wma santiago general assembly – reports contents

WorldMedical Journal

Vol. No. 4, December 200551

OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.

G 20438

wma Santiago General Assembly – Reports

ContentsEditorial

2005 – a Lesson: “Humanity’s need for Care” 85

Medical Ethics and Human Rights

Sponsorship Guidelines 86Enhancing the WMA Declarations on Human Rights 86

Medical Science, Professional Practice and Education

Health Care System Reform in Japan 88

The U.S. Health System: A Question of Access 90

WMA

Assembly Ceremonial Session, Santiago 2005 93

General Assembly, Santiago 2005 94

171th WMA Council Session 95

Resolution on Avian Influenza 97

Statement on Genetics and Medicine 98

Statement on Drug Substitution 100

Statement on Medical Liability Reform 101

General Assembly Associates’ Meeting 102Beyond statements and resolutions – Workingat the WMA Secretariat in Ferney-Voltaire 103

From the Secretary General’s desk

“Don’t forget the others” 104

WHO

FAO/OIE/WB/WHO Meeting on Avian Influenza and Human Pandemic Influenza 105Massive international effort stops polio epidemicacross 10 West and Central African countries 107

Telemedicine via Satellite 108

Regional and NMA News

European Region 108

Latin America and the Caribbean 109

Korean Medical Association 109

Letters to the Editor 110

Review 111

Website: http://www.wma.net

WMA Directory of National Member Medical Associations Officers and Council

Association and address/Officers

WMA OFFICERSOF NATIONAL MEMBER MEDICAL ASSOCIATIONS AND OFFICERS

i see page ii

President-Elect President Immediate Past-PresidentDr K. Letlape Dr Y. D. Coble Dr J. AppleyardSouth African Med. Assn. 102 Magnolia Street Thimble HallP.O. Box 74789 Neptune Beach, FL 32266 108 Blean CommonLynnwood Ridge 0040 USA Blean, Nr CanterburyPretoria 0153 Kent, CT2 9JJSouth Africa Great Britain

Treasurer Chairman of Council Vice-Chairman of CouncilProf. Dr. Dr. h.c. J. D. Hoppe Dr Y. Blachar Dr N. HashimotoBundesärztekammer Israel Medical Association Japan Medical AssociationHerbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome10623 Berlin 35 Jabotisky Street Bunkyo-kuGermany P.O. Box 3566 Tokyo 113-8621

Ramat-Gan 52136 JapanIsrael

Secretary GeneralDr O. KloiberWorld Medical AssociationBP 63 France

ANDORRA SCol’legi Oficial de MetgesEdifici Plaza esc. BVerge del Pilar 5,4art. Despatx 11, Andorra La VellaTel: (376) 823 525/Fax: (376) 860 793E-mail: [email protected]: www.col-legidemetges.ad

ARGENTINA SConfederación Médica ArgentinaAv. Belgrano 1235Buenos Aires 1093Tel/Fax: (54-114) 383-8414/5511E-mail: [email protected]: www.comra.health.org.ar

AUSTRALIA EAustralian Medical AssociationP.O. Box 6090Kingston, ACT 2604Tel: (61-2) 6270-5460/Fax: -5499Website: www.ama.com.auE-mail: [email protected]

AUSTRIA EÖsterreichische Ärztekammer(Austrian Medical Chamber)

Weihburggasse 10-12 - P.O. Box 2131010 WienTel: (43-1) 51406-931Fax: (43-1) 51406-933E-mail: [email protected]

REPUBLIC OF ARMENIA EArmenian Medical AssociationP.O. Box 143, Yerevan 375 010Tel: (3741) 53 58-63Fax: (3741) 53 48 79E-mail:[email protected]: www.armeda.am

AZERBAIJAN EAzerbaijan Medical Association5 Sona Velikham Str.AZE 370001, BakuTel: (994 50) 328 1888Fax: (994 12) 315 136E-mail: [email protected] / [email protected]

BAHAMAS EMedical Association of the BahamasJavon Medical CenterP.O. Box N999NassauTel: (1-242) 328 6802Fax: (1-242) 323 2980E-mail: [email protected]

BANGLADESH EBangladesh Medical AssociationB.M.A House 15/2 Topkhana Road, Dhaka 1000Tel: (880) 2-9568714/9562527Fax: (880) 2-9566060/9568714E-mail: [email protected]

BELGIUM FAssociation Belge des SyndicatsMédicauxChaussée de Boondael 6, bte 41050 BruxellesTel: (32-2) 644-12 88/Fax: -1527E-mail: [email protected]: www.absym-bras.be

BOLIVIA SColegio Médico de BoliviaCasilla 1088CochabambaTel/Fax: (591-04) 523658E-mail: [email protected]: www.colmedbo.org

BRAZIL EAssociaçao Médica BrasileiraR. Sao Carlos do Pinhal 324 – Bela VistaSao Paulo SP – CEP 01333-903Tel: (55-11) 317868 00

Fax: (55-11) 317868 31E-mail: [email protected]: www.amb.org.br

BULGARIA EBulgarian Medical Association15, Acad. Ivan Geshov Blvd.1431 SofiaTel: (359-2) 954 -11 26/Fax:-1186E-mail: [email protected]: www.blsbg.com

CANADA ECanadian Medical AssociationP.O. Box 86501867 Alta Vista DriveOttawa, Ontario K1G 3Y6Tel: (1-613) 731 9331/Fax: -1779E-mail: [email protected]: www.cma.ca

CHILE SColegio Médico de ChileEsmeralda 678 - Casilla 639SantiagoTel: (56-2) 4277800Fax: (56-2) 6330940 / 6336732E-mail: [email protected]: www.colegiomedico.cl

Titlepage: Semmelweis Hospital. Prof. I. Semmelweis worked in this hospital, later named after him, when he left Vienna after the initial rejection of his ideas about the transmission of infection.

Editorial

2005 – a Lesson: “Humanity’s need for Care”

The editorial in the September issue was entitled “Backwards to the future?”. As this yeardraws to its close it is natural to look back over the past 12 months and to consider wherewe are and where we are going.

Internationally there has been much activity in the health field tackling long standing dis-ease problems, as such HIV/AIDS and Malaria. Preventive policies such as basic immuni-sation, the provision of impregnated mosquito nets continue to reduce morbidity and savemany lives, when the resources available permit their use and provision. Despite the ef-forts to eliminate poliomyelitis major efforts are still needed to deal with the threat of sud-den outbreaks requiring rapid large scale immunisation programmes, and the declarationby WHO of Tuberculosis in Africa as an emergency, both highlight the need for constantvigilance and continuing action. At the same time the underlying problem of poverty inmany parts of the underdeveloped, the developing and even the so-called developedworld, appear as far as ever from solution although the global summit meetings may assist.

All this has been complicated by natural disasters, such as those arising in SoutheastAsia, Pakistan and even in such a highly developed and affluent country as the USA, andmade sudden demands on health care resources both in terms of materials and skilled per-sonnel.

Attention has been focused not only on the global shortage of healthcare personnel butalso on training and retention of physician policies in the face of developments such asthe “skills drain” phenomenon. Health Services Reform remains a high priority in manycountries and, both at national and international levels, continues to exercise those re-sponsible – health professionals, administrators and politicians – as to how to proceed, atwhat cost and at what speed change can or should be effected.

All of the above are having major impacts on many health professionals, including thephysicians. Long standing traditions of practice are being abandoned in the efforts tomeet the huge demands both of deprived populations and of those in more fortunate cir-cumstances, in a rapidly changing society where speed of access to knowledge and scien-tific developments are leading to new expectations.

Positive developments, increasing scientific knowledge, proven healthcare reform poli-cies are of course to be welcomed, and the physicians, like others, should be prepared toadapt their professional style of practice appropriately – points we have sought to empha-sise in these columns. The changes are, however, often very radical. Reform of the basicmedical curriculum, the changing role of individual health professionals and professionalworking practices are not easy to adapt to the speed which some politicians consider pos-sible. Adequate consultation and co-operation on all sides is essential to achieve them.

One thing however remains constant regardless of the problems and issues mentionedabove, it is the continuing need for care and relief of humanity’s sick and suffering. This,the medical profession clearly responded to the crises of the past year. Through the manychallenges which it will continue to face, this must remain at the centre of all its activityin the future.

Alan Rowe

Editorial

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Editorial note: Please accept our apologies that unfortunately, due to technical problems,it has not been possible to include all the reports of the Santiago WMA meeting in this is-sue. The rest will appear in the next issue.

NMAs and financial relationships with alloutside organisations needed to be consid-ered Dr. Appleyard (Immediate PastPresident) made the point that in any ‘rela-tionship’ there was potential for ‘influence’both ways, The WMA was not a passivepartner and we should never compromiseour own internationally accepted ethicalstandards, we should rather use any part-nership ‘platform’ to promote them. Dr. HMiyazaki (Japan) emphasised the impor-tance of transparency in all our financialarrangements Dr. Kloiber, the SecretaryGeneral, said that specific guidance hadbeen developed for sponsorship by com-mercial, governmental and charitable part-nerships for specific projects or pieces ofwork which were consistent with existingWMA policies. He was advised by theSponsorship Advisory Committee, whichreviewed all potential developments. Dr.Kloiber said that he personally had beenone of the greatest critics of commercialsponsorship. In response to the questionabout how much existing sponsors hadattempted to ‘influence’ the WMA, he saidhe had not experienced any attempt toinfluence the association whatsoever. Dr.Kloiber felt that a Work Group could iden-tify the concerns expressed and review theexisting guidelines

The committee agreed unanimously to rec-ommend “That Council establish a WorkGroup consisting of the Chairs of theMedical Ethics and Finance and PlanningCommittees, to review the WMA CorporateRelationship Guidelines”. This was subse-quently AGREED by Council. ■

This issue was discussed during the meet-ing of the WMA Ethics Committee inSantiago. We feel it to be of sufficient gen-eral interest to include in the Journal.(The following report is based on noteskindly provided by Dr. Appleyard to whomwe are most grateful. Edit.)

Dr. Bagenholm introduced the issue of theacceptance by the WMA of commercialsponsorship funding. She indicated that thecurrent financial situation for the WMAwas difficult in that membership dues didnot cover the WMA’s expenses. Somemember organisations had approached herwith their concerns that the WMA hadbecome dependent on financial sponsor-ship from the pharmaceutical industry formany of its activities. Posing the questionas to why such industries want to sponsorour activities, she said they becameinvolved so that they could influence us. Ifthe WMA was thought to be influenced bythe pharmaceutical industry, it would looseits credibility. Dr. Bagenholm, recognizedthat there were guidelines agreed by theCouncil for such sponsorship, but felt thatthey needed to be revisited to considerwhether it is ethical to receive sponsorship,from the pharmaceutical industry and whatwould be the financial implications. Thedelegate from Denmark agreed that the eth-ical and financial aspects should be recon-sidered and suggested a small group com-prising the Chair of Ethics and the Chair ofFinance and Planning be set up who couldreceive information about how NMAs arecoping with these problems in their owncountries. (This was subsequentlyapproved by Council.) He felt that theWMA mission was to foster the indepen-dence of the profession and set the highestpossible ethical standards for physiciansworldwide. Ethics and Human Rights werefundamental to our profession. NationalMedical Associations founded the WMAwith these issues foremost in their minds


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and we are only as strong as the individualcomponents of the ‘chain’ of our member-ship associations.

Jon Snaedal, (Iceland) Icelandic MedicalAssociation and former chair of Ethicsagreed that the WMA needed to be finan-cially ‘autonomous’ and should not rely onother sources of finance. If we were seen tobe influenced by our Sponsors the WMAwould cease to be respected.

Dr. Johnson (UK) agreed that the idealwould be that the WMA was self funding.With the cost of all the activities atInternational level with all our partners thiswas not possible and he asked what was theevidence of the WMA being influenced bythe current sponsors Dr. Kgnosi Letlape,President Elect, told the meeting that therewere different issues in different countries,In South Africa the main influence on theProfession was that of Government and hefelt that Industry was much more under-standing of the importance of the indepen-dence of the Profession. Without their part-nership and support, the Association wouldnot be able to function the way it does as anadvocate for its members. Ms. Wapner (Israel) said that where there were mattersof ethics and finance, ethics was preemi-nent. She recognized the concerns raised.Any change in standards should apply to all


Sponsorship Guidelines

The WMA was founded in 1947 to attemptto ensure that never again would doctors becomplicit in human rights abuses. The “bigthree” WMA declarations – Geneva,Helsinki and Tokyo – aim to raise ethicalstandards globally, and to protect the rightsof the vulnerable. Despite these carefully

drafted words stories of medical involve-ment in human rights abuses still emerge.Current draft amendments to the Declara-tions of Tokyo and Geneva and to the Regu-lations in Times of Armed Conflict are thelatest attempt to fortify this global consen-sus.

Enhancing the WMA Declarations on Human RightsV. Nathanson


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The sad fact is that prisoners are subjectedto human rights abuses – both torture andcruel inhuman and degrading treatment invery many countries. Involvement by doc-tors, when it occurs, is often a part of theprocess; doctors resuscitate the torture sur-vivor so that he or she can be torturedagain. They certify fitness for harsh inter-rogations and for frankly abusive practices.They falsify death certificates or other keyparts of medical and legal records. At thesame time other doctors are putting them-selves at risk in decrying the torturers, doc-umenting abuse, giving evidence in courts,opposing systematic and episodic practicesthat put people at risk of abuse and usingmedical knowledge and expertise to protectthe vulnerable and challenge the abusers.

Allegations have emerged from a variety ofsources about the abuse of prisoners in AbuGhraib and in Guantanamo Bay.1 While nocases have been brought against doctorsthere are stories in circulation of doctor in-volvement that would, if true, amount to se-rious ethical failures. While these are notthe only places where such medical abusesare alleged they are important as they high-light apparent weaknesses in current WMApolicy. The BMA has led a WMA Councilworking group that has prepared amend-ments to existing policy that will, we be-lieve, strengthen the appropriate prohibi-tions.2

One issue that has arisen in relation tothese allegations as well as to those fromsome other countries, is that medicalrecords are being provided to interrogatorsto aid in targeting of harsh interrogation ortorture. Although the Declaration of Tokyois read by most people as disallowing thispractice, it does not currently say so ex-plicitly. In too many countries physicians’notes, recorded to help their patients and toinform other health care workers abouttheir findings and treatment plans, are in-stead used to undermine the safety and se-curity of the individual. Some physiciansappear willing to hand over such notes, oreven to help the prison authorities usemedical information to devise a pro-gramme that will undermine the mental orphysical health of a detainee. They arguethat as the code is silent on the prohibition,it does not in fact exist. 3

For that reason an amendment has beensuggested to make this prohibition explicit.This will not only strengthen the hand ofthose doctors who refuse to hand overrecords to prison authorities, but it may alsohelp doctors who work for agencies visitingprisons and detention centres as part of thechecks and balances system of internationalregulation, including the Red Cross, theUNHCHR, Amnesty International andMSF. This specific amendment has alsobeen repeated in the Regulations in Timesof Armed Conflict, to make doubly certainthat this prohibition exists regardless of cur-rent political and security circumstances.

The carefully constructed language ofWMA declarations and regulations can alsobecome obscure over time as common lan-guage usage changes. This is why the sug-gestions for amendments include removingthe concept that physicians’ consciencesshould be their guides and its replacementwith a requirement to adhere to internation-al conventions on human rights, interna-tional humanitarian law and WMA declara-tions on medical ethics. The internationallaws are easily found; they are the GenevaConventions and associated protocols ofwhich the ICRC acts as guardian. “The oth-er laws and conventions are available on-line from the UN or the WMA itself.” Allare clear; torture is prohibited, and we eachhave an absolute right not to be subjected tosuch treatment.

So are these changes a response to as yetunproven allegations about Abu Ghraib andGuantanamo Bay? No; not only to these,

but also to similar allegations to similarabuses in many places

Many associations reading these changesmay wonder if they are necessary. I believethat they are; the number of reports Amnestyand others can produce of medical involve-ment in abuse makes change and reinforce-ment of high norms essential. They give us,as doctors, a chance to rededicate ourselvesto stopping abuse by doctors, or medicalcomplicity. They give us a chance to ap-plaud those colleagues who stick their headsabove the parapet, putting themselves at riskby adhering to the highest standards. Theygive us an opportunity to condemn those wethink unworthy of their medical licences.They can act as a call to arms for all of us todefend vulnerable people around the world.In short; they are an opportunity for theWMA to reassert its core reason for existing.

Prof. Vivienne NathansonDirector of Professional ServicesBritish Medical [email protected]

1 See, for example, Lewis NA. Red Cross findsdetainee abuse in Guantanamo. New YorkTimes, Nov 30, 2004: A1. Okie S. Glimpses ofGuantanamo – medical ethics and the war onterror. NEJM 353;24 15 Dec 05.

2 See WMA paper MEC/Misc/Dec20053 Bloche G, Marks J. When Doctors go to War.

NEJM 352:3-6 6 Jan 054 http://www.icrc.org/Web/Eng/siteeng0.nsf/

html/genevaconventions.5 http://www.wma.net. ■

Nurses and Physicians Welcome Libyan Court’s Decision to Reverse Death SentencesThe International Council of Nurses and the World Medical Association have welcomed the decision ofLibya’s Supreme Court to reverse the death sentences and order a retrial for five Bulgarian nurses anda Palestinian doctor, accused of deliberately infecting more than 400 children with AIDS. The supremecourt has quashed the sentences and accepted the appeal against the lower court ruling on both sub-stance and procedure. Prosecutors agreed with defence lawyers that there were “irregularities” in thearrests and interrogations of the accused. Expert evidence that the cause was probably poor hygiene atthe hospital appeared to have been ignored. Indeed, infections were believed to have occurred beforethe accused started work at the hospital, and continued after their arrests.ICN and WMA call for a speedy retrial that will consider the evidence presented by internationalexperts and liberate the health professionals.

