world medical journal ed 4

WMA General Assembly, Tokyo 2004

WorldMMeeddiiccaall JJoouurrnnaall

Vol. No. 4, December 200450

OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.

G 20438

ContentsEEddiittoorriiaall 85New WMA Secretary-General 85Presidential address by Dr. Yank D. Coble, Jr, MD to the world medical assembly, Tokyo 86WMA has a new President 86MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttssMedical ethics and bereavement 89The World Medical Association statement concerning the relationship between physicians and commercial enterprises 91The World Medical Association Regulations in times of armed conflict 92The World Medical Association Statement on health emergencies communication and coordination 93Note of clarification on paragraph 30 of the WMA Declaration of Helsinki 95MMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee aanndd EEdduuccaattiioonnAccount by Dr. James Appleyard of his Presidential year of office 2003–2004 95The future of medical technology – Implications for medical education and practice 97Blame your genes for a restless night’s sleep – new research revealed 99WWHHOONew tools and increased funds will beat malaria, say global leaders 100Skilled attendants vital to saving lives of mothers and newborns 101A globally effective HIV vaccine requires greater participation of women and adolescents in clinical trials 101Landmark report could influence the future of medicines in europe and the world 102Who awards million dollar contract for global treatment preparedness activities 105WWMMAA SSeeccrreettaarryy GGeenneerraallFrom the Secretary General’s Desk 106WWMMAAThe Ceremonial session of the World Medical Association General Assembly, Tokyo 2004 107Meeting of the WMA General Assembly, Tokyo, 9th October 2004 108RReeggiioonnaall aanndd NNMMAA NNeewwssPatients’ Access To Care At Risk With America’s Broken Medical Liability System 110Tobacco Control Capacity Building 112

The President addresses the Emperor and Empress at the JMA reception

The new President addresses the WMA Ceremonial session

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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 CouncilDr. K. Vilmar Dr. Y Blachar Dr. T.J. MoonSchuberstr.58 Israel Medical Association Korean Medical Association28209 Bremen 2 Twin Towers, 35 Jabotisky St. 302-75 Ichon1-dong,Yongsan-gu,Germany P.O. Box 3566, Ramat-Gan 52136 Seoul 140-721

Secretary GeneralDr. D. HumanWorld Medical AssociationBP63, 01212 Ferney-Voltaire CedexFranceTel (33) 4 50 40 75 75 Fax (33) 4 50 40 59 37E-mail: [email protected]

ANDORRACol’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

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

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

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

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

BAHAMASMedical Association of the BahamasJavon Medical CenterP.O. Box N999Nassau Tel: (1-242) 328 6802Fax: (1-242) 323 2980E-mail: [email protected]

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

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

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

BRAZILAssociaçao 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

BULGARIABulgarian Medical Association15, Acad. Ivan Geshov1431 SofiaTel: (359-2) 954 -11 69/Fax:-1186E-mail: [email protected]: www.blsbg.com

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

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

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EditorialThose arriving in Tokyo for the Council, the Scientific meeting and the General Assemblyof the World Medical Association, might be forgiven if they felt a sense of forboding whenthey were greeted with persistent and rather gloomy rain and mist. Indeed, this may wellhave been enhanced by the not insignificant earthquake one night and the typhoon twodays later. However, the excellent scientific meeting, impeccable efficiency of the organi-sation and the warm hospitality of the Japanese Medical Association, more than compen-sated for the vagaries of the weather.

The meeting was further greatly honoured by the presence of the Emperor and Empress ofJapan at the Opening Reception, and the Chief Secretary of the Cabinet (the Prime Ministerbeing out of the country), the Minister of Health and the Governor of Tokyo at theCeremonial session (see report p. 107).

The scientific session was also a success, addressing the advantages and the problems ofadvanced medical technology and also the subject of Continuing Medical Education andPhysicians’ Autonomy (various papers appear in this issue).

The General Assembly is reported on page 108. Among the decisions of the Assembly appearsa note of clarification on article 30 of the Declaration of Helsinki. While this will undoubted-ly not be the last we shall hear on this subject, interested parties will no doubt take their timeto quietly consider and debate what appears to be the controversial issue of the rights of par-ticipants in clinical trials, before returning to the subject at some point in the future.

Meanwhile, the world moves on and the unavoidable delay in publishing this issue (due toillness), has meant that we have all experienced the terrible consequences of the “naturaldisaster” in South-East Asia. The global response in terms of aid, both financial and otherresources, to this terrible event has been unprecedented. In all of this the medical profes-sion, both through its national medical associations and other organisations geared to deal-ing with major disasters, reacted quickly and responsibly both in terms of provision ofhuman resources and other forms of assistance. At the same time the profession and thepopulation in general must not neglect the continuing needs of populations threatened bymajor scourges such as famine and other forms of deprivation, AIDS/HIV and Malaria. Theneeds of the world are huge – part of which depends on medical care. This is not only theresponsibility of governments and administrations, but also a professional responsibilityfor the medical profession thoughout the world.

