especially to rural areas in a country might
be used as a yardstick to measure the extent
of its level of development of healthcare [2].
Adequate and equitable distribution of
healthcare facilities in rural areas is critical
to human capital development [10]. Before
the establishment of these health facilities,
most residents in Nigerian rural settlements
depended on traditional health services, but
presently there exists a variety of healthcare
services in Nigeria [14]. Though the pri-
mary healthcare centres were established in
both rural and urban areas in Nigeria with
the intention of equity and easy access re-
grettably the rural populations in Nigeria
are seriously underserved when compared
with their urban counterparts [2].Therefore
the government should encourage public-
private partnership in healthcare delivery at
affordable prices to people residing in rural
areas as is done in the urban areas, as this
would be achieved through the provision of
basic infrastructure such as accessible roads,
electricity etc [10].
Challenges of Healthcare
in Rural Nigeria
There are challenges facing health care de-
livery in rural areas. A large percentage of
the Nigerian population living in rural ar-
eas have been affected with several diseases
with deleterious consequences both on their
health and finance [3] due to the shortage
of healthcare workers in rural areas. There
are many challenges to healthcare in Nige-
rian rural communities.
1. Lack of good roads and other means of
transportation to the health facility:
This transportation problem is a signifi-
cant problem in the management of pri-
mary healthcare centres [2]. In order to
overcome the barrier of distance to the
utilization of healthcare facilities in the
rural communities, government should
establish the primary health centres in
the core rural areas close to where the
people live.
2. Lack of training for healthcare work-
ers: There is lack of training most times
available to healthcare professionals
working in rural areas compared to
those working in the urban for instance
there is no continuous medical educa-
tion/continuous professional develop-
ment for medical doctors in the rural
areas and this is a prerequisite for the
renewal of medical doctors and dentists
practising licence by the Medical Den-
tal and Medical Council of Nigeria. Ac-
ademic isolation has been identified as
NIGERIA
38
Medical Ethics
Introduction
The Icelandic Medical Association was one
of the 27 founding members of the WMA
in 1947 but in October this year the first
constituent WMA meeting will be held in
Iceland. The venue of the General Assem-
bly is the extraordinary music and confer-
ence centre Harpa by the harbour in cen-
tral Reykjavik. For the first time, a two and
a half day conference on medical ethics is
planned replacing the traditional scientific
day. It has been a challenge to organize a
conference in parallel with the obligatory
meetings of the assembly. The last day is
specifically organized around the central
issues of the WMA, based on some of its
most important policies such as the Decla-
ration of Geneva and the Helsinki Decla-
ration. We are hoping for good attendance,
not only by the delegates of the assembly
but by all those working on medical eth-
ics in the respective medical associations
as well as others that are interested in fol-
lowing the dialogue inside the WMA on
medical ethics.
one of the factors that discourage doc-
tors from working in underdeveloped
areas.Training deficiencies is a restrain-
ing factor that needs to be addressed to
enable medical practitioners to deliver
equitable and quality service in district
and cottage hospitals which are located
in rural areas [12].
3. Lack of basic infrastructure in Nige-
rian rural areas: There is lack of basic
infrastructure in the rural communities.
This discourages healthcare workers
from staying at their duty posts when
posted to the primary healthcare centres
and other district, cottage and general
hospitals located in rural areas. These
include lack of electricity, telecom-
munication services, social amenities
and schools for their children. Poorly
equipped and managed hospitals, in-
appropriate training and an excessive
workload are significant contributors to
poor healthcare facilities in rural areas
[15]. Better healthcare in the Nigerian
rural communities could be achieved
through the provision of basic infra-
structure such as accessible roads, elec-
tricity, water, schools and essential drugs
[10].
Healthcare is very important to both resi-
dents of urban and rural areas. There is
shortage of healthcare workers in develop-
ing countries with Nigeria inclusive. Most
of the healthcare workers in Nigeria are
concentrated in the urban communities
where there are better amenities and career
opportunities.There is need for government
to tackle the challenges facing both the de-
livery of healthcare services and healthcare
professionals in the rural areas in order to
encourage all cadres of health workers to
develop interest in working in rural areas.
References
1. Eme OI, Uche AO, Uche IB. Building a solid
healthcare system in Nigeria: challenges and
prospects.Acad J Inter Stud,2014,3 (6),501-510.
2. Abdulraheem IS, Olapipo AR, Amodu MO.
Primary healthcare services in Nigeria: critical
issues and strategies for enhancing the use by
the rural communities. J Pub Health Epid, 2012,
4 (11), 5-13.