Japan is experiencing a lowering of thebirth rate and an aging of the population. In1985, population from 0 to 4-year-oldaccounted for 6.2% of the total population.In 2004, the figure declined to 4.5%. On theother hand, the elderly over 65 years oldaccounted for 10.3% of the total populationin 1985 and increased to 19.5% in 2004. Asthis indicates, the population structure israpidly changing. In the current year, 2005,population aged 4 years old or below is4.5% of the total population, and this figureis estimated to decrease to 3.6% in 2025.People aged 65 years or over, however,account for 19.9% of the total population inthe current year, 2005, and this is estimatedto increase to 28.7% in 2025. These trendsof declining birth rate and aging populationare expected to continue at an even moreaccelerated rate in the future. This situation,combined with the deteriorated financialbasis of the nation, is calling for socialsecurity reform. Health care system reformis currently underway to keep the systemsustainable in the future, supported by bal-anced economic and fiscal foundation.

The government proposes a basic policyplan for health care system reform. It isnecessary to radically change all parts ofthe health care system, while taking intoaccount changes in the medical environ-ment, the rapidly declining birth rate andaging population, and the current stagnanteconomy, as well as advances in medicaltechnologies and shifts in the public’s atti-tude. It is also essential to reform the healthcare system, health care delivery system,medical fee programme, and the healthinsurance system. In other words, a healthsystem that meets the demands of thechanging environment is required. In addi-tion to the basic points for reform, the gov-ernment also proposes the followingimprovement, They are, the importance ofrespecting the patients’ point of view, pro-

motion of disclosure of health information,reestablishment of safe and assured healthcare, provision of quality and efficienthealth care, establishment of a health caredelivery system of high quality and effi-ciency, separation of roles between medicalinstitutions for more focused and efficientmedical services, ensuring necessary healthservices in communities, cultivation ofhuman resource in health care and improve-ment of their quality, improvement of thestructural basis for health care, and theimprovement of the foundation for healthcare to support lives in the 21st century.

However, the government is pushing poli-cies to “contain health costs” to “ensureappropriate health costs” because of wors-ening national finances. It is trying to intro-duce the total budget system of health carecosts as well as controlling the increasingcosts to suppress the growth of social secu-rity costs lower than the economic growth.

What is needed for health care from thegeneral public is improved quality and safe-ty of health care. From the government’spoint of view, however, it is containment ofhealth costs. The problem may be how wellthe medical profession can meet theseneeds. The Japan Medical Association(JMA) advocates that it is fundamentallynecessary to ensure the health insurancesystem which permits every citizen toequally receive health services with aninsurance card, anytime and anywhere,which may be most characteristic ofJapan’s health system.

The JMA considers that all the people havea right to lead a healthy life, and enhance-ment of social security for this purpose isan obligation of the government. Healthcare is an asset for the public good, anddevelopment of the foundation of the healthcare system is the responsibility of thenation. The government should not fit


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health care to the economy. The economyshould be fitted to health care. To securequality health care and provide safe healthservices, financial resources to cover thehealth costs are necessary. We maintainthat the policies to contain health costssurely lead to lowered quality of healthcare and may block the promotion of safermedical services.

In relation to the health status of Japan,according to the report by WHO, Japanretains the longest average life expectancyin the world. As for the health care costs,when total health care costs are comparedwith GDP, Japan has the 17th lowest healthcare cost among the OECD countries.Furthermore, in comparison with othercountries for health achievement, Japanranked No. 1 in life expectancy and inoverall rating of health achievement.Japan’s health insurance system is anexcellent system with high performance atlow cost.

Looking at the trends of national healthcare expenditure and live expectancy, thegrowth of expenditure and average lifeexpectancy for females, is in proportion. Ofcourse, there are other factors such asadvances in medical technologies andincrease disease in the elderly. However,the increase in expenditure is obviouslylinked and corresponds with the growth ofaverage life expectancy. The containmentof health expenditure could, therefore,shorten life expectancy.

The financial resources of Japan’s healthcosts consist of public expenditure (taxes),premium from employers and the insured,and patient cost sharing. From 1990 to2002, the percentage of public expenditureshowed little changes. As for the premi-ums, the burden on the employersdecreased, while the percentage of patientcost sharing increased. This is because ofthe increase in the patient’s co-payment formedical services from 20% to 30% afterApril 2003 and the establishment of thefixed amount of payment by the elderlywhich started in October 2002. In Japan, alimit is set for patients’ co-payment at72,300 yen (approximately 650 US dollars)for the general public, except for low-income earners. However, the government


Health Care System Reform in JapanHideki Miyazaki, MD, Ph.DVice President, Japan Medical AssociationPresented at WMA Scientific Session, Santiago

has been taking policies to increase thecosts to be paid by the patient in the pastfew years. It is contrary to the principles ofinsurance when you consider that theinsured who pays the premiums to be cov-ered by the insurance has to pay extra coststo receive health services.

There is a large gap between the employ-ee’s pension insurance rate and the healthinsurance rate. This partly accounts for thedeficit of the health costs. The health insur-ance rate has hardly changed since 1980. In2003, the employee’s pension insurancerate dropped because premiums werecharged for total remuneration, includingbonuses. The insurance rate up to the year2018 has been set by law. However, there isno policy to increase the health insurancerate further and when compared with theemployee’s pension, it is undervalued. Thehealth insurance rate, if increased, will helpto secure resources for the health costs.

Japan’s national contribution ratio which isthe ratio of tax burden and social securityburden has been showing around 37% forthe past 18 years which is very low. In thegovernment’s policy, the rate should besuppressed below 50% at the highest, but itis already at a low level, compared withother developed countries.

The comparison of the ratio of nationalhealth expenditures to GDP, and the break-down of public and private spending inmajor countries, suggests that health costsin Japan need an increase of 1 to 2% of pub-lic spending to GDP when compared withSweden, France, and Germany. From thispoint of view, the government should allo-cate more of its money on health care areas.

I have just explained the current situation inJapan. The problem in the health care sys-tem reform to be discussed here is that thenumber of insurers in Japan is extraordinar-ily large when compared with health careinsurance systems of other countries. In theRevised Health Insurance Act enacted 2years ago, integration and unification ofdifferent kinds of insurances is one of theitems to be studied in the future.

In 2004, the number of insurers managedby the national government is 1, whilethose managed by health insurance soci-

eties is 1,674 and those managed by sea-men’s insurance is 1. As for the mutual aidinsurance, the number of insurers managedby the national government employeesmutual aid associations is 23; those man-aged by local government employees mutu-al aid associations is 54; those managed byprivate school teachers & employees mutu-al aid is 1. As for national health insurance,the number of insurers managed by munic-ipalities is 3,224 and those managed byassociations is 166. The total number ofinsurers is 5,144 with the total of insuredpersons being 94,248,000.

Currently there is a discussion to integrateand reorganize the insurers in each prefec-ture, and it is suggested firstly to integratethose managed by municipalities and bynational government.

The Japan Medical Association is propos-ing basic policies for the health care systemreform.

We firstly and strongly advocate for main-taining the universal health insurance sys-tem. We are also suggesting the creation ofnew Medical Insurance System for theElderly to address public concerns. Thesystem with the national government asinsurer would cover only those aged 75years and older. However, the system willbe managed by the local government after acertain period of time. We are proposing forthe financial sources of this system special;10% of the contribution from the patient,10% from insurance premiums, with–con-sideration for low-income earners, and 80%from public expenses and national mutualassistance such as consumption tax and cig-arettes tax. If a health insurance system isseen as a part of social security system, it isnecessary to increase public funding or taxto meet its need for financial sources.

Compared to other in major countries, theprice of cigarettes is the lowest for Japanand it is necessary to discuss various relat-ed matters including a consumption taxscheme and a proposal for an earmarked taxfor health car.

A rise in cigarette prices may be the mostefficient measures to cut the number ofsmokers. We are proposing to utilize the

increased tax for financial resources forhealth care.

Health care should not be regulated by age.This is natural when you think about char-acteristics of the elderly and their potentialdiseases. The Medical Insurance System forthe Elderly will be based on self-help, andmutual and public assistance. The healthinsurance system in Japan provides benefitsin kind sufficiently to meet people’s needsfor health care. In Japan, the Long-termCare Insurance System was established forthose aged over 40 years of age in 2000,which provides cash benefits to supportlong-term or nursing care. The fund comesfrom the premiums and public spending.The level of nursing care required is divid-ed into 5 levels, each having a set quota. Wedistinguish between a long-term or nursingcare and medical care. And necessaryarrangements are being made between thetwo areas of care. Therefore, the Long-termCare Insurance System, which providescash benefits, and the health insurance sys-tem cannot be integrated. Control of thegrowth rate of health costs based on theeconomic indicators such as GDP shouldnot be permitted because it disturbs neces-sary and safe health care.

To enhance the level of health services forthe elderly, it is important to promote pre-ventative measures against lifestyle-relateddiseases to keep the elderly healthy. Co-pay-ment by patients should be decreased andshould not exceed the current level. Thegovernment should extend the retirementage of workers to 65 years of age. All retiredemployees should join the National HealthInsurance which provides benefits whichwill be covered by patients’ co-payment,premiums and mutual assistance betweenemployee’s health insurance systems.

The government managed health insurancesystem has been enlarged by the SocialInsurance Agency and been establishingand managing hospitals. Retired bureau-crats of the Health, Labour and WelfareMinistry have been obtaining jobs at thesehospitals. A reform is going to abolish thesehospitals.

As for the health care delivery system, in acomparison of the average number of visitsper person per year in major countries, it is


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21 higher times in Japan, the highest figure.However, health cost per one visit in Japancompared with other countries in 63 US dol-lars, which is very low. To sum it up, it canbe said that health cost in Japan is very low.

In an international comparison of the healthcare delivery system in 1998, the number ofbeds per 1,000 people was high at 13.1 inJapan, while the number of physicians per100 beds was low at 12.5. Furthermore, thenumber of nursing staff per 100 beds wasalso low at 43.5, with the longest averagenumber of hospital stays being 31.8. Therate of outpatient visits stand at 16.0. Thisreveals the facts that in Japan the people

have many opportunities to visit any kindof medical institutions under the universalhealth insurance, the period of hospital stayis long, and a patient is attended by a smallnumber of physicians and nursing staff.

To shorten the hospital stay, we are tryingto review the organizational problems relat-ed to the inpatient settings, health caredelivery system, and the revision of themedical fees. The Japan Medical Asso-ciation is making its utmost efforts to main-tain the universal health insurance whichJapan is proud of, to provide necessary andsafer health care services for all the nationof Japan. ■


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I am delighted to be here today on behalf ofthe American Medical Association. Myvisit with you continues a decades-long tra-dition of mutual friendship and support.And our friendship, now and in the future,is even more vital than it has been in thepast. Together, we face potential pandemicsand terrorist threats. Public health chal-lenges from tsunamis, hurricanes, earth-quakes and floods. We are subject to eco-nomic and political decisions made faraway that have immediate impact in ourcommunities – that affect access to care andquality of care for our patients. More thanothers, perhaps, we recognize that diseaseand discord, that epidemics and terrorists,alike, respect no boundaries.

We also know that knowledge and ourmutual caring for our patients know noboundaries, either. No boundaries and nolimits. In such a world, cooperation amongour associations and within the WMA ismore important that ever. I shines like a bea-con – a model for ethical behavior for allother professions and associations. Today,as we discuss the strenghts and weaknessesof our nations’ health care systems, we canlearn from each other. Identify the best prac-

tices – and the worst pitfalls. And steer our-selves toward a better, healthier worldtomorrow.

The UninsuredThis is something the American MedicalAssociation is trying to deal with in myhomeland, the United States.

There, medical care is financed and deliv-ered through both public and privatemeans. Persons over the age of 65 are cov-ered under the Medicare program, adminis-tered by our national federal government.The economically disadvantaged are eligi-ble for Medicaid, administered on the statelevel with partial federal funding.

Most American workers get their healthinsurance through their employers, a prac-tice that started during World War II, whenwages were controlled. Health insuranceemerged as a way to enhance benefits forworkers who couldn’t get salary increases.

For some people, this patchwork systemworks well. For those with access, the U.S.offers what I believe is the highest quality

care in the world, despite our significantdelivery and systems problems.

But for others, it barely functions, if at all.For instance, there are almost 46 millionAmericans who have no health insurance.That’s about 15 percent of our population –a national disgrace.

The employer-based system of healthinsurance is showing signs of weakness.

More than 80 percent of the uninsured – 36million of them – work or are members ofworking families. They hold down jobs anddraw a paycheck. For them, living withouthealth insurance has terrible consequencesfor health and economic well-being. Theylive sicker and die younger. Often, theydelay seeking help until they are sufferingfrom a more advanced stage of disease –when treatment is often more expensive –and less effective.

But it takes a toll on more than the individ-ual. It extracts a heavy cost on our societyin terms of reduced employment and pro-ductivity, and the flood of uninsured intoemergency departments and free clinics hasa price tag, too.

In 2004, American taxpayers spent 35 bil-lion U.S. dollars from uncompensated,publicly-funded care. That’s $4 million perhour every day. And this number doesn’ttake into account the additional billions ofdollars spent on privately given care,including uncompensated care by physi-cians.

Managed Care Concentration

So the question is, how do we in the UnitedStates repair our system? It is flawed, andfails to give coverage to enough people.

One of the most severe issues, not onlywith those who have no health insurance,but for all American patients, is continuityof care – the patient-physician relationship.That relationship has been under siege inrecent decades in the U.S.

In my practice, I’ve seen some of mypatients for many years. I know their med-ical histories. I can follow up on old prob-lems or see subtle changes that a stranger

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might not. In these circumstances, a patientfeels comfortable – and is better able to askquestions and communicate.

This patient-physician relationship is thecornerstone of medicine. A healthy andcontinuous relationship with a physiciancan lower costs by getting a patient accessto the health care system at an earlier stageof a disease.

But with the spread of privately run man-aged care in the U.S., this continuity hasbeen disrupted. Patients often move fromphysician to physician – when theiremployers change health plans – or whentheir physician decides not to contract witha given insurer.

Perhaps it is because with some of the moreabusive insurers – physicians are paid lessto see more patients and work longer hours.

It is clear that a more competitive insurancelandscape would help protect the quality ofmedical care – and ultimately lower costsfor consumers.

What we have structured is a cost-basedcare system – while we should be offering acare-based cost system. We need to putdecisions about health care coverage – backwhere they belong: in the hands of patients– and their physicians.

In the United States, a handful of gianthealth insurance companies dominate themarket. It makes it difficult for an individ-ual physician to negotiate patient careissues with what are essentially monopo-lies.

Managed care organizations have consoli-dated at a record pace in the United States,with more than 350 mergers and acquisi-tions in one five-year span.

The AMA is working to redress this imbal-ance.

We believe regulators should start lookingmore closely at the behavior of the healthinsurance industry. Also that physiciansshould be able to negotiate more effective-ly with large health insurance companies.Because when the health care market land-scape is dominated by just a few giant com-panies, it forces physicians to accept unfair

contracts which can have serious implica-tions for patient care.

Single-Payer Not the Answer

Some would argue that the solution to theproblem of the uninsured would be to adopta single-payer national health insuranceplan. Most of you in this room practiceunder such a system, in one form or anoth-er.

Proponents of such a system are passionateand vocal. But we at the American MedicalAssociation respectfully disagree. Webelieve a single-payer system in the UnitedStates would:

• Require physicians to negotiate a bind-ing fee schedule;

• Discourage hospital expansions andcapital purchases;

• Eliminate the health insurance industry,eliminating institutional memory andhundreds of thousands of jobs;

• Force employers to transfer money ear-marked for health benefits to a nationalhealth insurance program.

• And discourage the innovation that hasdriven medical advances and innova-tions in the United States over the pastcentury.

To us, this runs counter to freedom, choice,and private enterprise, qualities ingrained inthe American psyche, and which fuelAmerican society.

Such a system would be exponentiallymore difficult to manage in the UnitedStates than it is almost elsewhere, becausewe have a “melting pot” society with aremarkably diverse and diffuse character. Itmakes our country especially resistant toone-size-fits-all solutions imposed fromabove.

The AMA believes that by implementing asingle-payer system, the United Stateswould be trading one set of problems foranother.

• We would see long, detrimental waitsfor care and the rationing of care.

• We would be slow to adopt new tech-nology and maintain facilities.

• We would be bound by price controls,which eventually drive up costs;

• And it would create a gigantic bureau-cracy that interferes with clinical deci-sion making.

Would a single-payer system save usmoney? We don’t think so. We believe thatsuch a conclusion is rooted in faulty andincomplete comparisons of administrativecosts between the United States and coun-tries that offer a single-payer system.

It has long been recognized that publicinsurance imposes a variety of costs onpatients, including excessive wait times, aproliferation of short visits, and lack ofaccess to certain services and procedures.