Alan Rowe

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New WMA Secretary-GeneralDr. Otmar Kloiber has been appointed to be the next Secretary-Gene-ral of the World Medical Association following Dr. Delon Human.

Dr. Kloiber is currently Deputy Secretary General of the Bundesärt-zekammer (German Medical Association) where for many years hewas the Foreign Relations Advisor, and has extensive knowledgeboth of WMA, and the affairs of many national medical associations(particularly the problems in Central and Eastern Europe) and ofinternational organisations and NGO’s. Dr. Kloiber has also been amember of the German Parliamentary Commission on Law and Ethics in Modern Medi-cine.He had previously worked at the Max-Plank Institute in Cologne and was a Postdoc-toral Fellow in the University of Minnesota USA from 1985-86. Dr. Kloiber will take uphis post on the 1st February 2005.

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Following his investiture as President of theWorld Medical Association, Dr. Cobleopened his address expressing his gratitudeto those who elected him, to the retiringPresident and his fellow officers, to theSecretary-General, Dr. Delon Human, tothe American Medical Association and itsdelegation at WMA, also to his WMA pre-decessors from the USA.

Dr. Coble continued“All of you have given me opportunities towork hard for a worthy cause. To seek andto strive for the best health care for the peo-ple of the world, through the pursuit of thehighest standards of medical care, medicaleducation, medical ethics and medical sci-ence.

These things form the intellectual founda-tion and the creative spark of the art ofmedicine. They are ingrained in the Charterof the World Medical Association. They areour mission and our charge –“Caring,Ethics and Science” – the three fundamen-tal, enduring traditions. Fulfilling this mis-sion- living out these ideals- is what givesus the power to be strong, effective advo-cates for patients and for our profession theworld over. Through changes in govern-ments, changes in policies, changes in eco-nomic and in medical science and methods,we will flourish.

At this moment of history, the wealth ofnations is not the most pressing issue; it israther, the health of nations.

Indeed, one of the most pressing issues fac-ing nations, be they first world or third-post-industrial or developing – is access tocare, how to deliver medical and health careof high quality (including public health andpreventive medicine) to the greatest num-ber of their citizens, with the maximumpossible efficiency. This at a time when thequality of medical care and the good healthof our patients, face unprecedented chal-lenges both locally and globally, naturaland man-made.

These challenges include AIDS, SARS,resistant tuberculosis, Malaria, the threat ofbio-terrorism, bureaucratic meddling,changing health policies, an unprecedentednumber of ageing citizens, unprecedentedmigration of physicians, and the need – inmany lands if not most – for health caresystem reform. All of these things make

global co-operation essential if we as physi-cians are to protect the public health. Ourincreasingly open borders and our increas-ingly mobile populations are creating a richenvironment for infectious agents, posing aserious threat to human health and interna-tional security. New infectious diseasessuch as SARS can emerge and travel swift-ly around the globe, mutating and infectingless resilient hosts. These microbes respectno international borders or the landscape’sphysical barriers.

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Presidential address by Dr. Yank D. Coble, Jr,MD to the world medical assembly, Tokyo

WMA has a new PresidentYank D. Coble, Jr., MD, MACP, MACE, became Presidentof the World Medical Association in Tokyo, Japan, inOctober of 2004. Dr. Coble served as Chair of the WMA’s2003-2004 Committee on Finance and Planning, has been aDelegate to the WMA since 2002, and is Past President ofthe American Medical Association.

A graduate of Duke Medical School, Dr. Coble also receiveda degree in clinical medicine of the tropics from the LondonSchool of Hygiene and Tropical Medicine. He is a clinicalprofessor of medicine at the University of Florida School ofMedicine and was formerly Professor of Medicine andFamily Medicine and Chair of the Department of Community Health and FamilyMedicine. Dr. Coble is listed in “The Best Doctors in America” and in 2002 was select-ed by Modern Healthcare as one of the “100 Most Powerful People in Healthcare.”

Under the auspices of the Office of International Research at the National Institutes ofHealth (NIH), he cared for patients and conducted medical research in Egypt, Nigeriaand England from 1964 through 1969. During this time, he made site visits to more than50 countries. Most recently, he served on the U.S. delegation to the WHO’s 2003 and2004 World Health Assembly.