3. Udoudo MGM, Umoh GS. Can government
deliver quality rural healthcare? Empirics on
malaria prevention and control in Nigeria. Asian
J Econ Modelling, 2016, 4 (2), 70-81.
4. Omogbadegun Z. Development of a framework
for collaborative healthcare services delivery. In-
ter J Adv Comp Sci Apli, 2013, XXX(No XXX),
1-9, www.ijacsa.thesai.org accessed 2018.
5. Strasser R, Kam SM, Regalado SM. Rural
healthcare access and policy in developing coun-
tries. Annual Rev Pub Health, 2016, 37, 395-
412, www.annualreviews.org
6. Okoli U, Eze-Ajoku E, Oludipe M, Spiek-
er N, Ekezie W, Ohiri K. Improving qual-
ity of care in primary healthcare facilities
in rural Nigeria: successes and challenges.
Health Serv Res Manag Epid, 2016, 1-6, doi.
10.1177/2333392816662581
7. O’Connor B, Bagg W. Encouragers and dis-
couragers affecting medical graduate’s choice of
regional and rural practice locations. Rural Re-
mote Health,2017,17,4247,doi org/10.226051/
RRH4242
8. Adindu A, Asuquo A. Training human resource
for 21st
century Nigerian health sector. Global J
Hum Res Manag, 2013, 1 (3), 1-11.
9. Udoh U, Uyanga J. Housing conditions and
health in rural Nigeria: a study of Akwa Ibom
State. Res Hum Soc Sci, 2013, 3 (18), 34-42,
www.iiste.org accessed 2018.
10. Awoyemi TT, Obayelu OA, Opaluwa HI. Effect
of distance on utilization of healthcare services
in rural Kogi State, Nigeria. J Hum Ecol, 2011,
35 (1), 1-9.
11. Adebayo O, Labiran A, Emerenini CF, Omoruji
L. Health workforce for 2016-2030: will Nigeria
have enough? Inter J Innovative Healthcare Res,
2016, 4 (1), 9-16.
12. Okoli U, Mohammed SA, Ejecka C, Oshin T,
Okigbo A, Ekezie W. Strengthening primary
healthcare services in rural Nigeria: the poten-
tial of using midwives as skilled birth attendants.
Health Systems Policy Res, 2016, 3 (2), 18, 1-7.
13. Obembe TA, Osungbade KO, Olumide EA,
Ibrahim CM, Fawole OI. Staffing situation of
primary healthcare facilities in federal capital
territory Nigeria: implication for attention and
retention policies. Afr J Soc Manag Sci, 2014,
5 (2), 84-90.
14. Efe SI. Healthcare problem and management in
Nigeria. J Geo Reg Plan, 2013, 6(6), 244-254.
15. De Villiers MR, De Villiers PJP. Doctors views
of working conditions in rural hospitals in the
Western Cape. SA Fam Pract, 2004, 46 (3), 21-
26.
Dr. Buowari, Dabota Yvonne,
Riverine Community Medical
Centre, Port Harcourt, Nigeria.
E-mail: dabotabuowari@yahoo.com
International Congress on Medical Ethics,
a Risk Worth Taking?
39
BACK TO CONTENTS
Medical Ethics
The medical ethics
conference (MEC)
At the opening of the conference, WMA
president Yokokura and the Health Minis-
ter of Iceland will address the participants
in addition to the president of the Icelandic
Medical Association and the President of
the conference. Following the opening cer-
emony, the Secretary General of WMA, Dr.
Otmar Kloiber will give an overview of the
history of the WMA. As the conference is
not only for delegates to the Assembly, this
is a very good opportunity to inform of the
activities of the WMA through the decades
since its foundation 71 years ago and the
impact it has had.
Generally, there are two parallel sessions,
most of them organized with a specific
theme, i.e. invited symposia. In addition,
there are two sessions with free oral presen-
tations. The general rule for a symposium
is three presentations at 20 minutes each
and 30 minutes of discussion. This is rather
unusual but it has to be pointed out that
this is not a classical scientific conference,
rather a forum for dialogue and discussions.
Therefore an ample time for discussions is
planned for in each symposium. Another
point worth mentioning is that the last day
is specific for the topics that are central to
the WMA even though all other topics are
important in one way or another.This is the
classical scientific day of a WMA General
Assembly as it has been practiced for de-
cades. The central policy documents of the
WMA such as the Declaration of Geneva
(DoG), the International Code of Medical
Ethics (ICME), the Declaration of Hel-
sinki (DoH) and the Declaration of Taipei
(DoT) will be discussed. Some of them
have recently been revised (DoG and DoT)
but others are in a starting phase of the next
revision (if so decided) such as the ICME
that is very linked to DoG.The most known
policy of WMA, the DoH was revised in
2013. There are now some ideas of changes
that will be discussed at the conference. It
remains to be seen if this will lead to a new
round of revision, it is up to the formal bod-
ies of WMA to decide.