In June 2003, the Chairman of the BritishMedical Association characterized theU.K.’s single-payer health care system as:

“The stifling of innovation by excessive,intrusive audit … the shackling of doctorsby prescribing guidelines, referral guide-lines and protocols … the suffocation ofprofessional responsibility by target-settingand production-line values that leave littleroom for the professional judgment of indi-vidual doctors or the needs of individualpatients.” So say a physician with long,first-hand experience with a single-payerhealth system.

We have to recognize that nothing worth-while – comes without a price. The fact isthat effective prices play a role in the provi-sion of, and access to, services in any healthcare system, not just market-based systems.

In the final analysis, consumers clearly pay,in one way or another – regardless of thesystem.

Any system that offers access to care with-out direct charges to consumers generatesdemand for care that exceeds what can bedelivered. Ultimately, there is no guaranteethat even medically urgent services will beavailable when needed.

The AMA has a viable solution – one thatdoes not limit the universe of choices andthat does not dictate a single-payer systemas the only path toward universal healthcoverage.


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AMA Plan for the Uninsured

The AMA has long advocated that everyAmerican should have health insurance andthus access to medical care. We’ve beenworking with other major players on theAmerican health care scene to raise the pro-file of this issue – and to remind the publicof its urgency. We believe the country willseriously address this issue eventually.

As Winston Churchill once said,“Americans can always be counted on to dothe right thing … after they have exhaustedall other possibilities”.

The American Medical Association believewe have a plan that would expand healthinsurance coverage in our country. We thinkit’s the right thing to do.

The plan is simple:

• Give people money to buy their ownhealth care coverage.

• Give wealthy people less money. Givemore to poor people.

The AMA plan has three pillars – tax cred-its, individual ownership and selection ofplans, and regulatory reform.

The most central point to understand – isthe system of tax credits. Under the AMAplan, all workers would get a tax creditlarge enough to ensure they could purchaseaffordable coverage. The tax credit wouldbe inversely related to income. This meansthat the people with the lowest incomes –those most likely to be uninsured – wouldget the biggest subsidy. The tax creditswould be refundable, so families that owelittle or no taxes would still get a credit.Finally, the credits would be available inadvance, so that families who can’t affordmonthly premiums don’t have to wait for ayear-end refund to bye coverage.

What’s more, Americans could choose andpurchase a health care plan that fits theirneeds.

At present, of those companies that offerhealth care coverage only one in six offersa choice of more than one plan. Under theAMA insurance proposal, employees couldchoose to get coverage through theiremployers or not.

This would empower people. Allow them todo what federal government employees,including members of our U.S. Congress,can do today. That is to choose from a widearray of plans. This in turn, would createcompetition and vibrant health insurancemarkets.

Finally, our plans for regulatory reformwould also bring sanity and reason to thecurrent maze of market regulations forhealth insurance.

Currently, some regulations aimed at pro-tecting high-risk individuals have the unin-tended consequence of a driving up thenumber of people who are insured.

We aim to create a more sensible regulato-ry system. A system that gives incentives topatients to purchase coverage before theyget sick. And that gives incentives to insur-ers to cover high-risk individuals. Overall,our plan to expand health care coverage andchoice – would get 94 percent of Americanscovered. This is just one example of howwe could improve market regulations forhealth insurance and get more people cov-ered in the process.

These kind of market-based approaches forreform in the United States are alreadyshowing promise. The removal of somemandates, for example, has made possible anew kind of plan that combines highdeductible insurance with health savingsaccounts – HSAs. These accounts allowconsumers to use tax free dollars to pay forout of pocket health care costs, or to rollthose dollars over. Nationwide, more thanone million people have already signed upfor HSAs. And the best part is that the sta-tistics show that about one-third of themwere previously uninsured. [U.S. Chamberof Commerce].

Can groups like families of the develop-mentally and mentally disabled benefitfrom these kinds of market-driven reforms,too? We think so. That’s why we endorsethe concept of a tax-exempt medical trust toprovide for the long-term health care needsof disabled family members. And we thinkthis concept should be linked to our overallplan to finance health care for allAmericans. [H-165.893]

There’s no reason that anyone should be leftout of the picture (when it comes to creat-ing a system driven by choice), that has thepotential to increase quality of life andreduce costs for all patients.

The AMA’s plan of action is a good one. Ifenacted nationally, it could give more than94 percent of Americans health coverage.

It is an idea with powerful support. Duringthe most recent U.S. presidential campaign,the candidates from both major politicalparties endorsed the general concept ofusing tax credits for individuals to purchasehealth care coverage. However, given cur-rent government budget challenges, weknow it’s unlikely that our plan will beenacted nationally soon. That’s way we arewilling to support an incremental approach.For example, we would like to see pilotprograms on local government levels to tryout our reforms. Such pilot programs couldfocus on particularly vulnerable popula-tions such as a low-income people, chil-dren, or the chronically ill. Pilot programshave the added benefit of allowing policy-makers to guide future decisions throughactual data an experience and letting themsee how the AMA plan could work on anational scale.

An editorial from one of America’s leadingnewspaper, The Detroit News said, “TheAMA is offering a credible blueprint forfundamental health care reform. It deservesa hearing in Congress.” We agree.

But we know that this won’t be easy. That’swhy our leadership is bringing our ideas toa group called the Search for CommonGround. This group has all the major play-ers and associations in health care –employers, health plans, physicians andmany more. The one thing we have in com-mon is that we’re all frustrated that 45 mil-lion Americans are uninsured and 10 to 15million more are underinsured. The missionof this group? To cover as many people aspossible as soon as possible through non-governmental solutions. Together, we canget coverage for the millions of Americanswho lack it and we can maintain the integri-ty and quality of American medicine in theprocess.

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ConclusionOne thing is certain – whatever insuranceplan we arrive at will be a uniquelyAmerican system, with uniquely Americancharacteristics. Yet perhaps we can showthe world a different approach to providinghealth coverage to everyone in our commu-nities – and our countries.

We have a motto in the American MedicalAssociation that goes like this:

“Together we are stronger.”

It sounds self-evident, but it is a powerfulidea.

Working together – in meetings just likethis – we all become stronger.

Our profession becomes stronger. We learnfrom each other. We find out more about whatworks in medicine – and what doesn’t. Andwe reinforce the foundation of science, ethics,caring and compassion that supports all wedo. Through our work our patients are betteroff. No matter what our health care system.No matter what our country. The commitmentof the world’s physician to their patients isone thing that doesn’t need reform. ■

The ceremony was opened by the President,Dr. Yank D. Coble Jr., who warmly thankedthe Chilean Medical Association and itsleaders for the excellent arrangements andthe warmth and hospitality which had beenshown to the participants. He then called onDr. Juan Luis Castro, President of theChilean Medical Association, to address theAssembly.

Dr. Castro in welcoming the Assembly, saidthat the Chilean Medical Association was avoluntary organisation with 20000 mem-bers. Speaking about the problems of theprofession in Chile, he referred both to theneed to improve salaries (stating that onqualification earnings were about $ 300and after five years might reach $30000),but stressed that a major problem was thatof lawsuits and liability He mentioned thatthese resulted in about 180 trials a year andspoke of the pioneering experience in LatinAmerica of creating the Foundation forLegal Assistance (FALMED) to managelawsuits against the physicians and avoidincreases in insurance costs. Anotherimportant achievement was the restorationof ethical defence for the Association. At atime when many countries were undergoing

processes of health reform, Chile was noexception. There, physicians are witnessingchanges which will impact greatly on themedical profession and its relations withpatients.

Thanking him Dr. Coble then introduced Dr.Pedro Garcia, the Chilean Minister ofHealth, who addressed the Assembly. Hewelcomed delegates and referred to theimportance of the profession meeting to dis-cuss problems. As a doctor himself and as apolitician he was, of course, interested in thechallenges facing society. Referring to thecomplexity of the geography of Chile hesaid this posed many problems for healthcare, but there was a long history of healthcare in the country and they still looked tophysicians to keep up with new develop-ments in scientific knowledge and healthcare. In his view it was there was need forpoliticians and physicians to work togetherto solve these problems and he was there-fore particularly delighted that the WMAhad chosen to meet in Chile. He congratulat-ed all the bodies responsible for the organi-sation of the meeting, in particular, theChilean Medical Association. He pointedout that 80% of Chilean doctors were mem-

bers of the CMA, of which he had been onefor many years. He hoped that delegateswould be able to get some idea of theChilean Health Reforms and also that theywould see something of the country duringtheir visit. He would be happy to respond toany questions and he closed by wishing theWMA a very successful conference.

Dr. Blachar, the Chair of Council, paid atribute to Dr. Yank Coble for his outstand-ing services during his Presidential term ofoffice and invested him with the PastPresident’s medal following which Dr.Coble gave his valedictory address (Thiswill appear in WMJ 52 (1))

Dr. Blachar then introduced the newPresident Dr. Kgosi Letlape and invited himto take the oath of office. Following this,Dr. Blachar invested him with thePresident’s Badge of Office and invited himto address the meeting (see InauguralPresidential Address p. 94).

Dr. Blachar after thanking the speakers fortheir addresses and once again the membersof the Chilean Medical Association for invit-ing the WMA to hold its General Assemblyin Santiago, adjourned the meeting. ■

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Honourable Minister of Health Dr. PedroGarcia, Dr. Castro, the President of theChilean Medical Association, HonouredGuests, Ladies and Gentlemen

Thank you for the privilege you have givenme to serve as President of the WorldMedical Association. I assume this role onbehalf of all physicians on earth, but pleaseindulge me as I single out particularly mybrothers and sisters of Africa.

I would firstly like to congratulate Dr. YankCoble on an extraordinary Presidency.Through his Presidential initiative of“Caring Physicians of the World”, he hasmanaged to re-establish the fundamentalvalues of medicine–caring, ethics and sci-ence. Together with the book on caringphysicians, he has succeeded in making usfeel good about being doctors again–soYank, thank you again for your leadership,dedication and commitment to our profes-sion. I find it a humbling experience to fol-low him as President and hope that I will beable to rise to the occasion.

An old Israeli saying states that you have tolook back to where you have come from, tobetter see where you are heading. Lookingback over the last few years, it is gratifyingto note that the WMA has unquestionablygrown into the representative voice ofphysicians. The World Health Organi-zation, World Bank and other UN agenciesturn to the WMA if they need to hear theviews of physicians. Through our alliancewith the International Council of Nurses,International Pharmaceutical Federationand the World Dental Federation we havealso been able to make major break-throughs in the field of public health.

Within the WMA there have also been verypositive developments. Our role as the cus-todians of medical ethics has been rein-forces by the successful revision of theDeclaration of Helsinki and the launch ofthe WMA Ethics Manual. The impact ofthe manual has been immediate and very

front line physicians. In addition, theWMA called for Taiwan to be included inthe WHO surveillance and response net-work, as they are a separate health entity,not receiving any funding or assistancefrom China. Here we are in 2005, withavian flu posing as a possible disaster of aproportion we have not seen since theSpanish Flu epidemic in 1918, when mil-lions died. Yet we do not have a fully func-tional network where the physicians andmedical associations are directly linked toWHO. The gab in the global public healthnetwork, Taiwan, a country with 23 millioncitizens, has not been yet addressed. Ifavian flu is transmitted from China toTaiwan, as had happened with SARS, thereare still no formal channels open betweenWHO and Taiwan to exchange technicaldata and provide help. Clearly we need tobe more vocal and active as social leadersto make sure that all measures can be takento include all the peoples of the world inpreparing for health disasters.

The UN Commanding Officer in RwandaGeneral Dallaire said that after shakinghands with the devil in Rwanda he knowsthere is a God. Noting that SARS nevercame to Africa in 2003 I have also come toknow fully that God is there for all of us.

I offer you another story from my own con-tinent. Last year the fundamentalist gover-nor of Nigeria’s Kano State halted all polioimmunisation efforts because of allegedand unsubstantiated claims that it was partof a plot to sterilize Muslim girls. By thetime he relented, polio hat spread to 12African countries that had previously beenfreed of the disease, thereby dramaticallysetting back global eradication efforts andforcing the rest of the world to continuevaccination programmes–another classicexample of where politics ruled over healthimperatives. Where were we, the physi-cians of the world, in preventing this kindof disaster? We can and should prevent thisfrom happening again!

In Northern Europe over the last year,physicians have expressed their severe dis-satisfaction with the new trend of rationingof care, ever increasing paper work, workhours and diminishing remuneration. Thisled to protest actions in France, Germany

WMA General Assembly, Santiago 2005Inaugural Presidential AddressDr. T. K. S. Letlape

significant. From its publication in Januarythis year, it has now already been distrib-uted worldwide and translated into at least12 languages.

The WMA’s recent contributions in healthrelated human rights have also been wel-comed by my compatriots from Africa. Wecannot encourage the WMA enough to helpphysicians to be involved as the advocatesand protectors of patients and the vulnera-ble groups in society. It will be part of myPresidential plan to help push forward ourhealth-related human rights agenda.

I see the future role of the WMA as moreand more that of social leaders, in additionto our role as the leaders of the health careteams. I would like to tell you three storiesfrom the North, South and East to illustratethis point.

In the East we currently have an outbreakof avian flu. You will remember that in2003 the world endured the SARS epidem-ic, where hundreds of patients died inChina, Taiwan, Singapore and Canada. Atthe Time the WMA argued strongly for theestablishment of a global surveillance andresponse network which would include

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and Belgium. As governments find it diffi-cult to fund health care services (from thepatients’ own money), rationing hasincreasingly been used to balance accounts.This has placed great pressure on thepatient-physician relationship and physi-cian autonomy. In September Belgian doc-tors protested against a proposed new gov-ernment policy, whereby the Ministry ofHealth could intervene whenever the coun-try’s health insurance budget goes intodeficit, effectively being able to excludefinancial benefits for certain types of diag-nosis or treatment. What is in fact happen-ing is that health care is being dumpeddown to the lowest common denominatorof cost. Even more importantly, rationing isslowly destroying the art and professionalpractice of medicine, the patient-physicianrelationship and patient access to all treat-ment options. Physicians are expected toact as administrative clerks and accoun-tants and their professional role downgrad-ed to select the least expensive, not the bestavailable, treatment for their patients.

This trend of political considerations deny-ing our patients the best possible healthcare services is unacceptable. We cannotallow politics to stand in the way of effec-tive handling of epidemics or disastersaffecting both national and internationallevels. It highlights the fact that physiciansneed to become more effective in shapingthe health policy environment, rather thanbe shaped by it.

As I mentioned before, the last WMAPresidency very effectively re-affirmed thefundamental values of medicine. Duringmy term as President, I would like to placethe focus on patient-centred medical care.As physicians we can draw encouragementfrom the fact that patients still regard us asthe most trusted source of health informa-tion, but as communicators we can domuch better. Patients are overawed with theinformation they can now source from theinternet, but recent reports show that physi-cians still don’t communicate effectivelyenough with their patients. During my termI hope that we can revisit out policy onpatient information and communicationand develop a training manual on the sub-ject, as we have done so successfully forethics and human rights. We must remem-

ber always that our responsibilities comebefore our rights.

We have two themes in the vision of theWorld Medical Association, these are ethicsand access. Whilst we have been in theforefront on ethics, there is still a lot to bedone on access. We have collective respon-sibility globally to ensure access to basichealthcare for all citizens of the word. TheMillennium Development Goals are beingrolled back and those that are needing helpare not necessarily receiving it. Globally,healthcare is being under-funded and physi-cian autonomy is interfered with, thusundermining patients` rights. Doctors needto work together with civil society to createa safer world that can fund health careappropriately.

I come from South Africa, the epicentre ofthe HIV and AIDS epidemic. Therefore Iwould like to close with an impassionedplea for the WMA and all its members tofully taken on the responsibility of combat-ing HIV. This is still a growing disease,where the role physicians can and shouldplay has not been optimized. This is espe-cially true for our role in prevention. So faronly a limited number of full scale preven-tion efforts have been developed with effec-tively target “at risk” populations, the infra-structure of health systems, societal atti-tudes and individual beliefs and motiva-tions.

Remember, prevention in HIV and AIDS isABCD, the four letters of the alphabet col-lectively and in the proper sequence; selec-

tive application of the alphabet is hazardousto the health of the people.

We need to ensure that our doctors aretrained appropriately to fulfil the role thatthey play as leaders and healers. Medicalschools train them to be great healers; weneed to find a way to appropriately trainthem to be great leaders too. We need a pro-gramme to assist National MedicalAssociations to get doctors to be good lead-ers as well. I will dedicate my years as pres-ident to realise this objective as a follow-onto caring physicians, so that we can emulatethose caring physicians and truly put ourpatients first.

There are three things to remember:

1. Health is political even for doctors butwe will be non-partisan and engageothers, as opposed to confronting them.

2. Health is a foundation for peace not abridge, for as we saw in the aftermath ofKatrina, bridges were swept away butthe foundations remained.

3. A quote from Nelson Mandela: “Afterclimbing a great hill, one finds thatthere are many more hills to climb.”

Having seen the hills and mountains ofChile, I wonder if Mr. Mandela ever livedin Chile!

I would like to end by thanking our hosts,the Chilean Medical Association for theirunforgettable warmth and hospitality dur-ing this Assembly. We are inviting you allto our Assembly in South Africa next yearwhere we will try to emulate them. ■

(We are particularly indebted to Dr.Appleyard for his background notes on thismeeting. Ed.)

The 171th Council meeting took place inSantiago, Chile on 14th October 2005.

The meeting was opened by the Chairman,Dr. Blachar who called on the SecretaryGeneral to give his report.