Among his many leadership roles, Dr. Coble has been a member of the AdvisoryCommittee to the Director of the NIH. He co-chaired both the 35th anniversary celebra-tion of the NIH’s Office of International Medicine and the 50th anniversary celebrationof the Human Genome Project.

A distinguished leader in medicine, Dr. Coble is a Past President of the American Societyof Internal Medicine, American Association of Clinical Endocrinologists, and AmericanCollege of Endocrinology. He currently holds appointments on the boards of Research.America, National Osteoporosis Foundation, Institute of Medicine Roundtable onEnvironmental Health Sciences, Research and Medicine, Campaign for Public Health,and Hospice of Northeast Florida. He has also served on the Board of Directors of theNational Quality Forum, the Joint Commission on the Accreditation of HealthcareOrganizations and the National Guideline Clearinghouse of the Agency for HealthcareResearch and Quality.

Dr. Coble and his wife Shereth reside in Neptune Beach, Florida and have five childrenand ten grandchildren.

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Our weapons against these microbes arebecoming less effective as they developresistance to the drugs, which once keptthem at bay.

For medicine to survive these threats, itmust continue to push the boundaries of sci-ence and technology. By so doing we makelonger, better lives available to allhumankind. From these challenges, fromadversity of all kinds we can learn as weovercome. Learn because we overcome.

Recently, I was in a country where physi-cians offered a candid admission – that theirgovernment delayed the medical communi-ty from releasing what they knew aboutSARS when they knew it.

Because of this, valuable time was lostaddressing the epidemic and identifying thedisease. This country’s scientists knew thestructure of SARS, knew what it was andhow dangerous it was for two monthsbefore it could be reported. Ultimately thissilence cost lives and cost the country $80million.

But because of physician inspired publicpressure there has been a change.Physicians and other scientists in the coun-try can now freely report their findings.This provided clear evidence of the value ofdisclosure, of co-operation and the trans-parency of science, not only for the healthof a country, but for its economy and itswealth.

From adversity has come knowledge andprogress in the fight against contagion.

In an African nation, a physician was dis-charged from his duties as a hospital super-intendent in early 2002 for “insubordina-tion”, because he allowed a public healthorganisation to use space in his facility toadminister HIV prophylaxis to rape vic-tims. At the time when he was fired, thatnation’s Health Ministry prohibited the useof HIV drugs as a method of prevention andtreatment after HIV exposure. Because ofthe international pressure brought to bear,in part because of this physician’s case, thisgovernment changed its policy on HIVtreatment.

Through the adversity suffered by thesebrave physicians, medicine was advanced.

These are the types of obstacles we face asa community, and which we must overcometogether.

The traditions of medicine are what enablephysicians to work together under difficultconditions.

Consider the Addis Ababa Fistula Hospitalin Ethiopia, where in one of the world’smost impoverished regions physicians treatwomen suffering form obstetric fistula, adebilitating childbirth injury still commonin the developing world. Or Dr. PaulFarmer, who for 20 years has worked todevelop a community-based health networkin Haiti. He helped implement one of thefirst AIDS treatment programmes in thedeveloping world and an innovative treat-ment for patients with multi-drug-resistanttuberculosis.

I have seen adversity and a common goalunite physicians with my own eyes. InNigeria before the Biafran War, I helpedwork on a nutrition survey of the entirecountry – a co-operative effort with physi-cians from America and Nigeria (Ibo,Yoruba, Hausa and Faluni) all workingtogether.

At the London School of Tropical Medicineat the time of the Six-day War in 1967, Iwatched Christian, Jewish, Muslim andHindu physicians work side by side for thebetterment of all nations, all faiths and allpeoples.

Through adversity we find co-operationand innovation. We learn from each otherand take inspiration from each other,because we are all in this together. We mustdelight in our diversity, but always remem-ber the danger of discord. There is poweronly in unity. With enthusiasm, hard workand hope, we can take the challenges weface in medicine and turn them into oppor-tunities for better health. But only if weremain responsible for out traditions ofethics, caring and science. Only if we workwith our patients and others to topple thebarriers to quality medical care. Only if weare active, united members of our profes-sion.

Without science and its application, ethicsand caring alone are merely good inten-tions, only well intentioned kindness.

It is our commitment to science and the life-long process of learning that science, thatdirects, expands and makes unique what wedo, as physicians. We must not permit oth-ers to diminish our scientific standards.

Ethics is what compels us to put the inter-ests of the patient first, or in someinstances, that of the public.

This is the heart of my message today – thateverything we do, we do for our patients –The sick, the infirm, the elderly – thosemost vulnerable among us throughout theworld, those who most need physicians, ourtraditions, our advocacy and our autonomy.