The only social event that is planned for
the participants is the reception at the City
Hall,an event that is for both the MEC and
the GA. In addition our travel agency, the
Iceland Travel is organizing many tours for
the participants.
The web site of the conference is www.
medicalethicsiceland.is
A Facebook page has been created: www.
facebook.com/events/33292879056658
The General Assembly (GA)
The GA will have the usual format, which
is not necessary to describe for the read-
ers of the WMJ. Every location is however
unique and so it is in Iceland. This is the
most northern capital in the world and the
weather can be unpredictable. It will most
likely be around 10°C and hopefully, the
windy season has not begun but that varies
from one year to the next. There might be
opportunities to see the Northern lights as
the autumn is the best time but the visibility
needs to be good.The main hotel is not ad-
jacent to the venue and thus transportation
is provided for. There will be a city tour for
the accompanying persons on Thursday and
the classical half-day tour for all the partici-
pants is scheduled on Friday. On that tour,
the GA members and their accompanying
persons will visit Thingvellir,the area for the
oldest parliament in the world, established
the year 930 and on going since then apart
from 45 years in the early eighteen century.
It is also a very interesting geological area
as it is the most visible rift on land between
Europe and America. The dinner will take
place in a replica of the oldest type of houses
in the country that were built by the settlers
in the 8th
century.
To take a risk
The Icelandic Medical Association is cel-
ebrating its 100 years anniversary in 2018.
There are many special events organized
through the year celebrating the profession,
not only for its work and its contribution
to society but also for other contributions
such as in music and literature as some doc-
tors have been quite influential in these ar-
eas. The GA and the MEC in October is
however the biggest event. There are some
risks taken by organizing the conference.
First of all, it is to some extent parallel to
the GA and that creates some difficulties
and has been criticised. Another risk is on
the finances. The Association is taken full
financial responsibility for the event even
though WMA will contribute with speak-
ers and other support.As there is ever grow-
ing competition regarding conferences and
as this is the first time an international con-
ference focusing purely on medical ethics is
organized, it is obvious that the organizers
could not count on good attendance. The
Association is however in good standing
and the event will take place and hopefully
be memorable for all of us.
Jon Snaedal,
President of the International
Conference on Medical Ethics
2.-4. October 2018
Reykjavik, Iceland
Jon Snaedal
40
Public Health
Making sense of what a cancer diagno-
sis means is monumental for anyone. How
much more complicated and unbearable for
low literacy patients and children who really
don’t understand their diagnosis or what is
happening to them? Globally, the absence of
suitable health educational material, particu-
larly for those whose home language is not
English, severely aggravates misunderstand-
ing and treatment non-compliance.
The Speaking Book® is a multi-media edu-
cational tool developed specifically to deliv-
er critical health information to vulnerable
patients and communities in an interactive,
non-threatening and culturally appropriate
way. Using 16 audio buttons that follow the
written text of each page of the Book allows
the patient to follow the book and listen to
the messages,if they are unable or unwilling
to read.
Speaking Books® has just launched a
brand new book – “Children Coping with
Cancer” – created for children in paediat-
ric oncology wards in the USA. Written in
English and Spanish, this ground-breaking
Book was developed with the input and
assistance from a number of paediatric on-
cologists; is endorsed by the WMA, funded
by Pfizer, and has the support of the Rotary
Club of Hilton Head. Together with Pfizer
and Rotary Clubs in the USA,the Speaking
Book® Children Coping with Cancer will be
distributed in all children’s cancer centres and
hospitals free of charge whilst stocks last.
“In addition”, according to Brian Julius,The
President and Founder of Speaking Books®,
“we have included on the back page a list of
really useful resources for parents and care
givers to contact for cancer related ques-
tions, financial and emotional support”
The two narrators of the Book, Cade Kris-
cunas (11) and EfrainTinoco (10) are mem-
bers of The Rotary Club of Hilton Head’s
“Early Act Programme” for young Rotar-
ians. Together their narration of this Book
in English and Spanish delivers a message
of hope and courage to children with cancer.
With a push of a button, children in oncol-
ogy wards (and their families) can listen to
David telling his story about being a child
with cancer; can learn about cancer; and can
be entertained and distracted.
David provides an understanding and re-
latable voice for children. “I had cancer too.
I am here to keep you company while you’re
in the hospital. I know you might be scared
or in pain now.” He explains, in an easy to
understand way,what cancer is and how chil-
dren can cope. In writing the Book, research
showed that many children with cancer and
other life-threatening illnesses feel they are to
blame for being sick or that their illness is a
punishment. David emphasises that cancer is
an illness.“You cannot catch it from someone
and you cannot make anyone else sick. You
did not get cancer because you were naughty
or because you did something wrong.”