Secretary General’s Report

Dr. Otmar Kloiber thanked the President,Dr. Yank Coble, for his dedication and forthe ‘added value’ he had given to the Asso-ciation through the “Caring Physicians ofthe World” initiative. The resulting bookprovides insight into how our physician

171th WMA Council Session

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colleagues throughout the world serve theirpatients under conditions that are often hardto accept. The initiative had also supportedconferences in different parts of the world.Dr. Kloiber also thanked all NMAs for theirresponse to the disaster caused by theTsunami and mentioned that money wasstill being collected. He expressed his grat-itude to specific NMAs for their support, inparticular for the staff time provided by theAMA, in particular to Sharon Ostrowskiand Robin Menes, to the BMA, whichthrough Dr. Vivienne Nathanson providedsupport for Work Groups, the CanadianMedical Association and Dr. Bill Thouldfor the Business Development Group, theGerman Medical Association especially forDr. Parsa-Parsi’s secondment, Ms LeahWapner and the Israeli Medical Asso-ciation, also to the Norwegian MedicalAssociation for the online courses.

Turning to restructuring of WMA OfficeTeam, he reported that since the last meetingof Council Ms. Emma Viaud, a member ofStaff, had left the office. Dr. Parsi had beenseconded to the office for three months andhad, among other items, worked on thedevelopment of the TB Course, Outreach toArab Countries, and on the Regional Officefor Africa in SAMA.

The Prison Medical Course had now beentranslated into Spanish and is available on aCD-Rom.

Dr. Kloiber appealed to all NMAs to assistthe Office in Ferney Voltaire by makingavailable secondments for one of their staffto work at the WMA for three months untilanother member of staff has been employedIt was felt that this could provide a valuableeducational opportunity for NMAs’ juniormedical staff.

Dr. Kloiber thanked Johnson and Johnsonfor their continuing support of the EthicsUnit and the production of the EthicsManual and to the South African, Australianand Norwegian MA’s for their work on theTB project.

Following the successful completion of theimplementation of the Istanbul Project infive nations with the ICRT, the work will beextended to other countries through a fur-ther grant from the European Commission.

Dr. Kloiber reported that the FDI had nowjoined the World Health Professions Alli-ance. At a very successful WHPA Receptionon Patient Safety held at the same time asthe World Health Assembly. Sir LiamDonaldson, Chairman of the World Alliancefor Patient Safety, gave the keynote address.A joint seminar will be held next year onthree topics, the Reporting of MedicalErrors, Counterfeit Medicines and onHuman Resources for Health.

Turning to finance and organisation, Dr.Kloiber told Council that his first priorityfollowing his appointment was to ensuresound financial governance. In this he hadhad great support from Mr Adi Hällmayrand Dr. Karsten Vilmar, the TreasurerEmeritus. He had had to apply the brakes togive an emergency stop to expenditure.Stating that his main concern was to knowhow much of the WMA could be used foradvocacy he commented that the WMA hadestablished a high reputation internationallyand its opinion was increasingly beingsought for its professional expertise.

Concerning Forced Sterilizations, since thelast Council meeting Dr. Kloiber had beenin correspondence with the Slovak MedicalAssociation about allegations that somePhysicians in Slovakia had been involvedin forced sterilisations (an illegal practice inthat country). The Slovak Medical Asso-ciation had investigated these allegationswith the Slovakian Government. The Boardof the Slovakian Medical Association hadwritten, stating that the allegations couldnot be confirmed and that none of the mem-bers of the Slovakian Medical Associationhad been involved.

Dr. Kloiber reported that since the lastCouncil Session he had attended meetingsof the AMA, BMA, Norwegian MA andCuban Medical Association. He valuedthese personal contacts and by participatingin the meetings had a greater understandingof local issues. Further visits to other NMAswill be undertaken next year.

DuesThe Revision of the Dues system as proposedby the Treasure Emeritus was considered.Dr. Plested (AMA) asked if the full implica-

tions of the proposed changes had beenexplored and whether some NMAs woulduse this schedule as an opportunity to reducetheir dues. Dr. Kloiber replied that he antici-pated that the changes would be cost neutral.The NMA’s from poorer nations would beable to receive more votes in proportion totheir subscriptions and become moreinvolved in the activities of the WMA. Thelower cost would encourage non membersfrom poorer nations to join. He emphasisedthat there would be no change in the duespaid by the larger and richer NMA’s, whoprovide 85% of the WMAs dues revenue.

After Dr. Johnson (BMA) agreed that therecommendations had to be taken as a ‘pack-age’, the revised dues system was AGREED.

SponsorshipDr. Plested (AMA) proposed that the speci-fication for new Sponsorship projects shouldbe reassessed to ensure robust projections foranticipated Income and Expenditure. Hemoved a motion, seconded by Dr. Nelson(USA),‘that the Secretary General workwithin the existing guidelines to maximisenon-dues income“. This was AGREED.

Medical Ethics CommitteeReportThis was presented by the Chairman, Dr.Bagenholm.

Minor Revisions of Declarations etc.

The Declaration of Lisbon, as revised, wasapproved.

It was agreed that a work group be convenedby the AMA with the BMA to integrateNMA comments on the ‘Statement ofEthical Issues concerning patients withMental Illness’, which was re-classified asrequiring major revision.

Major Revisions of Declarations etc.

It was resolved that all the Documents clas-sified as requiring major revisions bereferred to NMA’s for comment.

Concerning the Policy Review of theDeclarations of Geneva, of Tokyo, and theRegulations in Times of Armed Conflict, Dr.Nathanson gave an oral report on her pro-

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posals to amend these statements. It wasAGREED that the proposals of the BMAsconvened Work Group be circulated toNMA’s.

Sponsorship Guidelines

Dr. Bagenholm reported on the discussionwithin her committee on the principle ofaccepting sponsorship It was AGREED thatCouncil establish a Working Group of theChairs of Ethics and of Finance andPlanning Committees, to review the WMA’sCorporate relationship Guidelines (see page86 for fuller account of the discussion).

Socio-Medical AffairsCommittee ReportDr. Haddad in presenting his report, intro-duced for the first time a Consent Calendarfor the Recommendations of his Committee.This procedure involves the presentation ofall the Recommendations from theCommittee together as one recommenda-tion, with the option that any member ofCouncil could request the withdrawal of anyspecific recommendation, for further debate.

The report was for the first time presentedas a consent calendar, which meant that allrecommendations that were not challenged(extracted) were then voted for en bloc andapproved.

Dr. Plested suggested the extraction of para2.2.1, the Proposed Statement on Reducingthe Global impact of Alcohol. This enabledhim to speak in favour of the documentemphasising the point made within it of thenecessity for a Strategic Framework similarto the one on Tobacco, following this thestatement was agreed unanimously (theAlcohol Statement will appear in the nextissue of WMJ).

Skills Drain

The BMA had prepared two backgroundpapers on the Healthcare Skills Drain fromDeveloping Countries.These will be distrib-uted to NMA’s for information.

Finance and PlanningCommitteeDr. John Nelson presented his report of themeeting of the committee. All the recom-

mendations were adopted without furtherdebate including the revised dues structure.(see also Dues above)

Other Business

Recommendations on Business Develop-ment and on Non-dues income were agreed(see above!).

Disaster Planning

It was AGREED that a Work Group beestablished to consider the preventive mea-sures and contingencies necessary forDisaster Planning including the possibleAsian Flu pandemic. The Canadian, SouthAfrican, German and American MA’s willcontribute to this.

Preventing Chronic Diseases

Dr. Appleyard (IPP) referred to his report toCouncil in May concerning the WHO initia-tive on Preventing Chronic Diseases andstressed the importance of the major finan-cial burden this would place on developingcountries. WHO was launching the initia-tive at the end of October and it would beappropriate for the WMA to identify itselfwith this important preventive venture. Inview of the time constraints he suggested aspecial Council Resolution:

„The WMA (Council) welcomes theWHO Report on “Preventing ChronicDiseases, a vital investment, and recom-mends that all NMA’s work with healthprofessional organisations, interestedstakeholders and their Governments, to

prevent and relieve the increasing burdenof chronic disease.

This was formally proposed by Dr. Haddadand seconded by Dr. Wu.

Dr. Kloiber raised concerns about the finan-cial impact saying that he had no capacity toattend the launch later in the month.

After further debate to which Dr. Appleyardreplied, reading out for translation purposesa brief background paper he had prepared,the Council Resolution was AGREED nemcon, with the caveat that there would be noadditional cost incurred.

(full WHO report is accessible atwww.who.int/chp/chronic_disease_report/overview_en.pdf)

Executive Committee

Dr. John Nelson raised a question about thecomposition of the Executive Committee,expressing concern at the exclusion of thethree Presidents as non-voting members.Presidents were elected from the GeneralAssembly representing all the NMAs, notjust those larger NMA’s who had ‘bought’seats on the Council with their largerdeclared membership. Dr. Kloiber said thathe was bound by the last decision of Councilthat only the voting members of Councilwould be included on the executive. Thesehad been specified as the Chair of Council,Deputy Chair, and the Chair of the threeCommittees. The Executive committee hadalready decided to revisit the issue again. ■

The World Medical Association recog-nizes the potential global morbidity andmortality as a result of the H5N1 strain ofavian flu. This possibility increases withevery passing day as more countries findinfected birds in their territories. TheWMA will work with member NMAs, the

WHO and other stakeholders to track theprogress of the disease and propose thenecessary measures to minimize itsimpact on the global human population.The WMA also urges governments toengage with NMAs to prepare for the pos-sibility of a pandemic.

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Preamble 1. In recent years, the field of genetics has

undergone rapid change and development.The areas of gene therapy and geneticengineering and the development of newtechnology have presented possibilitiesinconceivable only decades ago.

2. The Human Genome Project opened newspheres of research. Its applications alsoproved useful to clinical care by allowingphysicians to utilize knowledge of thehuman genome in order to diagnose futuredisease, as well as to individualize drugtherapy (pharmacogenomics).

3. Because of this, genetics has become anintegral part of primary care medicine.Whereas at one time, medical geneticswas devoted to the study of relatively raregenetic disorders, the Human GenomeProject has established a genetic contribu-tion to a variety of common diseases. It istherefore incumbent upon all physiciansto have a working knowledge of the field.

4. Genetics is an area of medicine with enor-mous medical, social, ethical and legalimplications. The WMA has developedthis statement in order to address some ofthese concerns and provide guidance tophysicians. These guidelines should beupdated in accordance with developmentsin the field of genetics.

Major Issues:

Genetic Testing

5. The identification of disease-related geneshas led to an increase in the number ofavailable genetic tests that detect diseaseor an individual's risk of disease. As thenumber and types of such tests and thediseases they detect increases, there isconcern about the reliability and limita-tions of such tests, as well as the implica-

tions of testing and disclosure. The abilityof physicians to interpret test results andcounsel their patients has also been chal-lenged by the proliferation of knowledge.

6. Genetic testing may be undergone prior tomarriage or childbearing to detect thepresence of carrier genes that might affectthe health of future offspring. Physiciansshould actively inform those from popula-tions with high incidence of certain genet-ic diseases about the possibility of pre-marital and pre-pregnancy testing, andgenetic counseling should be made avail-able to those individuals or couples whoare considering such testing.

7. Genetic counseling and testing duringpregnancy should be offered as an option.In cases where no medical intervention ispossible following diagnosis, this shouldbe explained to the couple prior to theirdecision to test.

8. In recent years, with the advent of IVF,genetic testing has been extended to pre-implantation genetic diagnosis of embryos(PGD). This can be a useful tool in caseswhere a couple has a high chance of con-ceiving a child with genetic disease.

9. Since the purpose of medicine is to treat,in cases where no sickness or disability isinvolved genetic screening should not beemployed as a means of producing chil-dren with pre-determined characteristics.For example, genetic screening should notbe used to enable sex selection unlessthere is a gender-based illness involved.Similarly, physicians should not counte-nance the use of such screening to pro-mote non-health related personal attribut-es.

10. Genetic testing should be done only withinformed consent of the individual orhis/her legal guardian. Genetic testing forpredisposition to disease should be per-formed only on consenting adults, unless

there is treatment available for the condi-tion and the test results would facilitateearlier instigation of this treatment.

11. Valid consent to genetic testing shouldinclude the following factors:

a. The limitations of genetic testing,including the fact that the presence of aspecific gene may denote predisposi-tion to disease rather than the diseaseitself and does not definitively predictthe likelihood of developing a certaindisease, particularly in multi-factorialdisorders.

b. The fact that a disease may manifestitself in one of several forms and invarying degrees

c. Information about the nature and pre-dictability of information receivedfrom the tests.

d. The benefits of testing including therelief of uncertainty and the ability tomake informed choices, including thepossible need to increase or reduce reg-ular screenings and checkups, and toimplement risk reduction measures

e. The implications of a positive resultand the prevention, screening and/ortreatment possibilities.

f. The possible implications for the fami-ly members of the patient involved.

12. In the case of a positive test result thatmay have implications for third partiessuch as close relatives, the individual test-ed should be encouraged to discuss theresults of the test with such third parties.In cases where not disclosing the resultsinvolves a direct and imminent threat tothe life or health of an individual, thephysician may reveal the results to suchthird parties, but should usually discussthis with the patient first. If the physicianhas access to an ethics committee, it is

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preferable to consult such a committeeprior to revealing results to third parties.

Genetic Counseling

13. Genetic counseling is generally offeredprior to marriage or conception, in orderto predict the likelihood of conceiving anaffected child, during pregnancy, in orderto determine the condition of the fetus, orto an adult, in order to determine suscepti-bility to a certain disease.

14. Individuals at higher risk for conceiving achild with a specific disease should beoffered genetic counseling prior to con-ception or during pregnancy. In addition,adults at higher risk for various diseasessuch as cancer, mental illness or neuro-degenerative diseases in which the riskcan be tested for, should be made aware ofthe availability of genetic counseling.

15. Because of the scientific complexityinvolved in genetic testing as well as thepractical and emotional implications ofthe results, the WMA sees great impor-tance in educating and training medicalstudents and physicians in genetic coun-seling, particularly counseling related topre-symptomatic diagnosis of disease.Independent genetic counselors also havean important role to play. The WMAacknowledges that there can be very com-plex situations requiring the involvementof medical genetics specialists.

16. In all cases where genetic counseling isoffered, it should be non-directive andprotect the individual's right not to be test-ed.

17. In cases of counseling prior to or duringpregnancy, the prospective parents shouldbe given information to provide the basisfor an informed decision regarding child-bearing, but should not be influenced bythe physicians' personal views in this mat-ter and physicians should be careful not tosubstitute their own moral judgment forthat of the prospective parents. In caseswhere a physician is morally opposed tocontraception or abortion, he/she may

choose not to provide these services butshould alert prospective parents that apotential genetic problem exists and makenote of the option of contraception orabortion as well as treatment alternatives,relevant genetic tests, and the availabili-ty of genetic counseling.

Confidentiality of results

18. Like all medical records, the results ofgenetic testing should be kept strictly con-fidential, and should not be revealed tooutside parties without the consent of theindividual tested. Third parties to whomresults may in certain circumstances bereleased are identified in paragraph 12.

19. Physicians should support the passage oflaws guaranteeing that no individual shallbe discriminated against on the basis ofgenetic makeup in the fields of humanrights, employment and insurance.

Gene therapy and genetic research

20. Gene therapy represents a combinationof techniques used to correct defectivegenes that cause disease, especially in thefields of oncology, hematology andimmune disorders. Gene therapy is notyet an active current therapy but is still ina stage of clinical investigation.However, with the continued develop-ment of this field, it should proceedaccording to the following guidelines:

a. Gene therapy performed in a researchcontext should conform to the require-ments of the Declaration of Helsinkiwhile therapy performed in a treatmentcontext should conform to standards ofmedical practice and professionalresponsibility.

b. Informed consent should always beobtained from the patient undergoingthe therapy. This informed consentshould include disclosure of the risks ofgene therapy, including the fact that thepatient may have to undergo multiplerounds of gene therapy, the risk of animmune response, and the potential

problems arising from the use of viralvectors.

c. Gene therapy should only be undertak-en after a careful analysis of the risksand benefits involved and an evaluationof the perceived effectiveness of thetherapy, as compared to the risks, sideeffects, availability and effectiveness ofother treatments.

21. It is currently possible to undertakescreening of an embryo in order to pro-vide stem cell or other therapies for anexisting sibling with a genetic disorder.This may be considered acceptable med-ical practice where no evidence exists thatthe embryo is being created exclusivelyfor this purpose.

22. Genetic discoveries should be shared asmuch as possible between countries, so asto benefit humankind and reduce duplica-tion of research and the risk inherent inresearch in this area.

23. In the case of genetic research performedon large, defined population groups,efforts should be made to avoid potentialstigmatization.

Cloning

24. Recent developments in science have ledto the cloning of a mammal and raise thepossibility of such cloning techniquesbeing used in humans.

25. Cloning includes both therapeutic clon-ing, namely the cloning of individual stemcells in order to produce a healthy copy ofa diseased tissue or organ for transplant,and reproductive cloning, namely thecloning of an existing mammal to producea duplicate of such mammal. The WMAcurrently opposes reproductive cloning,and in many countries it is considered topose more of an ethical problem than ther-apeutic cloning.

26. Physicians should act in accordance withthe codes of medical ethics in their coun-tries regarding the use of cloning and bemindful of the law governing this activity.