Sir William Osler said, “Caring is the mostimportant thing – so do it first. For it is thecaring physician who most inspires hopeand trust”.

In that spirit, I would like the members ofthe World Medical Association to be knownas “The Caring Physicians of the World”.

Toward that end, we are asking that each ofour national medical associations too nom-inate one to three of their physician mem-bers who best reflect the principles of car-ing, ethics and science. We will select some50 or 80 of these physicians and featurethem in a publication to be distributed atour annual meeting in Santiago, Chile inOctober 2005. We are grateful for the sup-port of the Pfizer Medical HumanitiesInitiative in this publication effort. The pub-lication will be disseminated around theworld to national medical associations,governments, foundations and other inter-ested groups. This activity will also includea dedicated website, a series of regionalmeetings and bridges to other opportunities.

We seek the most caring physicians in theworld, and we want the world to know whothey are. We also want the world to knowwho we are at the World MedicalAssociation- what we do, what we standfor, and the values we embrace in the ser-vice of our patients and the public health

Caring – Ethics – ScienceOur Caring is evident in our everyday workand the millions of hours of charity care weprovide in the four corners of the globe.

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Our Ethics guide not only our practice ofmedicine, but also the practice of interna-tional physician organisations

Our medical science is evident in our grow-ing success at treating and curing diseasesonce thought to be fatal, in the miracles oforgan transplants, vaccines, chemotherapy,medical genetics and advanced technology.

Caring, Ethics and Science, are the watch-words of our profession. But everywhere Igo around the world, physicians are beingsubjected to ever greater pressures.Subjected to forces that make it more andmore difficult to live out the credo of ourcalling. The elimination of patient choiceand the erosion of appropriate physicianautonomy, put the sacred patient – physi-cian relationship in jeopardy.

So it falls to us, we who represent interna-tional medicine to help restore pride, pas-sion, enthusiasm and optimism among ourcolleagues wherever they practice, wherev-er they are challenged. The irony is that weare small, but our power to do good and towield influence, is great.

We will reach out

- and encourage national medical associ-ations to form where none exist today;

- to assist in the development of qualitycare and to enhance safety;

- and focus attention on developing worldissues, HIV/AIDS, hunger and infec-tious diseases; violence, terrorism andtorture; obesity, diabetes and cardiovas-cular disease; with Regional meetingsof our WMA;

- in the houses of parliaments, the legisla-tures, the board rooms, in partnershipwith our brother and sister organisa-tions.

And we will reach out with a strong,authoritative voice, as a fierce guardian ofethics and human rights on the internation-al stage – because we remain the globalvoice of medicine.

It is a voice I have constantly heard in theyears since I embarked on my course ofstudy in international research – a journeythat took me to Egypt, Nigeria and London.Since then, I have visited health care, edu-

cation and research facilities in more than60 countries. These travels have given meunconditional respect for our global profes-sion of medicine, and a deep sense of aweat the remarkable trust and hope which ourcalling commands and inspires.

I’ve witnessed the world of physicians likeyou more extensively that I could haveimagined. I’ve seen your skill and caringand compassion in settings from the mostadvanced hospital to the most remote clin-ic, and seen how you manage the expecta-tions created by innovations in medicine.

In these forty years I have seen much suf-fering – but I have also seen much relief ofsuffering. I have seen how good healthleads to more literacy, more equality ofopportunity in political and economic mat-ters and in environmental improvements.When health improves, all other aspects oflife improve. While health experts andeconomists may differ on how to go aboutit, the goal is the same, and the rewards aretremendous.

Politicians and governments like to to thinkof medical care and research as a cost- anexpense. But we know that medical careand research is an investment, a value – onewith tremendous return.

In some countries there is a need for basicssuch as clean water, edible food and reliableelectricity. But in these places they stillknow and respect their doctor. Our patientsvalue medial research and innovation. Theyvalue medical care and they do not wanttheir care undermined or withheld.

We must make sure that our patients under-stand how the problems we face as physi-cians undermine our ability to deliver thatcare. We need to communicate the value ofour work and its importance to our patients,to the media and to our governments.

We need to continue to communicate thevalue of our work to each other. Few thingsare as central to the development of scienceand medicine as the exchange of informa-tion. By sharing information, either in jour-nals or textbooks, or in international confer-ences such as these, we reaffirm what weunderstand about the art and science ofmedicine and broaden our knowledge base.These are gifts we bring back to our

patients and our communities – gifts we canuse to make medical practice in our respec-tive nations better, stronger than everbefore.

Experiences such as this gathering are alsogifts to us as physicians. They presentopportunities for friendship, for greaterunderstanding, not only of science andhealth policy, but also of culture and histo-ry. They challenge us to see our professionand ourselves from a new perspective, andchange us for the better.