From counting flowers, to finding the
squirrel hiding in the garden, to drawing
pictures, David and Children Coping With
Cancer distracts sick kids from the pain of
treatment.The Speaking Book® is colourful
and interactive. David chats naturally with
his young audience and helps them feel less
lonely and afraid.
Childhood cancers are very different in na-
ture, cause and treatment to adult cancers.
While generally childhood cancers tend to
respond better to treatments that adult can-
cers, they require specialist paediatric treat-
ment by a paediatric oncologist. The occur-
rence of childhood cancer is significantly
less than that of adult cancer.To develop the
expertise required, the medical team needs
to see a large number of patients. This has
Multi-Media Educational Tool Created to
Help Children Cope with Cancer
Brian Julius
III
BACK TO CONTENTS
Public Health
led to childhood cancers worldwide being
treated mostly in public sector hospitals.
While the expertise is generally in a pub-
lic hospital, often there is insufficient time
to devote to each patient. There are wait-
ing lists and busy staff and the environment
can be all the more overwhelming for a
child and for a family who may not speak
English. It is for this reason that Children
Coping with Cancer was created as a dual-
language English/Spanish Book.
David explains what cancer is in a way that
is engaging and comprehensible. He asks
his listeners to copy a picture in the Book
as quickly as they can. It isn’t quite right…
“When we grow, our cells and DNA split
into two and make a copy of each other like
the copy of your picture. Kids grow really
fast and sometimes the copy isn’t the way
it should be. That’s what cancer is.” He ex-
plains that there are different types of can-
cer and that it can start in any part of the
body. Cancer can spread but it is always
named for the place where it starts.
Through the
Book, David ex-
plains the treat-
ment teams to
the child. He
reaches out to
each listener, en-
couraging them
to trust their
teams and all the tests and procedures.“You
have a lot of different people on your team
to make sure that you will get well.” One
of the strengths of the Speaking Book® is
that it answers questions that may not be
able to be asked. Many patients who use the
Speaking Book® feel like their doctor is al-
ways with them, answering their questions,
and reinforcing healthy treatment compli-
ance. For children with cancer, and for their
families, having a reassuring expert at the
touch of a button is incredibly powerful.
David will tell you the same advice,will play
the same games, and share the same secrets
with you every time you press the button.
For people trying to grasp a diagnosis of
cancer, this reassurance is comforting, edu-
cational and empowering.
“Our experience with all Speaking Books®
has always been so positive, and we know
this latest book will go a long way to help
reduce Children’s Fears and improve their
understanding of Cancer, that it is not
catching, was not their fault, and that they
are being looked after by wonderful people
dedicated to their treatment.” Says Marc
Chioda, Medical Director, Pfizer Oncology. 
Each child is different. Some worry. Others
get upset or become quiet, afraid, or defiant.
Some express their feelings in words, others
in actions.Children Coping with Cancer offers
all children,across age groups,to express how
they feel and connect with another child in
a safe space. In the absence of fact, children
use their imaginations to make up answers to
unanswered questions. Answering questions
honestly can be extremely challenging for
families who don’t have the language capac-
ity to really grasp what is happening to their
child. The Speaking Book® is dual language
for exactly this reason.
David (Cade Kriscunas and Efrain Tinoco)
are honest with their listeners that treat-
ment may hurt; that they may feel scared
and sick. They also have words of wisdom
for their young listeners… “We know that
you want to be brave and strong and not cry
or show how you feel. I used to try and pre-
tend I was fine but I learned that being re-
ally brave means telling other people when
you feel weak or sick.”
It is in this spirit that this Speaking Book®
is dedicated to Dr. Jack Watters, former
Pfizer Vice President and Fellow and Trust-
ee of both the New York Academy of Med-
icine, and Help Aged International who
passed away on June 30th
2015 from Cancer.
He was an invaluable supporter for public
health care and a tireless advocate of health
care education. He did so much to promote
health care education to the most vulner-
able communities, and is sorely missed.
Speaking Books® have been developed in
more than 40 languages for distribution
in over 30 countries worldwide. Child-
hood cancer is certainly not limited to the
USA. While this Book has been created,
with Pfizer,the WMA and the Rotary Club
Hilton Head, for childhood cancer centres
across the United States of America, it is
the aim to offer this Book to children and
families across the globe.
Brian Julius
Speaking Books, Hilton Head, USA
Website: www.speakingbooks.com
E-mail: bj@speakingbooks.com
IV