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Introduction

1. The prescription of a drug representsthe culmination of a careful delibera-tive process between physician andpatient aimed at the prevention, amelio-ration or cure of a disease or problem.This deliberative process requires thatthe physician evaluate a variety of sci-entific and other data including costsand make an individualized choice oftherapy for the patient. Sometimes,however, a pharmacist is required tosubstitute a different drug for the oneprescribed by the physician. The WorldMedical Association has serious con-cerns about this practice.

2. Drug substitution can take two forms:generic substitution and therapeuticsubstitution.

3. In generic substitution, a generic drugis substituted for a brand name drug.However, both drugs have the sameactive chemical ingredient, samedosage strength, and same dosageform.

4. Therapeutic substitution occurs when apharmacist substitutes a chemically dif-ferent drug for the drug that the physi-cian prescribed. The drug substitutedby the pharmacist belongs to the samepharmacologic class and/or to the sametherapeutic class. However since thetwo drugs have different chemicalstructures, adverse outcomes for thepatient can occur.

5. The respective roles of physicians andpharmacists in serving the patient'sneed for optimal drug therapy are out-lined in the WMA Statement on theWorking Relationship betweenPhysicians and Pharmacists inMedicinal Therapy.

6. The physician should be assured bynational regulatory authorities of thebioequivalence and the chemical andtherapeutic equivalence of prescriptiondrug products from both multiple andsingle sources. Quality assurance pro-cedures should be in place to ensuretheir lot-to-lot bioequivalence and theirchemical and therapeutic equivalence.

7. Many considerations should beaddressed before prescribing the drugof choice for a particular indication inany given patient. Drug therapy shouldbe individualized based on a completeclinical patient history, current physicalfindings, all relevant laboratory data,and psychosocial factors. Once theseprimary considerations are met, thephysician should then consider com-parative costs of similar drug productsavailable to best serve the patient'sneeds. The physician should select thetype and quantity of drug product thathe or she considers to be in the bestmedical and financial interest of thepatient.

8. Once the patient gives his or her con-sent to the drug selected, that drugshould not be changed without the con-sent of the patient and his or her physi-cian. Failure to follow this principlecan result in harm to patients. Onbehalf of patients and physicians alike,National Medical Associations shoulddo everything possible to ensure theimplementation of the following rec-ommendations:

Recommendations

9. Physicians should become familiarwith specific laws and/or regulationsgoverning drug substitution where theypractise.

10.Pharmacists should be required to dis-pense the exact chemical, dose, anddosage form prescribed by the physi-cian. Once medication has been pre-scribed and begun, no drug substitutionshould be made without the prescribingphysician's permission.

11. If substitution of a drug product occurs,the physician should carefully monitorand adjust the dose to ensure therapeu-tic equivalence of the drug products.

12.If drug substitution leads to seriousadverse drug reaction or therapeuticfailure, the physician should documentthis finding and report it to appropriatedrug regulatory authorities.

13.National Medical Associations shouldregularly monitor drug substitutionissues and keep their members advisedon developments that have special rele-vance for patient care. Collection andevaluation of information reports onsignificant developments in this area isencouraged.

14.Appropriate drug regulatory bodiesshould evaluate and ensure the bioe-quivalence and the chemical and thera-peutic equivalence of all similar drugproducts, whether generic or brand-name, in order to ensure safe and effec-tive treatment.

15.National Medical Associations shouldoppose any action to restrict the free-dom and the responsibility of the physi-cian to prescribe in the best medicaland financial interest of the patient.

16.National Medical Associations shouldurge national regulatory authorities todeclare therapeutic substitution illegal,unless such substitution has the imme-diate prior consent of the prescribingphysician.

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1. A culture of litigation is growing aroundthe world that is adversely affecting thepractice of medicine and eroding theavailability and quality of health careservices. Some National MedicalAssociations report a medical liabilitycrisis whereby the lawsuit culture isincreasing health care costs, restrainingaccess to health care services, and hin-dering efforts to improve patient safetyand quality. In other countries, medicalliability claims are less rampant, butNational Medical Associations in thosecountries should be alert to the issuesand circumstances that could result inan increase in the frequency and severi-ty of medical liability claims broughtagainst physicians.

2. Medical liability claims have greatlyincreased health care costs, divertingscarce health care resources to the legalsystem and away from direct patientcare, research, and physician training.The lawsuit culture has also blurred thedistinction between negligence andunavoidable adverse outcomes, oftenresulting in a random determination ofthe standard of care. This has led to thebroad perception that anyone can suefor almost anything, betting on a chanceto win a big award. Such a culturebreeds cynicism and distrust in both themedical and legal systems with damag-ing consequences to the patient-physi-cian relationship.

3. In adopting this Statement, the WorldMedical Association makes an urgentcall to all National MedicalAssociations to demand the establish-ment of a reliable system of medicaljustice in their respective countries.Legal systems should ensure thatpatients are protected against harmful

practices, physicians are protectedagainst unmeritorious lawsuits, and“standard of care” determinations areconsistent and reliable, so that all par-ties know where they stand.

4. In this Statement the World MedicalAssociation wishes to inform NationalMedical Associations of some of thefacts and issues related to medical lia-bility claims. The laws and legal sys-tems in each country, as well as thesocial traditions and the economic con-ditions of the country, will affect the rel-evance of some portions of thisStatement to each National MedicalAssociation but do not detract from thefundamental importance of such aStatement.

5. An increase in the frequency and sever-ity of medical liability claims mayresult, in part, from one or more of thefollowing circumstances:

a. Increases in medical knowledge andmedical technology that haveenabled physicians to accomplishmedical feats that were not possiblein the past, but that involve consider-able risks in many instances.

b. Pressures on physicians by privatemanaged care organizations or gov-ernment-managed health care sys-tems to limit the costs of medicalcare.

c. Confusing the right to access tohealth care, which is attainable, withthe right to achieve and maintainhealth, which cannot be guaranteed.

d. The role of the media in fosteringmistrust of physicians by questioningtheir ability, knowledge, behaviour,and management of patients, and by

prompting patients to submit com-plaints against physicians.

6. A distinction must be made betweenharm caused by medical negligence andan untoward result occurring in thecourse of medical care and treatmentthat is not the fault of the physician.

a. Injury caused by negligence is thedirect result of the physician's failureto conform to the standard of care fortreatment of the patient's condition,or the physician's lack of skill in pro-viding care to the patient.

b. An untoward result is an injuryoccurring in the course of medicaltreatment that was not the result ofany lack of skill or knowledge on thepart of the treating physician, and forwhich the physician should not bearany liability.

7. Compensation for patients suffering amedical injury should be determineddifferently for medical liability claimsthan for the untoward results that occurduring medical care and treatment,unless there is an alternative system inplace such as a no-fault system or alter-nate resolution system.

a. Where an untoward result occurswithout fault on the part of the physi-cian, each country must determine ifthe patient should be compensatedfor the injuries suffered, and if so, thesource from which the funds will bepaid. The economic conditions of thecountry will determine if such soli-darity funds are available to compen-sate the patient without being at theexpense of the physician.

b. The laws of each jurisdiction shouldprovide the procedures for deciding

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liability for medical liability claimsand for determining the amount ofcompensation owed to the patient inthose cases where negligence isproven.

8. National Medical Associations shouldconsider some or all of the followingactivities in an effort to provide fair andequitable treatment for both physiciansand patients:

a. Establish public education programson the risks inherent in some of thenew advances in treatment modali-ties and surgery, and professionaleducation programs on the need forobtaining the patient's informed con-sent to such treatment and surgery.

b. Implement public advocacy pro-grams to demonstrate the problemsin medicine and health care deliveryresulting from strict cost contain-ment limitations.

c. Enhance the level and quality ofmedical education for all physicians,including improved clinical trainingexperiences.

d. Develop and participate in programsfor physicians to improve the qualityof medical care and treatment.

e. Develop appropriate policy positionson remedial training for physicians

found to be deficient in knowledgeor skills, including policy positionson limiting the physician's medicalpractice until the deficiencies arecorrected.

f. Inform the public and government ofthe dangers that various manifesta-tions of defensive medicine maypose (the multiplication of medicalacts or, on the contrary, the absten-tion of the physicians, the disaffec-tion of young physicians for certainhigher risk specialties or the reluc-tance by physicians or hospitals totreat higher-risk patients).

g. Educate the public on the possibleoccurrence of injuries during med-ical treatment that are not the resultof physician negligence, and estab-lish simple procedures to allowpatients to receive explanations inthe case of adverse events and to beinformed of the steps that must betaken to obtain compensation, ifavailable.

h. Advocate for legal protection forphysicians when patients are injuredby untoward results not caused byany negligence, and participate indecisions relating to the advisabilityof providing compensation for

patients injured during medical treat-ment without any negligence.

i. Participate in the development of thelaws and procedures applicable tomedical liability claims.

j. Develop active opposition to merit-less or frivolous claims and to con-tingency billing by lawyers.

k. Explore innovative alternative dis-pute resolution procedures for han-dling medical liability claims, suchas arbitration, rather than court pro-ceedings.

l. Encourage self-insurance by physi-cians against medical liabilityclaims, paid by the practitionersthemselves or by the employer if thephysician is employed.

m.Encourage the development of vol-untary, confidential, and legally pro-tected systems for reporting unto-ward outcomes or medical errors forthe purpose of analysis and for mak-ing recommendations on reducinguntoward outcomes and improvingpatient safety and health care quality.

n. Advocate against the increasingcriminalization or penal liability ofmedical acts by the courts.

Dr. G Dumont was re-elected Chair and theminutes of the meeting in Tokyo 2004 wereapproved.

Arising from the minutes, Dr. Kloiber, theSecretary General, reported that, followinglast year’s resolution in connection withforced sterilisation of women in the SlovakRepublic, he had written to the Slovak

Medical Association. The Slovak Ministryof Health had investigated the allegationwith the Medical Association. The allega-tions were found to have no foundation.The Slovak Medical Association had writ-ten to WMA stating that no member of theSMA had been involved in this practicewhich was illegal in the Slovak Republic.

General Assembly Associates’ Meeting,Santiago 2005

The Secretary General, reporting on the totalnumbers of Associate Members commentedthat he was reviewing the role of AssociateMembers in the future, pointing out that theInternational Dental Federation’s associatemembers played a more proactive role.Responding to a proposal by Dr. Mont-gomery, the longest serving member presentat the meeting, that the meeting be disband-ed, Dr. Appleyard opposing this ,said thatthe Associate’s meeting had produced somehelpful statements, citing the two whichwere on the agenda as examples. Junior doc-tors were keen to form a group within WMA

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and he referred to IFMSA members beingeligible for free associate membership ofWMA for three years after graduation. Dr.Kloiber confirming this, pointed out that res-olutions of the Associates’ meeting were sentto the General Assembly, although Counciltended to consider them first.

After an extensive debate it was agreed thatthe Secretary General would report back onhis deliberation.

Dr. Montgomery proposed, seconded by Dr.Nelson, that Assembly business be consid-

ered next on the agenda. Although this wasopposed by Dr. Fransblau, the motion wasadopted by a large majority.

The meeting then elected Drs. Montgomeryand Smoak as representatives at the GeneralAssembly.

The meeting then considered a resolution onMedical Assistance in Air Travel submittedby the late Dr. Odenbach, presented on hisbehalf by Dr. Kloiber. This was supportedby Dr. Montgomery. Dr. Appleyard felt thatthe issue of liability in circumstances where

humanitarian help was offered was impor-tant and proposed that the motion bereferred to Council in the first instance. Theproposal was seconded by Dr. Montgomeryand the Resolution was adopted.

A second proposed Resolution on ChildSafety in Air travel, was introduced by Dr.Kloiber, expressing concern that adequatesafety systems for babies and small chil-dren had not been implemented. After somediscussion the Resolution was passed unan-imously. ■

The author of the following note spent threemonths in the WMA Office this year andwrites about the experience and what itoffers.

The voice of the World Medical Associationis considered as the opinion of millions ofphysicians from every region of the world.Its function has always been to constitute afree, open forum for the frank discussion ofmatters related to medical ethics, medicaleducation, and socio-medical affairs. Withits declarations and statements it has con-tributed significantly to national and inter-national debates. Approved by its GeneralAssembly, WMA documents guide nationalmedical associations, health care, govern-ments, non-governmental organisations andUnited Nations agencies.

The World Medical Association has also,however, always been involved in manyother activities beyond statements and reso-lutions. A number of global projects andprogrammes are continuously initiated,supported or conducted by the WMA.These activities might not be as visible andwell known to the health care communityand the general public.

Who is doing all the work?

People might assume that a few tens ofhighly specialized staff members workinexorably in the high-tech offices of alarge WMA headquarters. The WMA mustsurely work with heavy administration andstaff budgets?

In truth, for reasons of economy, and inorder to operate within the vicinity ofGeneva-based international organizationslike the WHO and other UN agencies, theInternational Red Cross and internationalassociations, the WMA Secretariat wastransferred in 1975 from New York to itspresent location in Ferney-Voltaire, Franceclose to Geneva.

Membership of the World MedicalAssociation is voluntary and its budget isfunded from membership fees from nation-al medical associations. Hence, funds arelimited and vary significantly. The WMAhas been a marvel in managing projects,programmes and its meetings and assem-blies with extremely small budgets. ItsSecretariat operates with a small permanent

staff only, but manages to accomplish animpressive amount of work.

The WMA would certainly be interested tocommit itself to even more projects andactivities. However, more manpowerwould be necessary. One way to increasecapacities at WMA is its programme forhealth care professionals to spend three tosix months at the WMA Secretariat inFerney-Voltaire. National medical associa-tions may use this opportunity to send astaff-member for a short-term “training” atthe WMA Secretariat.

There is certainly no better way to get toknow the work of the WMA and experi-ence the job environment of a truly interna-tional organization.

It is a win-win-situation

Fellows are able to dive into „hands on“work from the very first day. Apart fromsome routine work which clearly helps tounderstand the every-day work of an inter-national organization, Fellows have thechance to take on the management of indi-vidual projects. Fellows routinely interactwith senior health care experts from thevarious health care organisations and workself-responsibly and independently.

For example, this summer the WMA start-ed a project to develop an online course forphysicians on multi-drug-resistant tubercu-

Beyond statements and resolutions – Workingat the WMA Secretariat in Ferney-VoltaireDr. Ramin Parsa-Parsi, MD, MPH, German Medical Association

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losis (MDR-TB). The WMA had previous-ly developed a similar programme forphysicians in prisons. This training courseis being developed to train physicians tomore effectively diagnose, prevent andtreat MDR-TB. The WMA is collaboratingwith the South African MedicalAssociation and its Foundation forProfessional Development on this project.The WMA is also collaborating with theWHO and several national medical associ-ations in order to produce a state-of-the artand universally accessible product. TheNorwegian Medical Association is trans-forming the material into the online formatand the German Medical Association ishelping with logistic support. The manage-ment and the coordination of the entire pro-ject is performed by WMA staff. Althoughthe coordination of all stakeholders andinternational experts can be challenging,helping to make this project happen is atruly exciting and rewarding task. The finalproduct will be an important contributionto the global fight against MDR-TB.

For another project the WMA collaborateswith the International RehabilitationCouncil for Torture Victims (IRCT) on aEuropean Union sponsored project. Usingthe “Istanbul Protocol” as a manual, physi-cians are trained in effective investigationand documentation of torture and othercruel, inhuman or degrading treatment orpunishment. The training seminars werecompleted in five pilot countries: Morocco,Mexico, Uganda, Sri Lanka and Georgia.WMA experts participated in coordinationand evaluation meetings and attendedpreparatory missions and training semi-nars. The WMA particularly fostered theidentification process with national med-ical associations and used its special exper-tise in medical ethics during seminars.Also, the collaboration with other organiza-tions, local authorities and consultants hasbeen helpful and important in the process.The continuation of the project with a newphase is projected to run over a three-yearperiod and will most probably start byJanuary 2006. The new project will includea consolidation of activities in the five cur-rent project countries and initiate activitiesin five new countries. Furthermore it willsupport capacity-building activities for

rehabilitation centres and strengthen thecollaboration between centres and localhuman rights organizations. The IRCT andthe WMA have a formal partnership in thisproject with shared responsibilities. Thecollaboration has been extremely good.Regular contact and discussions on keyissues helped ensuring a coordinated andefficient process.

Applications are welcomeBeing involved in the work of various dif-ferent projects, fellows will experience theentire spectrum of health care services andsystems. Furthermore, regular communica-tion with representatives of national med-ical associations, including new and futureWMA members, helps understanding thedifferences and similarities of physicianorganizations worldwide. Also helping toprepare Council meetings and the Annual

General Assembly is indeed rewarding. Inshort: Working at the WMA Secretariat is aunique experience.

National Medical Associations who areinterested in the fellowship programmemay contact the WMA Secretariat inFerney-Voltaire. Interested parties may alsocontact previous fellows for more detailedinformation.

Please contact:

Dr. Ramin Parsa-Parsi Phone: 030/ 4004 56-366

The World Medical Association13, ch. du LevantCIB - Bâtiment A01210 Ferney-VoltaireFrancePhone: +33 4 50 40 75 75Fax: +33 4 50 40 59 37e-mail: [email protected] ■

While currently the whole world seems toworry about the prisoners in GuantánamoBay those incarcerated in the other prisonsof Cuba seem to be forgotten. Men andwomen asking for nothing but freedom,who are not involved in terrorism, war oroppression, are being held as prisoners ofconscience permanently or repeatedly,some for decades. Many of them have notsurvived the special treatment by the Cubangovernment and others possibly will die.