No one better understands the obstacles toquality health care than physicians and theirpatients. That is why, as WMA President Iwill take my cue from the people in thefrontlines and make your agenda – yourindividual country’s health care agenda,and your patients’ agenda – my agenda –our agenda.

To fulfil this mission we have to be deter-mined and stay that way – we can’t give upor give in. This is a time of excitement andanticipation – for me a time of wonder andexpectation. I look forward to workingtogether as we shepherd the spirit of inter-national medicine into this 21st century. Ican only hope that my time as Presidentwill strengthen the bonds that unite us all.Bonds such as our shared commitment tothe best science – to caring and compassion– and to excellence in every aspect of med-icine – bonds such as our commitment toprofessional integrity, and to the ethic thatrequires us to put our patients first.

As physicians we can do much on our own,but we can do even more together. TheWMA and its members are, and will contin-ue to be an ethical beacon and a force ofendless possibilities.

So let us continue to build bridges amongour national associations and among theindividual physicians in this room, and con-tinue to share our dreams of better healthfor all. As I look ahead to the next year, itoccurs to me that there is no greater giftthan this “To see medicine’s traditions livedto the fullest, and to work to protect thosetraditions from harm”.

How can we not be enthusiastic and opti-mistic about our profession with suchenduring traditions- about our opportunity

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to be useful and of value every day- andabout the marvels of modern medicine?

There is an old Japanese proverb “The go-between wears out a thousand sandals”.We must be willing to wear out a thousandsandals – or more – in our advocacy for ourpatients and our profession.

Together, the family of medicine will bringits agenda to the global stage. We willencourage and lead patients and other part-ners to stand beside us. We will tear downthe barriers that stand between our patientsand us, and between us and quality medicalcare. We will be “The Caring Physicians ofthe World”.

Medical Ethics and Human Rights

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Medical ethics and bereavement

Although there have been a great manypublications and conference presentationson ethical issues related to death and dying,the ethical literature on the physician’sresponsibilities to bereaved persons is rela-tively scant. In their interactions with thebereaved, physicians can either providebenefit or inflict harm, and so such interac-tions require ethical analysis and guidance.The bereaved are not the physician’spatients, so the well-established principlesof the physician-patient relationship arenot necessarily applicable.

In this article I propose a set of ethical prin-ciples for the interactions of physicianswith the bereaved, namely, respect, com-passion and truthfulness. The application ofthe principles will be illustrated by casevignettes. Particular attention will be givento the resolution of possible conflictsbetween principles, for example, compas-sion vs. truthfulness.

Ethical ResponsibilitiesThe WMA Declaration of Geneva requiresof the physician that “The health of mypatient will be my first consideration”, andthe International Code of Medical Ethicsstates, “A physician shall owe his patientscomplete loyalty and all the resources of hisscience”. However, the care of patientsoften involves interactions with familymembers, particularly when the patients areunable to make decisions about their ownmedical care. A considerable degree of con-sensus has developed on the ethical and

legal principles for dealing with familymembers in such situations, although theapplication of these principles is often prob-lematic.2 However, there has been very lit-tle consideration to date of the responsibili-ties of physicians to family members afterthe patient’s death.

Some might argue that physicians have nosuch responsibilities. Just as the physician-patient relationship ends with the death ofthe patient, so also do any professional rela-tionships with the bereaved family mem-bers. If they are in need of consolation orsome other type of care, they should seek itfrom bereavement counsellors, clergy orother specialists in the field.

A strong case can be made for an opposingview, namely, that physicians shouldaddress the needs of the bereaved.Sometimes physicians are the only oneswho can fulfil these needs and their refusalto do so can result in harm to the bereaved.Examples of such situations are presentedbelow.

Ethical Principles

Some of the ethical principles that governthe physician-patient relationship are equallyappropriate to the relationship of physicianswith the bereaved. Others, such as informedconsent and confidentiality, are not as appro-priate. The shared principles are these:

• Compassion – have understanding andempathy for those who are suffering.

• Respect for persons – acknowledge andpromote their dignity and their autono-my.

• Truthfulness – do not lie, and be discreetwhen disclosing unwelcome or unwant-ed information.

Sometimes the application of these princi-ples can be challenging, not least becausethey can conflict with one another.Moreover, the needs and wishes of thebereaved may conflict with those of thepatient prior to death. It is, of course,preferable to anticipate and prevent con-flicts before they arise. But if this has notbeen done, then a conflict-resolutionprocess is required.