While for many of us Cuba may be seen asa cheap Caribbean holiday resort, for thoseliving there the paradise may have somedark spots. For more than forty years Cubahas been under communist dictatorship.What has been overcome in most of the for-mer communist countries in Europe, terror,intimidation, oppression, and prosecution

of those who want freedom, still lives inCuba.

The “Cuban Spring 2003” stands for anaggressive “cleaning-up” campaign whichthe communists carried out in Cuba: As faras it is known in the free world, 75 personswere sentenced to long prison terms of upto 28 years. The way they are treated is sim-ilar for totalitarian regimes. Methodsinclude imprisonment far away from theirfamilies, placment together with violentcriminals, intimidation of family membersand reduced allowances for visits. Leftwithout sufficient food some loose weightrapidly, and food and medicine brought byrelatives has been taken away.

The World Medical Association has repeat-edly remembered the fate of CubanPhysicians. They are outstanding col-

From the Secretary General’s desk

“Don’t forget the others”

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leagues fighting for the freedom of theCuban People and for the freedom of med-icine in their country. What they currentlyget is hell on earth. Six of them are knownto us, they and their families and friendsdeserve our attention as examples of allthose who pay a high price in the strugglefor freedom. The following information hasbeen compiled from various sources:

Dr. OSCAR ELÍAS BISCET, 44 years old,a specialist in internal medicine, is the pres-ident of the unofficial Lawton HumanRights Foundation. He has been detainedmore than two dozen times, charged with‘insult to the symbols of the homeland,’‘public disorder,’ and ‘incitement to com-mit an offence’. Dr. Biscet has been kept inspecial punishment cells for refusing tocarry out disciplinary measures. BeforeSpring 2003 when Dr. Biscet was arrestedlast, he had already been in prison for 3years. Now in December 2005 it adds up to6 years.

To discourage visits by his family he wastemporarily imprisoned in Prison Kilo 8 inthe province of Pinar del Rio, sharing a cellwith twelve other prisoners. He has beensentenced to 25 years in prison.

DR. MARCELO CANO RODRÍGUEZ, 41years old, is National Coordinator of theunofficial Cuban Independent MedicalAssociation, an association of medical pro-fessionals around the island. For notrespecting the prison rules for criminals Dr.Cano has not been allowed to see the sunfor 10 month. Dr. Cano has been sentencedto 18 years in prison.

DR. JOSÉ LUIS GARCÍA PANEQUE,aged 39, is a plastic surgeon and a memberof the Cuban Independent MedicalAssociation. He has worked as a journalist,as director of the independent news agencyLibertad and member of the independentJournalists’ Society. Dr. Paneque’s weighthas dropped from 86 to 48 kg and he ispresently in the infirmary of “Las Mangas”Prison in Bayamo. His health continues tobe critical. His wife is currently beingthreatened with imminent mob attacksagainst their home Dr. Paneque was sen-tenced to 24 years in prison.

DR. LUIS MILÁN FERNÁNDEZ, 36 yearold, is a member of the Cuban MedicalAssociation. In June 2001 he and his wife,Lisandra Lafitta, also a doctor, signed adocument called ‘Manifiesto 2001,’ callingamong other measures for recognition offundamental freedoms in Cuba. Togetherwith other health professionals they carriedout a one-day hunger strike to call attentionto the medical situation of detainees andother issues. Although without emotional ormental problems, he is now confined withmental patients in the psychiatric ward ofthe Prison of Boniato, in the province ofSantiago de Cuba. Dr. Milán Fernández,had been sentenced to 13 years in prison.

ALFREDO MANUEL PULIDO LÓPEZ,aged 45, graduated in 1983 in the specialtyof Stomatology, and Dentistry. He practiceduntil 1998, when he was fired from his jobfor joining the Christian LiberationMovement. In 2001 he joined the unofficialnews agency El Mayor in Camagüey forwhich he worked as journalist. Incarceratedin the Maximum Security Prison Kilo 7 hishealth is rapidly deteriorating. He is notonly suffering from severe migraine, buthas also experienced several hypoglycemicepisodes. Instead of providing treatment hehas been threatened that he gets a psychi-

atric evaluation to find out the sources ofhis headaches. Dr. Pulido López has beensentenced to 14 years in prison.

RICARDO ENRIQUE SILVA GUAL, 32,physician and member of the ChristianLiberation Movement like Dr. PulidoLópez. Dr. Siva Gual suffering from glau-coma. Dr. Silva Guall has been sentenced to10 years in prison.

Sources:

Coalition of Cuban-AmericanWomen/LAIDA [email protected].

Human rights firsthttp://action.humanrightsfirst.org/cam-paign/Biscet

Amnesty Internationalhttp://web.amnesty.org/library/Index/ENGAMR250022005

Internationale Gesellschaft fürMenschenrechtehttp://www.igfm.de

Medicina Cubanahttp://medicinacubana.blogspot.com/2005_09_01_medicinacubana_archive.html

For further information monitor our web-site: www.wma.net ■

Geneva, Switzerland, 9 November 2005.“Thank you for making this a remarkableand productive meeting. The world hasbeen watching and listening as, over thesethree days, the scale of the challenges hasemerged. The international solidarity toconfront these threats is clear. The urgencyof acting now is felt by us all. Precise rec-ommendations for action have emerged.Equally, precise offers of help and support

have been put forward, by both developingand industrialized countries.

I will now review the central points thathave come out of the meeting. Next I willoutline an integrated programme of actionwhich responds to the issues raised.

1. Minimizing the threat at source to bothanimal and human populations throughrapid reduction of the viral burden of

WHO

FAO/OIE/WB/WHO Meeting on AvianInfluenza and Human Pandemic InfluenzaClosing remarks of Dr. LEE Jong Wook, D.G., WHO

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H5N1 is essential. This entails timelynotification of outbreaks in birds, poul-try culling and vaccination as indicated,including „backyard“ flocks, and provi-sion of appropriate compensation forfarmers.

2. “Early warning” and surveillance sys-tems for animal and human influenza arecritical to effective response. The currentwindow of opportunity to intervene ismeasured in days. Transparent andimmediate reporting is essential.

3. The introduction of avian infection withH5N1 to other countries is predicted,following the patterns of migratorybirds, and as a result of production sys-tems and market practices. Other strainsof avian flu are also an ongoing andemerging threat and must be monitored.Strengthened veterinary services are acrucial aspect of detection and response.Open sharing of virus samples is essen-tial. Quality assured animal vaccinesproduced to international standardsshould be used in healthy poultry whenappropriate.

4. At present many governments are notready to cope with outbreaks, still less apandemic. Preparedness is vital in everycountry, in every Region. Integratedcountry plans will build on and strength-en existing systems and mechanisms.They will be comprehensive, costed, andevaluated. Response mechanisms shouldbe rehearsed through simulation exercis-es. These plans will include protection ofvulnerable groups such as children,refugees and displaced populations.

5. Resources needed to slow down or con-tain the emergence of a pandemic areinsufficient. Supplies of antiviral drugscurrently do not meet potential demand.Issues remain of equitable access tomedicines and deployment of stockpiles.

6. A universal non-specific pandemic vac-cine may be the ultimate protective solu-tion for human influenza. „Smart“ solu-tions are being investigated. Issues oftechnology transfer, resolution of licens-ing and regulatory obstacles, sustained

use of good manufacturing practices andpre-qualification are under discussion.Predictable, increased orders for season-al flu vaccine will support greater manu-facturing capacity, including in develop-ing countries.

7. Communications. The recent series ofhigh-level meetings on avian influenzaand human pandemic influenza havesuccessfully created a shared agenda.The public needs clear, regular, reliableinformation. Civil society, nongovern-mental organizations and other commu-nity groups must be involved.

8. A rich array of resources is potentiallyavailable to support government andinstitutional efforts. Countries that havesuccessfully controlled outbreaks ofavian influenza are prepared to help oth-ers.

9. Mechanisms for donor support are inplace. There is broad commitment tominimize transaction costs of interna-tional support through alignment andharmonization. International support tocountry plans should supplement nation-al resources, as well as existing donorresources, and should target resource-poor countries.

10. Investments are urgently needed atnational level – potentially reaching 1billion dollars over the next three years.An additional 35 million dollars is need-ed immediately to support high priorityactions by technical agencies at the glob-al level over the next six months.

The 10 points I have outlined need detailedand concrete actions. This meeting hasidentified a series of integrated actionsthat will start straight away.

1. Support the development of integratednational plans for avian influenza con-trol and human pandemic influenza pre-paredness and response.

2. Assist countries in aggressive control ofavian influenza in birds, and deepen theunderstanding of the role of wild birds invirus transmission.

3. Nominate „rapid response“ teams ofexperts to support epidemiological fieldinvestigations.

4. Strengthen country and regional capacityin surveillance, laboratory diagnosis,and alert and response systems.

5. Expand the network of influenza labora-tories, with regional collaborative sys-tems for access to reference laboratories.

6. Establish and integrate multi-countrynetworks for the control or prevention ofanimal trans-boundary diseases, andregional support units as established inthe Global Framework for theProgressive Control of Trans-boundaryAnimal Diseases.

7. Expand the global antiviral stockpile,and prepare standard operating practicesfor its rapid deployment to achieve earlycontainment.

8. Assess the needs and strengthen veteri-nary infrastructure in line with OIE stan-dards.

9. Map out a global strategy and work planfor coordinating antiviral and influenzavaccine research and development, andfor increasing production capacity andequitable access.

10.Put forward proposals to the WHOExecutive Board at its 117th meeting forimmediate voluntary compliance withrelevant articles of the InternationalHealth Regulations 2005.

11.Finalize detailed costing of countryplans and the regional and globalrequirements to support them, in prepa-ration for the January pledging meetingto be hosted by the Government ofChina.

12.Finalize a coordination frameworkbuilding on existing mechanisms at thecountry level, and at the global level,building on international best practices.

This is a challenging agenda which willrequire all our best efforts.” ■

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Public health experts have confirmed that apolio epidemic in ten countries in west andcentral Africa – Benin, Burkina Faso,Cameroon, Central African Republic, Chad,Côte d’Ivoire, Ghana, Guinea, Mali andTogo – has been successfully stopped. Theepidemic has paralysed nearly 200 childrenfor life since mid-2003, but no new caseshave been reported in these countries sinceearly June. At the same time, polio eradica-tion efforts are intensifying in Nigeria,where extensive disease transmission con-tinues, as part of a mass polio campaignacross 28 African countries beginning today.

Emergency efforts to stop the epidemic hadbeen launched under the auspices of theAfrican Union (AU), and largely underwrit-ten through US$ 135 million in emergencyfunding from the European Commission(EC), Canada and Sweden. The ten coun-tries, which had previously been polio-free,participated in a series of mass immunisationdrives across 23 countries, reaching as manyas 100 million children with multiple dosesof polio vaccine over the last 18 months.

Speaking on behalf of donors, EuropeanCommissioner for Development andHumanitarian Aid, Mr Louis Michel, said:„The reversal of these epidemics is precise-ly what EC development objectives are allabout. Such a rapid return on developmentinvestment is good for Africa, good fordonors, and most importantly, good for thechildren of Africa.“

Experts cautioned, however, that ongoingdisease transmission in remaining endemicareas continues to pose a risk of more out-breaks across the region. To minimise thisrisk, 28 African countries – including theten countries which have stopped their epi-demics – today launched the first elementof a ‘maintenance’ programme to sustainthis progress, with an additional series ofsynchronized immunisation activities toreach more than 100 million children withpolio vaccine in November and December.

The ‘maintenance’ programme is part of afour-pronged strategy to protect the US$ 4

billion invested globally since the 1988launch of the Global Polio EradicationInitiative. The other elements of the strate-gy include: strengthening routine immuni-sation at country level in close collabora-tion with the Global Alliance for Vaccinesand Immunisation (GAVI) and through thenew Global Immunisation Vision andStrategy (GIVS); increasing surveillancesensitivity and outbreak response capacity,and increasing both the number and qualityof polio campaigns in the remainingendemic areas, particularly in Nigeria.

The Nigerian government has signalledstrong commitments to further strengthen-ing its polio eradication programme. Withvirus now beaten back to the north of thecountry, efforts are focusing on re-deploy-ing support staff to the northern states dur-ing the upcoming immunisation campaigns.To succeed, however, Nigeria needs theongoing support of the international com-munity to ensure every child is reachedthroughout the country with polio vaccine.

Key to success is ensuring the necessaryfunds continue to be made available. A US$200 million funding gap for 2006 musturgently be filled, US$ 75 million of whichis needed by December, to ensure activitiesin the first quarter of next year can proceed.Underlining the urgency of closing thefunding gap, late arrival of funds may com-promise the quality of the immunisationcampaigns in some countries.

To support Nigeria and west and centralAfrica in polio eradication efforts, RotaryInternational is also gearing up its supportto the region. „Rotary club members fromacross North America, Europe and Asia arejoining fellow Rotarians in Africa to partic-ipate in the polio campaigns,“ commentedCarl-Wilhelm Stenhammar, President ofRotary International. „At Rotary, we arecommitted to doing everything we can tosupport Africa in their polio eradicationefforts“.Rotary International and its 1.2million volunteers worldwide have beenintegral to the global eradicate of polio.

Collectively, Rotarians have committedwell over US$ 600 million to the effort, andcontributed countless volunteer hours dur-ing immunization campaigns.

The polio eradication coalition includesgovernments of countries affected by polio;private sector foundations (e.g. UnitedNations Foundation, Bill & Melinda GatesFoundation); development banks (e.g. theWorld Bank); donor governments (e.g.Australia, Austria, Belgium, Canada, Den-mark, Finland, France, Germany, Ireland,Italy, Japan, Luxembourg, Malaysia,Monaco, the Netherlands, New Zealand,Norway, Oman, Portugal, Qatar, the Rus-sian Federation, Spain, Sweden, UnitedArab Emirates, the United Kingdom andthe United States of America); theEuropean Commission; humanitarian andnongovernmental organizations (e.g. theInternational Red Cross and Red Crescentsocieties) and corporate partners (e.g.Sanofi Pasteur, De Beers, Wyeth).Volunteers in developing countries alsoplay a key role; 20 million have participat-ed in mass immunization campaigns.

Since 1988, global eradication efforts havereduced the number of polio cases by morethan 99%, from 350,000 annually to 1,469cases in 2005 (as of 1 November). Six coun-tries remain polio endemic (Nigeria, India,Pakistan, Afghanistan, Niger and Egypt),however poliovirus continues to spread topreviously polio-free countries. In total, 11previously polio-free countries have beenre-infected in late 2004 and 2005 (Somalia,Indonesia, Yemen, Angola, Ethiopia, Chad,Sudan, Mali, Eritrea, Cameroon and Nepal).

For more information contact:

Sona Bari Oliver RosenbauerTelephone: +41 22 791 1476 Telephone: +41 22 791 383

Email: [email protected] Email: [email protected] Benin, Burkina Faso, Cameroon, Cape Verde,

Central African Republic, Chad, Côte d’Ivoire,the Democratic Republic of the Congo,Djibouti, Equatorial Guinea, Eritrea, Ethiopia,Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania,Niger, Nigeria, Senegal, Sierra Leone,Somalia, Sudan and Togo. ■

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These projects will be implemented byESA with the technical assistance of WHO.

Nowadays, the use of satellite-based Infor-mation and Communications Technologies(ICT) for telemedicine is progressing fromthe scouting phase towards a more stable andoperational profile, where integration intoexisting healthcare systems and the attain-ment of self-sustainability is increasinglybecoming an essential condition for success.

In this frame, the European Space Agencyin line with the recommendations of theTelemedicine Working Group (ref.‘Opportunities and Challenges of eHealthand Telemedicine via Satellite’, EuropeanJournal of Medical Research, vol.10, 2005,http://telecom.esa.int/telecom/media/docu-ment/Scientific%5FPublication%5FESA%5F Telemed.041222.final.pdf) is issuingthree invitations to tender to demonstratethe exploitation of Satcom in Telemedicineand validate the associated sustainabilitythrough a user driven approach.

The ultimate goal of this action is to pavethe way for a European Telemedicine viaSatellite Programme of direct benefit forthe Health community and which will bedeveloped in close consultation with WHO.The three invitations to tender are focusedon the following thematic areas:

Health Early Warning

The activity on Health Early Warning willbe aimed at the integration, deployment andvalidation of a Satcom based system devot-ed to gathering data from the field to predictcommunicable disease diffusion patternsand associated risks of outbreak. The sys-tem will also provide a fast and resilientway to distribute, over geographical areasearly warning and information to the popu-lation to facilitate the establishment of ade-quate protective measures to safeguard thepopulation’s health. The system will be con-ceived, in particular, to face healthcare con-sequences of catastrophic events.

Interconnectivity for Health-care Services andProfessional MedicalEducation bridgingCommunities in Eastern andWestern Europe

The activity of Interconnectivity forHealthcare Services and ProfessionalMedical Education bridging Communitiesin Eastern and Western Europe will estab-lish a pilot exploitation period and validatethe associated sustainability of the devel-oped satellite based service supportingremote medical consultation and healthcareprofessional education and collaborationbetween two medical systems, one in a

remote areas of Eastern Europe, and theother in a Western European country.