Case 1 – Compassion vs.truthfulness

Mr. A, a 30 year old single male, isadmitted to an emergency ward withsevere injuries resulting from an auto-mobile accident and dies soon after-wards. Medical tests administered uponadmission revealed the presence ofheroin, which may well have con-tributed to the accident. When Mr. A’sparents arrive at the hospital, they askthe attending physician what caused thedeath. The physician wonders whethershe should mention only the accident orshould reveal the possible contributingfactor as well. She fears that the familymight be devastated by this knowledge.

This case demonstrates a conflict betweenthe physician’s compassionate desire not toharm the family members and her duty totell the truth. It is also about the limits ofconfidentiality. Traditional medical ethicswas clear on this point, as is stated in theWMA International Code of MedicalEthics: “A physician shall preserveabsolute confidentiality on all he knowsabout his patient even after the patient hasdied.” However, current medical ethics rec-ognizes some exceptions to this principle.The British Medical Association advisesthat the obligation of confidentiality afterthe patient’s death “needs to be balancedwith other considerations, such as the inter-ests of justice and of people close to the

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deceased person”.3 And the AmericanMedical Association allows that, “When afamily or other decision maker has givenconsent to an autopsy, physicians may dis-close the results of the autopsy to the indi-vidual(s) that granted consent to the proce-dure”.4

In the case of Mr. A, it would be advisablefor the physician to enter into discussionwith the family to determine whether herfear of harming them is justified. Perhapsthey already knew that their son was addict-ed to heroin, and therefore they would notbe disturbed to know that this might havebeen a factor in his death. But if, after dis-cussion, her fear is confirmed, she could bejustified in withholding some informationboth to respect patient confidentiality andto avoid harming the family. Lying, howev-er, is never permissible.5

Case 2 – Compassion and respect in the face of blame

Mrs. B is an elderly patient in a criticalcare unit for management of multipleorgan failure. The medical team areagreed that there is no possibility ofarresting her decline and that henceforthher care should be palliative only. Thepatient is non-communicative so theteam turns to her family to seek agree-ment with this plan. The family mem-bers, perhaps hoping for a miracle, areadamant that the team continue theirefforts to prolong the patient’s life. Theteam agrees reluctantly to do so. Afterfive days of aggressive and apparentlyuncomfortable treatment, Mrs. B dies.The family members are angry andaccuse the team of not doing enough tosave their mother. Some of the team,among themselves, blame the family forMrs. B’s unnecessary suffering and wantto confront them openly about this.Others feel that compassion for the fam-ily requires that they accept these unjus-tified criticisms as part of the bereave-ment process.

In retrospect, the medical team may havewished that they had not acceded to thefamily’s wishes to continue aggressive

treatment for Mrs. B.6 However, they nowhave to make the best of a bad situation. Itseems clear to them that the family’s griefat the death of the patient is compounded bytheir anger that the treatment was not suc-cessful and perhaps also by remorse forcontributing to Mrs. B.’s prolonged suffer-ing and dying. Team members may sharethis remorse, which is made worse by thefamily’s unjust accusation.

In such a situation, the medical team maywell consider that they have no furtherresponsibility to the family. However, as inthe first case, the family members haveneeds that only the medical team can meet,and despite the obstacles, the team shouldtry to provide compassionate help to thefamily in coping with their grief. This mayinvolve inviting the family members to dis-cuss the case while reassuring them thateverybody had the best interests of Mrs. B.in mind, even though the decision to contin-ue treatment was, in retrospect, probablynot appropriate. Prior to encountering thefamily, the team members should meet bythemselves and try to come to terms withtheir own remorse and anger.

Case 3 – Patient’s Directivevs. Survivors’ Needs

Mr. C. a 64-year-old man, has just diedof a cardiac arrest. In his last will, madewhen he was 55, he stipulated that he didnot want any funeral or memorial ser-vice. His surviving wife, four childrenand eight grandchildren were very closeto him and are devastated by his death.Upon learning of his directive regardingno funeral or memorial service, they aretorn between their need to bring closureto their grief at losing him and theirdesire to respect his wishes. To helpresolve this conflict, they turn to his per-sonal physician for advice.

Although the physician is not the decisionmaker in this case, he has been asked foradvice because of his professional relation-ship with the patient while alive. The physi-cian is faced with a conflict between hisloyalty to his former patient and his com-passion for the bereaved survivors. Here

again, the survivors’ grief at losing theirloved one is compounded by another factor,in this case, his directive to have no funeralor memorial service. Even if the physicianfavours the survivors, he has to decidewhether they have the right to counteractthe express wishes of the deceased for theirown benefit.

On this latter point, the physician must con-sider two opposing views. The first is thatindividuals have the right to dispose of theirpossessions after death, as expressed intheir last will and testament, and nobodycan change their decisions. Arguably thiscan apply to how their corpse should betreated, even though it is not consideredproperty. The second view is that overrid-ing previously expressed wishes regardingfuneral arrangements cannot harm thedeceased person and therefore is permissi-ble if it will benefit others. At present thereis no ethical consensus as to which of theseviews should prevail, and hence physicianshave to decide for themselves which tofavour in specific situations.

Conclusion

Each of these cases illustrates a conflictbetween important ethical principles.Although it is preferable that all principlesbe upheld, sometimes one must take priori-ty over another. When such conflict arises,discussion among all those involved isimportant for reaching a decision that, if notunanimous, at least reflects a compromisethat is tolerable to all. As medical authori-ties, physicians have a special responsibili-ty to initiate such discussions and to con-tribute to their successful outcome.

John R. Williams

Readers’ comments on these cases are wel-come and a selection will be published inthe next issue of the Journal. Please sendthem to the Hon. Editor in Chief, HaughleyGrange, Stowmarket, Suffolk 1P14 3QT,United Kingdom, email:[email protected]

1 An earlier version of this article was present-ed at the 21st International Conference onDeath and Bereavement, Eilat, Israel, 23-25


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March 2004. The views expressed here arethose of the author, not of the World MedicalAssociation.

2 WMA (2005) Medical Ethics Manual 47-50,available at www.wma.net

3 BMA (2004) Medical Ethics Today: TheBMA’s handbook of ethics and law (2nd ed.),London, BMJ Books, 439

4 AMA (2002) Confidentiality of MedicalInformation Postmortem, available at www.ama-assn.org/ama/pub/category/print/8354.html

5 Jackson, J (2001) Truth, Trust and Medicine,London and New York, Routledge

6 WMA (2005) Medical Ethics Manual 46 and92, available at www.wma.net


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Approved by the WMA General Assembly, Tokyo 2004

A. Preamble

1. In the treatment of their patients, physi-cians use drugs, instruments, diagnostictools, equipment and materials developedand produced by commercial enterprises.Industry possesses resources to financeexpensive research and development pro-grammes, for which the knowledge andexperience of physicians are essential.Moreover, industry support enables thefurtherance of medical research, scientif-ic conferences and continuing medicaleducation that can be of benefit topatients and the entire health care system.The combination of financial resourcesand product knowledge contributed byindustry and the medical knowledge pos-sessed by physicians enables the develop-ment of new diagnostic procedures,drugs, therapies, and treatments and canlead to great advances in medicine.

2. However, conflicts of interest betweencommercial enterprises and physiciansoccur that can affect the care of patientsand the reputation of the medical pro-fession. The duty of the physician is toobjectively evaluate what is best for thepatient, while commercial enterprisesare expected to bring profit to ownersby selling their own products and com-peting for customers. Commercial con-siderations can affect the physician’sobjectivity, especially if the physician isin any way dependent on the enterprise.

3. Rather than forbidding any relationshipsbetween physicians and industry, it ispreferable to establish guidelines forsuch relationships. These guidelinesmust incorporate the key principles ofdisclosure, avoidance of obvious con-flicts of interest and the physician’sclinical autonomy to act in the bestinterest of patients.

4. These guidelines should serve as the basisfor the review of existing guidelines andthe development of any future guidelines.

B. Medical Conferences

5. Physicians may attend medical confer-ences sponsored in whole or in part by acommercial entity if these conform tothe following principles:

5.1 The main purpose of the conferenceis the exchange of professional orscientific information.

5.2 Hospitality during the conference issecondary to the professionalexchange of information and doesnot exceed what is locally customaryand generally acceptable.

5.3 Physicians do not receive paymentdircetly from a commercial entityto cover travelling expenses, roomand board at the conference or com-pensation for their time unless provided for by law and/or the pol-icy of their National MedicalAssociation.

5.4 The name of a commercial entityproviding financial support is pub-

The World Medical Association statement concerning the relationship between physicians and commercial enterprises

licly disclosed in order to allowthe medical community and thepublic to assess the informationpresented in light of the source offunding. In addition, conferenceorganizers and lecturers discloseto conference participants anyfinancial affiliations they mayhave with manufacturers of prod-ucts mentioned at the event orwith manufacturers of competingproducts.

5.5 Presentation of material by aphysician is scientifically accu-rate, gives a balanced review ofpossible treatment options, and isnot influenced by the sponsoringorganization.

5.6 A conference can be recognisedfor purposes of continuing med-ical education/continuing profes-sional development (CME/CPD)only if it conforms to the follow-ing principles:

5.6.1 The commercial entities actingas sponsors, such as pharmaceu-tical companies, have no influ-ence on the content, presenta-tion, choice of lecturers, or pub-lication of results.