Management of MedicalEmergency for CommercialAviation

The activity of Management of MedicalEmergency for Commercial Aviation willbe aimed to develop, integrate and validatein an operational environment a telemedi-cine service to support diagnosis from on-board civil aircrafts. The system will pro-vide interactive multimedia data exchangebetween aircraft and ground based medicalcenters to support decisions, in cases ofmedical emergency, on whether to go for aflight diversion and which actions to takeon board.

The details of these three invitations totender are available at the following URLaddress: ftp://ftp.estec.esa.int/pub/telemedi ■

A number of meetings in the European re-gion relating to health issues are of interestat both regional and international levels. Inan interesting development in 1994 an ini-tiative supported by the Catalan governmentand the European Union in a conferencesought to explore health care and healthcareproblems in the Mediterranean region. Enti-tled Euromed Health Forum (EuromedSalud) the outcome was the Declaration ofBarcelona (1994) urging co-operation in thehealthcare field between all the countriesbordering on the Mediterranean Sea, includ-ing those on the north coast of Africa, and atthe eastern end of the Sea. In November ofthis year the tenth anniversary of this wascelebrated with a further highly successfulForum in Barcelona. It explored such areasas health policy development, the use oftelemedicine and the regulation and licens-ing of healthcare physicians and other work-ers. A further declaration was issued ex-pressing the view of the Forum that these di-

alogues should continue and that a furthermeeting take place in two years time. Thisinitiative to dialogue and explore positivecollaboration represents a potentially inter-esting development in collaboration in theHealth sector between the northern side ofthe Mediterranean (mostly European Unioncountries), those at the eastern end, and onthe north African coast.

For more than 20 years there has been an an-nual meeting under the title of EuropeBlanche under the aegis of the Institut desSciences de la Santé (Paris), to discuss aspecific major health or health professionalproblem. These have included such topics asEurope and Medicines, Continuing medicaleducation, The Therapeutic Revolution etc.These meeting have provided an importantforum at which leading figures with an in-terest in health including researchers, physi-cians, healthcare providers and organisers,economists, ministers and other politicians

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and other relevant persons in society havebeen able to meet and discuss issues during atwo day meeting. The enlargement of theEuropean Community to 25 has introducednew considerations into the discussions.This year the meeting was held in the Bu-dapest, capital of one of the new members ofthe EU, the topic for discussion was “LivingLonger but Healthier Lives” exploring howto achieve health gains in the Elderly of the

European Union. At these meetings the Se-nior and Junior Europe and Medicine Prizesare awarded.

Finally, at a meeting organised by WMA andthe Caring Physicians of the World Net-work, leaders of national medical associa-tions in the European Region of the WorldMedical Association met in Prague in No-vember to discuss two major issues. Presen-

tations were given by WHO and other ex-perts on the two topics of discussion. Thefirst was on the “Skills Drain” among physi-cians and what actions NMAs can take. Thesecond topic was Human Avian Influenzawhen the meeting considered what actionscan be done by NMAs in collaboration withother institutions to prepare for a potentialpandemic. The presentations and discus-sions were both lively and productive. ■

Under the aegis of the Caring Physicians ofthe World Initiative, members of the GeneralAssembly of CONFERMEL met with repre-sentatives of WMA to discuss issues of im-portance to the medical profession, HealthPolicy and reform of the Health Sector, thenew role of physicians in society and howNMAs can meet the emerging needs of theirmembers at a meeting held on 10th Octoberprior to the WMA Assembly. A manifestowas issued in the name of the 12 countriespresent, Argentina, Bolivia, Brasil, CostaRica Ecuador, Honduras, Mexico, Nicaragua,Panama, Peru, Venezuela and Uruguay. It re-ferred to the difficult situation in these coun-tries such as poverty and unfairness which

continue, despite some advances in growthindices. In particular reference was made tothe consequent nutritional deficiencies, lackof sanitation ,drinking water and the highprevalence of malaria, dengue AIDS and tu-berculosis. Concern was expressed that theprocesses of reform and modernisation of thehealth sector in these countries promoted pri-vatisation of the public sector, deepening theinequities without substantial improvementin the quality of life and excluding large seg-ments of the population from health care.

Pointing out that reform and modernisationof the Health sector needs the participationof representative organisations of healthprofessionals attention was drawn to the

“The 2nd KEMAT team arrived in Abbot-tabad in the morning of October 22 andtook over all the tasks frorn the 1 teamwithout any reservatinn. As many yo physi-cians have joined the 2nd team, mostlycomposed by staff of Asian Medical Centerin Seoul, the camp was full of energy andvibrancy. Lawrnaker Mr. Seok Hyun Lee,the Chairperson of Health and WelfareCommittee of Korean National Assembly,also joined this team and supported all thecommitment and hard work of all the Kore-an medical teams and rescue teams dis-

patched to the quake-hit-areas taking afield assessment from Abbottabad via Bal-akot to Muzaffarabad. Over ten KoreanNGO`s are taking part in voluntary medicalwork in Patika, Balakot, Muzaffarabad,Batagram and Abbottabad.

Cases of scabies are continuously on therise and many people, especially children,are still in need of long-term medical atten-tion after being amputated. Dr. Irfan Khat-tak, general surgeon of Ayub Medical Com-plex and coordinator of voluntary medical

work said that they need medical equip-ment such as DERMATOSE or MESHERto take care of these patients. Drugs foranesthesia are also needed. Moreover, men-tal shocks they are going through alsoshould be brought under delicate treatment.

Operation Rooms of Ayub Medical Com-plex, once shut down of additional collapseare now functioning little by little. The 2ndKEMAT conduction five major surgeriesincluding skin graft for open fractures, K-Wire Reconstruction Operation andPROSTALAC at operation rooms in coop-eration of Pakistani doctors.

In Balakot mobile clinic, considerablenumbers of patients are suffering from diar-rhea and de-hydration. Scabies is a majorconcern here, too. The 2nd team has treatedtotal 2,810 patients (2,485 at Ayuh MedicalCenter, and 325 in Balakot mobile clinic).

Latin America and the Caribbean lack of priority given by governments in re-source allocation to the health care systemswhich among others affects quality of careand the rights of physicians and otherhealth personnel. The manifesto denouncedthe indiscriminate creation of medicalschools without social necessity, and thecreation of non-medical careers permittingthe illegal practice of medicine.

Expressing concern about inequitable com-mercial agreements relating to intellectualproperty and pharmaceuticals which limit ac-cess of citizens to drugs, and disregardingWTO agreements, the manifesto ends by reit-erating the professional organisations' commit-ment to the supervision of the quality of med-ical care and the autoregulation of the profes-sion through obligatory membership of a col-lege in accordance with national legislation. ■

Korean Medical AssociationActivity Report of the KMA Medical Team in to quake-affectedareas in Pakistan(Extract from this interesting report. Ed.)

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Replacing the tasks of the 2nd team, the 3rdKEMAT team, composed of six doctors,five nurses, one pharmacist, one policemanand two administrative staff, arrived in Ab-bottabad on October 29. The 3rd team spe-cially is composed by the staff of NationalPolice Hospital.

Due to the huge difference of temperaturesbetween day and night, the number of pa-tients coming down with the ART (AcuteRespiratory Infections) continues to inerease.At Ayub Medical Complex, quake-relatedemergency patients have decreased promi-nently, compared to the situation of twoweeks ago and more and more patients withchronic diseases come to see a doctor andwant to get medicines for their diseases.However patients in need of minor surgerydressing, cast and suturing still an average70–80 people a day.

More equipment and efforts are necessaryto be put prevention of epidemics. Al-though KEMAT is carrying out some pre-vention steps using a smoke disinfector,more organized projects should be urgentlyarranged and carried out.

In Balakot mobile clinic, cases of diarrheaskin diseases like scabies, and ARI are still

topping the list and many patients needingto get their dressing renewed, or need to getcare after ampulation keep visiting the mo-bile clinic.

The 3rd team has treated 3,395 patients all to-gether (2,353 at Ayub Medical Complex and1,040 at mobile clinic in Balakot), makingthe total number of patients through the ac-tivities of KEMAT is 7,505 approximately.

Ending its voluntary medical works, theKEMAT donated medicines (anti-scabiesdrugs, antibiotics, fluids, etc.) and medicalsupplies left from their activities to theAyub Medical Complex and some medi-cines to the Good Samaritan Hospital runby Korean missionaries in Pakistan.

Contact info of Korean Medical Associa-tion Medical Team (KEMAT; KMA Emer-gency Medical Assistance Team):

Ms Yoonsun Park, Chief of Strategie Plan-ning Team, KMA:

+822 794 2474 (ext. 120) (oftice) / +82 11792 6908 (mobile phone) ■

Sir,

First let me introduce myself: I am aPaediatric Surgeon, former Head of theDepartment of Surgery of the mainLisboa’s Children’s Hospital and also a for-mer President of the WMA (more than 20years ago – 1981/1983).

Secondly I would like to congratulate youand your co-workers for the excellent qual-ity of the “World Medical Journal”, which Iread always with great interest.

Finally I have to make a short comment onyour article “Saving the lives of SiameseTwins” [WMJ 51(2) 30-31, 2005].

My experience started in 1978 and stemsfrom 7, fully and personally operated pairs,with 9 survivors and 5 deaths (in one pairone child was already dead on arrival,another died of “malignant hyperthermia”after separation had already been per-formed, and the remaining one patientdying 1 month post-operatively, with peri-tonitis due to a leak in an intestinal anasto-moses). Lisboa and its Hospital D.Estefania, are not as fashionable and well-known worldwide, as the Hospital for SickChildren, (GOS), in London…!

My longest operation, with “total” recon-struction of omphaloischiopagus twins(boys, of which one had to remain a girl,due to only one existing penis) took 13.30hours, because, taking into account thetraining I received in England (GOS andAlder Hey), I was able to conduct the wholeoperation, in both twins, from “top to bot-tom” (and not having, at my side, severalsub-specialist, working in succession, in theAmerican Style). Also skin expandersproved unnecessary, after adequate iliacosteotomies.

The 7 survivors lead totally normal lives,and the 2 latest ones have only minor prob-lems and lead also, practically, normallives. The liver is usually the least problem,with no significant haemorrhagic danger, asnormally a reasonable noticeable demarca-tion exists between the 2 individual seg-

ments. The most difficult problem, for agood functional and aesthetic outcome, isassociated with the urinary tract, followedby the intestines. Osteotomies in the iliacbones usually do away with the need to usepreviously insert skin expanders.

In my opinion liver transplantation is not aprimary factor in the treatment of Siamesetwins, and its progress, no matter howdesirable it certainly is, will not benefitthese children (at least directly). Goodanaesthesia and intensive care (includingnurses), are the real issues, apart fromsurgery itself. No matter how well a sur-geon works, if anaesthesia and intensivecare are not also as good, the result may bedisastrous. In fact, the only really inopera-ble Siamese twins are those with a “com-mon heart”, and in which, the existing heartand major vessels, cannot be useful for anyof them (so malformed they are…).

As Horsley once said, “A beautiful opera-tion that ends with the death of the patientis not satisfactory surgery”.

Finally I believe it is completely wrong anda real pity, to abort Siamese twins, found atroutine echographies (as well as someapparently major malformations), as mod-ern Paediatric Surgery is able to correctthem (allowing those human beings, to leadnormal, useful and happy lives). Thatshould, I feel, be the main message to pro-mote!

Unfortunately abortion is what we find inthe “so-called” developed countries. Mostoperated Siamese twins come from devel-oping countries, where echography is notcurrently available and the diagnosis ismade only after birth!

Yours sincerely

Prof. Dr. Antonio Gentil Martins Rua de Campolide 166-G Lisbon 1070-096 PORTUGALEmail: [email protected] ■

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Sir,

With regards to your article about ‘Spray-on Skin Grafts’. I think this technique andother similar techniques involving the cul-ture of skin stem cells still has a long wayto go before they can be used for burnsinvolving the full thickness of the skin. I amnot familiar with the technology used atEast Grinstead but I suspect it may havebeen rather over hyped. Just this week therehas been an article in the Lancet from aFrench group using foetal skin cells whichgrow rapidly and are incorporated into acollagen matrix which have been used suc-cessfully in a small number of patients but

it is really a biological dressing which isreplaced by host tissue. The use of culturedskin cells obviously is attractive particular-ly now that the stem cells of the skin cannow be identified and grown quite rapidlybut this still provided a very thin layerwhich would not be adequate to replace afull thickness burn following excision ofthe scar.

However, this is an important area of devel-opment and many groups around the worldare working on the culture of cells of the skinand particularly the stem cells of the epider-mis and without question in due course suc-cessful clinical applications will be devel-

oped that would allow permanent replace-ment without scarring. This then would beperhaps suitable in reconstruction of the face.

Yours sincerely

Sir Peter Morris AC FRS FRCSHead, Centre for Evidence in Transplan-tation,Emeritus Professor, University of Oxford,Honorary Professor, University of London

The Royal College of Surgeons of England35-43 Lincoln’s Inn Fields, London WC2A 3PEwww.rcseng.ac.uk ■

Ethics of Research and Treatment inDeveloping Countries

François and Emmanuel Hirsch, editorsCollection Espace éthiqueParis, Librairie Vuibert, 200514.50 EuroISBN 2 7117 7278 0

When the World Medical Associationundertook the latest revision of theDeclaration of Helsinki in 1997, it encoun-tered issues in the application of ethics tomedical research in developing countriesthat had not arisen previously. The mostcontroversial articles in the 2000 version ofthe Declaration are precisely those thataddress these issues, namely, paragraph 29that deals with the comparator to be used ina clinical trial, and paragraphs 19 and 30that specify the obligations of researchersand research sponsors to those who serve asresearch subjects.

These same issues have been considered inother international statements on researchethics such as the 2001 National BioethicsAdvisory Commission (U.S.A.) report,

Ethical and Policy Issues in InternationalResearch: Clinical Trials in DevelopingCountries, the 2002 Council for InternationalOrganizations of Medical Sciences (CIOMS)International Ethical Guidelines forBiomedical Research Involving HumanSubjects, the 2002 Nuffield Council (U.K.)report, The Ethics of Research Related toHealthcare in Developing Countries and its2005 follow-up discussion paper with thesame title, and the 2003 European Group onEthics in Science and New TechnologiesOpinion #17 on the Ethical Aspects ofClinical Research in Developing Countries.As the 2005 Nuffield Council discussionpaper explains, these documents do not agreeon many of the key issues in research indeveloping countries.

In October 2002, a conference was held inParis to discuss these issues with particularreference to the francophone countries ofAfrica. The proceedings of this conferenceare the subject of this review. Many of thecontributors are African and they do not hes-itate to criticise the dominant ‘Western’ par-

adigm of medical research as it is applied intheir countries.

Two sets of essays set out the context forthe presentations that follow. The first dealswith the principles of human rights andmedical research, and the second describesthe methodology of clinical trials and relat-ed ethical issues.

The major part of the book consists ofseven substantial essays on Africanapproaches to biomedical research, each ofwhich points out shortcomings in the appli-cation of ‘Western’ research methodologyin Africa. According to Godfrey B. Tangwa,this methodology is based on a worldviewthat is quite alien to Africans, for whom“metaphysical concepts, ethics, customs,laws and taboos form a unique ensem-ble…” (p. 57). Whereas Western approach-es display an excess of epistemologicalconfidence, bordering on arrogance andoften resulting in imprudence, “the princi-pal value underlying African worldvisionsand concepts is its epistemological humilityand respectful prudence…” (p. 60). Certain

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ethical principles of great importance inWestern society, such as the confidentialityof personal information, must be applieddifferently in Africa where the family andthe community, not the autonomous indi-vidual, are the fundamental social units.The widespread suspicion of Westernresearchers and the revelations of racistmedical research in apartheid-era SouthAfrica, have provided fertile ground for thespread of conspiracy theories regarding theorigin and treatment of diseases such asHIV/AIDS. The rationing of medical treat-ment by ability to pay rather than by need iscontrary to the African view of healthcareas a service, not a commodity. To illustratethe Western attitude to Africa, Tangwa pro-vides a case study of a medical researcherin Cameroon who developed a promisingapproach to a vaccine for HIV but wasunable to get funding from any of theWestern research agencies because it didnot fit their paradigm of medical research.

An important concept in both medicalresearch and medical treatment is ‘quality’.In his article, Jean-Godefroy Bidima raisesmany questions regarding how this conceptapplies in Africa – quality of what, qualityfor whom, and how should it be measured(pp. 80-83). He goes on to discuss why theWestern concept of informed consent isinapplicable in much of Africa: “In certainAfrican cultures one does not express arefusal to someone in authority. Oneexpresses a refusal by not carrying out anorder that has been given, but formally oneagrees in order that the authority does notlose face. The caregiver is an authority, andwhen a sick African gives consent, whatdoes that signify? An agreement or simplepoliteness?” (p. 85)

The African understanding of clinical trials(‘essais thérapeutiques’) is explored byAssétou Ismaëla Derme in relation to pro-posed treatments for malaria. As with otherailments, malaria is considered to be notjust a physical affliction but a result ofupsetting the relationships of natural andsupernatural forces. Healing thereforerequires spiritual as well as physical mea-sures. Research on the prevention and treat-ment of malaria is complicated by the mul-tiple local terms used for the different phas-es of this illness. Researchers must take all

these factors into account when undertak-ing projects in Africa.

In the Ivory Coast, according to LazareMarcelin Poame, the concept of free andinformed consent to medical research ortreatment is largely unknown. Physiciansare the experts and the patient is expected,and expects, to follow their orders.Moreover, busy physicians simply do nothave the time required to present all theirpatients with the information necessary forinformed consent. Where consent is sought,it is usually from the family rather than theindividual patient. Despite all these obsta-cles, Poame believes that the practice ofinformed consent is achievable in the IvoryCoast and offers concrete suggestions formoving in this direction.

A French social scientist, ChristophePerrey, reports on a research project oninformed consent conducted in the IvoryCoast in which 57 women were interviewedabout their understanding of clinical trials,including the meaning of placebo. Despiteexplanations, it turned out that none of thewomen could explain what a placebo is andthey all were convinced that they hadreceived the experimental drug. Other chal-lenges to informed consent were differentunderstandings and terminology for thesymptoms and causes of diseases, the diffi-culty of getting spousal consent for awoman’s participation in the trial, andrumours about toxicity of the proposedintervention. If the principle of informedconsent is to be implemented in such set-tings, much more work is needed on itspedagogy.

In May 2002 the French National Agencyfor AIDS Research published a Charter ofEthics for Research in DevelopingCountries that addresses many of the issuesraised at this conference. In presenting theCharter, Brigitte Bazin noted some of thedifficulties in its implementation, includingthe absence of ethics regulations and com-mittees in many developing countries, thelack of resources for those ethics commit-tees that do exist, and the inability of non-profit agencies to provide continuing careto participants in research as required by theDeclaration of Helsinki.

In the final contribution from Africa,Patrice Emmanuel Mbo Abenoyap providesa perspective on these issues from Africantheology. Africans live simultaneously intwo worlds: the visible one of humans andfinite creatures and the invisible one ofenergies and powers. In the former, individ-uals are subordinate to the community; inthe latter, they are subordinate to supernat-ural forces. Both relationships challenge theWestern concept of individual autonomyand the related principle of informed con-sent. Moreover, the fact that one’s family isoften the only source of funds for one’smedical treatment entails that the familyhas a legitimate role to play in the consentprocess.

To complete the list of issues that need to beconsidered in relation to the ethics ofresearch in developing countries, the edi-tors included as an annex a summary of dis-cussions that took place in Paris in January2001 and that presumably inspired the con-ference that led to this book. The additionalissues mentioned include the following: theright to health, global disparities, lack ofdemocracy in some developing countries,the needs of migrants, corruption (a two-way process, involving corrupters as wellas corruptees), taboos, and learning fromdeveloping countries.

None of the issues, problems and chal-lenges raised in this book admits of easyanswers. However, they must first be recog-nized, and the authors have provided avaluable service in pointing out both theo-retical and practical difficulties in the appli-cation of international standards of researchethics in developing countries. The sugges-tions they make for improving the situationare worthy of further consideration, but asthe authors would be the first to admit,much more needs to be done. All thoseresponsible for international research ethicsshould follow the example of the editors ofthis book in seeking meaningful involve-ment of developing country representativesin both the review of policies and in thedesign and implementation of researchstudies.

John R. Williams, Ph.D.Director of EthicsWorld Medical Association ■

CHINA EChinese Medical Association42 Dongsi XidajieBeijing 100710Tel: (86-10) 6524 9989Fax: (86-10) 6512 3754E-mail: [email protected]: www.chinamed.com.cn

COLOMBIA SFederación Médica ColombianaCalle 72 - N° 6-44, Piso 11Santafé de Bogotá, D.E.Tel: (57-1) 211 0208Tel/Fax: (57-1) 212 6082E-mail: [email protected]

DEMOCRATIC REP. OF CONGO FOrdre des Médecins du ZaireB.P. 4922Kinshasa – GombeTel: (242-12) 24589/ Fax (Présidente): (242) 8846574

COSTA RICA SUnión Médica NacionalApartado 5920-1000San JoséTel: (506) 290-5490Fax: (506) 231 7373E-mail: [email protected]

CROATIA ECroatian Medical AssociationSubiceva 910000 ZagrebTel: (385-1) 46 93 300Fax: (385-1) 46 55 066E-mail: [email protected]

CZECH REPUBLIC ECzech Medical Association .J.E. PurkyneSokolská 31 - P.O. Box 88120 26 Prague 2Tel: (420-2) 242 66 201/202/203/204 Fax: (420-2) 242 66 212 / 96 18 18 69E-mail: [email protected]: www.cls.cz

CUBA SColegio Médico Cubano LibreP.O. Box 141016717 Ponce de Leon BoulevardCoral Gables, FL 33114-1016United StatesTel: (1-305) 446 9902/445 1429Fax: (1-305) 4459310

DENMARK EDanish Medical Association9 Trondhjemsgade2100 Copenhagen 0Tel: (45) 35 44 -82 29/Fax:-8505E-mail: [email protected]: www.laegeforeningen.dk

DOMINICAN REPUBLIC SAsociación Médica DominicanaCalle Paseo de los MedicosEsquina Modesto Diaz Zona UniversitariaSanto DomingoTel: (1809) 533-4602/533-4686/533-8700Fax: (1809) 535 7337E-mail: [email protected]

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EGYPT EEgyptian Medical Association„Dar El Hekmah“42, Kasr El-Eini StreetCairoTel: (20-2) 3543406

EL SALVADOR, C.A SColegio Médico de El SalvadorFinal Pasaje N° 10Colonia MiramonteSan SalvadorTel: (503) 260-1111, 260-1112Fax: -0324E-mail: [email protected]@hotmail.com

ESTONIA EEstonian Medical Association (EsMA)Pepleri 3251010 TartuTel/Fax (372) 7420429E-mail: [email protected]: www.arstideliit.ee

ETHIOPIA EEthiopian Medical AssociationP.O. Box 2179Addis AbabaTel: (251-1) 158174Fax: (251-1) 533742E-mail: [email protected] /[email protected]

FIJI ISLANDS EFiji Medical Association2nd Fl. Narsey’s Bldg, Renwick RoadG.P.O. Box 1116SuvaTel: (679) 315388Fax: (679) 387671E-mail: [email protected]

FINLAND EFinnish Medical AssociationP.O. Box 4900501 HelsinkiTel: (358-9) 3930 826/Fax-794Telex: 125336 sll sfE-mail: [email protected]: www.medassoc.fi

FRANCE FAssociation Médicale Française180, Blvd. Haussmann 75389 Paris Cedex 08Tel: (33) 1 53 89 32 41Fax: (33) 1 53 89 33 44E-mail: [email protected]

GEORGIA EGeorgian Medical Association7 Asatiani Street380077 TbilisiTel: (995 32) 398686 / Fax: -398083E-mail: [email protected]

GERMANY EBundesärztekammer(German Medical Association)Herbert-Lewin-Platz 110623 BerlinTel: (49-30) 400-456 363/Fax: -384E-mail: [email protected]: www.bundesaerztekammer.de

GHANA EGhana Medical AssociationP.O. Box 1596AccraTel: (233-21) 670-510/Fax: -511E-mail: [email protected]

HAITI, W.I. FAssociation Médicale Haitienne1ère Av. du Travail #33 – Bois VernaPort-au-PrinceTel: (509) 245-2060Fax: (509) 245-6323E-mail: [email protected]: www.amhhaiti.net

HONG KONG EHong Kong Medical Association, ChinaDuke of Windsor Building, 5th Floor15 Hennessy RoadTel: (852) 2527-8285Fax: (852) 2865-0943E-mail: [email protected]: www.hkma.org

HUNGARY EAssociation of Hungarian MedicalSocieties (MOTESZ)Nádor u. 36 1443 Budapest, PO.Box 145Tel: (36-1) 312 3807 – 311 6687Fax: (36-1) 383-7918E-mail: [email protected]: www.motesz.hu

ICELAND EIcelandic Medical AssociationHlidasmari 8200 KópavogurTel: (354) 8640478Fax: (354) 5644106E-mail: [email protected]

INDIA EIndian Medical AssociationIndraprastha MargNew Delhi 110 002Tel: (91-11) 337009/3378819/3378680Fax: (91-11) 3379178/3379470E-mail: [email protected] / [email protected]

INDONESIA EIndonesian Medical AssociationJalan Dr Sam Ratulangie N° 29Jakarta 10350Tel: (62-21) 3150679Fax: (62-21) 390 0473/3154 091E-mail: [email protected]

IRELAND EIrish Medical Organisation10 Fitzwilliam PlaceDublin 2Tel: (353-1) 676-7273Fax: (353-1) 6612758/6682168Website: www.imo.ie

ISRAEL EIsrael Medical Association2 Twin Towers, 35 Jabotinsky St.P.O. Box 3566, Ramat-Gan 52136Tel: (972-3) 6100444 / 424Fax: (972-3) 5751616 / 5753303E-mail: [email protected]: www.ima.org.il

JAPAN EJapan Medical Association2-28-16 Honkomagome, Bunkyo-kuTokyo 113-8621Tel: (81-3) 3946 2121/3942 6489Fax: (81-3) 3946 6295E-mail: [email protected]

KAZAKHSTAN FAssociation of Medical Doctors of Kazakhstan117/1 Kazybek bi St.,AlmatyTel: (3272) 62 -43 01 / -92 92Fax: -3606E-mail: [email protected]

REP. OF KOREA EKorean Medical Association302-75 Ichon 1-dong, Yongsan-guSeoul 140-721Tel: (82-2) 794 2474Fax: (82-2) 793 9190E-mail: [email protected]: www.kma.org

KUWAIT EKuwait Medical AssociationP.O. Box 1202 Safat 13013Tel: (965) 5333278, 5317971Fax: (965) 5333276E-mail: [email protected]

LATVIA ELatvian Physicians AssociationSkolas Str. 3Riga1010 LatviaTel: (371-7) 22 06 61; 22 06 57Fax: (371-7) 22 06 57E-mail: [email protected]

LIECHTENSTEIN ELiechtensteinischer ÄrztekammerPostfach 529490 VaduzTel: (423) 231-1690Fax: (423) 231-1691E-mail: [email protected]: www.aerzte-net.li

LITHUANIA ELithuanian Medical AssociationLiubarto Str. 22004 VilniusTel/Fax: (370-5) 2731400E-mail: [email protected]

LUXEMBOURG FAssociation des Médecins etMédecins Dentistes du Grand-Duché de Luxembourg29, rue de Vianden2680 LuxembourgTel: (352) 44 40 331Fax: (352) 45 83 49E-mail: [email protected]: www.ammd.lu


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MACEDONIA EMacedonian Medical AssociationDame Gruev St. 3P.O. Box 17491000 SkopjeTel/Fax: (389-91) 232577

MALAYSIA EMalaysian Medical Association4th Floor, MMA House124 Jalan Pahang53000 Kuala LumpurTel: (60-3) 40418972/40411375Fax: (60-3) 40418187/40434444E-mail: [email protected]: http://www.mma.org.my

MALTA EMedical Association of MaltaThe Professional CentreSliema Road, Gzira GZR 06Tel: (356) 21312888Fax: (356) 21331713E-mail: [email protected]: www.mam.org.mt

MEXICO SColegio Medico de MexicoFenacomeHidalgo 1828 Pte. Cons. 410Colonia Obispado C.P. 64060Monterrey, Nuevo LéonTel/Fax: (52-8) 348-41-55E-mail: [email protected]: www.fenacome.org

NEPAL ENepal Medical AssociationSiddhi Sadan, Post Box 189Exhibition RoadKatmanduTel: (977 1) 225860, 231825Fax: (977 1) 225300E-mail: [email protected]

NETHERLANDS ERoyal Dutch Medical AssociationP.O. Box 200513502 LB UtrechtTel: (31-30) 28 23-267/Fax-318E-mail: [email protected]: www.knmg.nl

NEW ZEALAND ENew Zealand Medical AssociationP.O. Box 156Wellington 1 Tel: (64-4) 472-4741Fax: (64-4) 471 0838E-mail: [email protected]: www.nzma.org.nz

NIGERIA ENigerian Medical Association74, Adeniyi Jones Avenue IkejaP.O. Box 1108, MarinaLagosTel: (234-1) 480 1569, Fax: (234-1) 493 6854E-mail: [email protected]: www.nigeriannma.org

NORWAY ENorwegian Medical AssociationP.O.Box 1152 sentrum0107 OsloTel: (47) 23 10 -90 00/Fax: -9010E-mail: [email protected]: www.legeforeningen.no

PANAMA SAsociación Médica Nacionalde la República de PanamáApartado Postal 2020Panamá 1Tel: (507) 263 7622 /263-7758Fax: (507) 223 1462Fax modem: (507) 223-5555E-mail: [email protected]

PERU SColegio Médico del PerúMalecón Armendáriz N° 791Miraflores, LimaTel: (51-1) 241 75 72Fax: (51-1) 242 3917E-mail: [email protected]: www.colmed.org.pe

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POLAND EPolish Medical AssociationAl. Ujazdowskie 24, 00-478 WarszawaTel/Fax: (48-22) 628 86 99

PORTUGAL EOrdem dos MédicosAv. Almirante Gago Coutinho, 1511749-084 LisbonTel: (351-21) 842 71 00/842 71 11Fax: (351-21) 842 71 99E-mail: [email protected]/ [email protected]: www.ordemdosmedicos.pt

ROMANIA FRomanian Medical AssociationStr. Ionel Perlea, nr 10Sect. 1, Bucarest, cod 70754Tel: (40-1) 6141071Fax: (40-1) 3121357E-mail: [email protected]: www.cdi.pub.ro/CDI/Parteneri/AMR_main.htm

RUSSIA ERussian Medical SocietyUdaltsova Street 85121099 Moscow Tel: (7-095)932-83-02E-mail: [email protected]@russmed.com

SINGAPORE ESingapore Medical AssociationAlumni Medical Centre, Level 22 College Road, 169850 SingaporeTel: (65) 6223 1264Fax: (65) 6224 7827E-Mail: [email protected]

SLOVAK REPUBLIC ESlovak Medical AssociationLegionarska 481322 BratislavaTel: (421-2) 554 24 015Fax: (421-2) 554 223 63E-mail: [email protected]

SLOVENIA ESlovenian Medical AssociationKomenskega 4, 61001 LjubljanaTel: (386-61) 323 469Fax: (386-61) 301 955

SOUTH AFRICA EThe South African Medical AssociationP.O. Box 74789, Lynnwood Rydge0040 PretoriaTel: (27-12) 481 2036/7Fax: (27-12) 481 2058E-mail: [email protected]: www.samedical.org

SPAIN SConsejo General de Colegios MédicosPlaza de las Cortes 11, Madrid 28014Tel: (34-91) 431 7780Fax: (34-91) 431 9620E-mail: [email protected]

SWEDEN ESwedish Medical Association(Villagatan 5)P.O. Box 5610, SE - 114 86 StockholmTel: (46-8) 790 33 00Fax: (46-8) 20 57 18E-mail: [email protected]: www.lakarforbundet.se

SWITZERLAND FFédération des Médecins SuissesElfenstrasse 18 – POB 2933000 Berne 16Tel: (41-31) 359 –1111/Fax: -1112E-mail: [email protected]: www.fmh.ch

TAIWAN ETaiwan Medical Association9F No 29 Sec1An-Ho RoadTaipeiDeputy Secretary GeneralTel: (886-2) 2752-7286Fax: (886-2) 2771-8392E-mail: [email protected]

THAILAND EMedical Association of Thailand2 Soi SoonvijaiNew Petchburi RoadBangkok 10320Tel: (66-2) 314 4333/318-8170Fax: (66-2) 314 6305E-mail: [email protected]: http://www.medassocthai.org/index.htm.

TUNISIA FConseil National de l’Ordredes Médecins de Tunisie16, rue de Touraine1082 Tunis Cité JardinsTel: (216-71) 792 736/799 041Fax: (216-71) 788 729E-mail: [email protected]

TURKEY ETurkish Medical AssociationGMK Bulvary,.Pehit Danip Tunalygil Sok. N° 2 Kat 4MaltepeAnkaraTel: (90-312) 231 –3179/Fax: -1952E-mail: [email protected]

UGANDA EUganda Medical AssociationPlot 8, 41-43 circular rd.P.O. Box 29874 KampalaTel: (256) 41 32 1795Fax: (256) 41 34 5597E-mail: [email protected]

UNITED KINGDOM EBritish Medical AssociationBMA House, Tavistock SquareLondon WC1H 9JPTel: (44-207) 387-4499Fax: (44- 207) 383-6710E-mail: [email protected] Website: www.bma.org.uk

UNITED STATES OF AMERICA EAmerican Medical Association515 North State StreetChicago, Illinois 60610Tel: (1-312) 464 5040Fax: (1-312) 464 5973Website: http://www.ama-assn.org

URUGUAY SSindicato Médico del UruguayBulevar Artigas 1515CP 11200 MontevideoTel: (598-2) 401 47 01Fax: (598-2) 409 16 03E-mail: [email protected]

VATICAN STATE FAssociazione Medica del VaticanoStato della Citta del Vaticano 00120Tel: (39-06) 6983552Fax: (39-06) 69885364E-mail: [email protected]

VENEZUELA SFederacion Médica VenezolanaAvenida OrinocoTorre Federacion Médica VenezolanaUrbanizacion Las MercedesCaracasTel: (58-2) 9934547Fax: (58-2) 9932890Website: www.saludfmv.orgE-mail: [email protected]

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ZIMBABWE EZimbabwe Medical AssociationP.O. Box 3671HarareTel: (263-4) 791/553Fax: (263-4) 791561E-mail: [email protected]