5.6.2 Funding for the conference isaccepted only as a contribution tothe general costs of the meeting.

C. Gifts

6. Physicians may not receive gifts from acommercial entity unless this is permit-ted by law and/or by the policy of theirNational Medical Association and itconforms to the following conditions:

6.1 The gift is only of nominal value.

6.2 The gift is not in cash.

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6.3 The gift, even one of nominalvalue, is not connected to any stip-ulation that the physician pre-scribes a certain medication, usescertain instruments or materials orrefers patients to a certain facility.

D. Research7. A physician may carry out research fund-

ed by a commercial entity, whether indi-vidually or in an institutional setting, if itconforms to the following principles:

7.1 The physician is subject only to thelaw, the ethical principles and guide-lines of the Declaration of Helsinki,and clinical judgmenet in performingresearch and does not allow himselfor herself to be subject to externalpressure regarding the results of hisor her research or their publication.

7.2 If possible, a physician or institutionwishing to undertake research

approaches more than one companyto request funding for the research.

7.3 Identifiable information aboutresearch patients or voluntary par-ticipants is not passed to the spon-soring company without the con-sent of the individuals concerned.

7.4 A physician’s compensation forresearch is based on his or her timeand effort and such compensationis in no way connected to theresults of the research.

7.5 The results of research are madepublic with the name of the spon-soring entity disclosed, along witha statement disclosing who request-ed the research. This applieswhether the sponsorship is direct orindirect, full or patial.

7.6 Commercial entities do not suppressthe publication of research results. Ifresults of research are not made pub-lic, especially if they are negative,

the research may be repeated unne-cessarily and thereby expose futureparticipants to potential harm.

E. Affiliations with Commercial Entities8. A physician may not enter into an affil-

iation with a commercial entity such asconsulting or membership on an advi-sory board unless the affiliation con-forms to the following prinicples:

8.1 The affiliation does not compro-mise the physician’s integrity.

8.2 The affiliation does not conflictwith the physician’s obligations tohis or her patients.

8.3 Affiliations and/or other relationshipswith commercial entities are fullydisclosed in all relevant situationssuch as lecturers, articles and reports.

9.10.2004


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1. Medical ethics in times of armed con-flict is identical to medical ethics intimes of peace, as established in theInternational Code of Medical Ethicsof the World Medical Association. Theprimary obligation of physicians is totheir patients; in performing their pro-fessional duty, their conscience shouldbe their guide.

2. The primary task of the medical pro-fession is to preserve health and savelife. Hence it is deemed unethical forphysicians to:

a. Give advice or perform prophylac-tic, diagnostic or therapeutic proce-dures that are not justifiable for thepatient’s health care.

b. Weaken the physical or mentalstrength of a human being withouttherapeutic justification.

c. Employ scientific knowledge to imperil health or destroy life.

3. During times of armed conflict, stan-dard ethical norms apply, not only inregard to treatment but also to all otherinterventions, such as research. Researchinvolving experimentation on humansubjects is strictly forbidden on all per-sons deprived of their liberty, especiallycivilian and military prisoners and thepopulation of occupied countries.

4. The medical duty to treat people withhumanity and respect applies to allpatients. The physician must always

give the required care impartially andwithout discrimination on the basis ofage, disease or disability, creed, ethnicorigin, gender, nationality, politicalaffiliation, race, sexual orientation, orsocial standing or any other similarcriterion.

5. Governments, armed forces and othersin positions of power should complywith the Geneva Conventions toensure that physicians and other healthcare professionals can provide care toeveryone in need in situations of armedconflict. This obligation includes arequirement to protect health care per-sonnel.

6. As in peacetime, medical confidential-ity must be preserved by the physician.Also as in peacetime, however, theremay be circumstances in which apatient poses a significant risk to otherpeople and physicians will need toweigh their obligation to the patientagainst their obligation to other indi-viduals threatened.

The World Medical Association Regulations in times of armed conflictAdopted by the 10th World Medical Assembly, Havana, Cuba, October 1956,Edited by the 11th World Medical Assembly, Istanbul, Turkey, October 1957, andAmended by the 35th World Medical Assembly, Venice, Italy, October 1983 andThe WMA General Assembly, Tokyo 2004

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7. Privileges and facilities afforded tophysicians and other health care pro-fessionals in times of armed conflictmust never be used for other thanhealth care purposes.

8. Physicians have a clear duty to care forthe sick and injured. Provision of suchcare should not be impeded or regard-ed as any kind of offence. Physiciansmust never be prosecuted or punishedfor complying with any of their ethicalobligations.

9. Physicians have a duty to press gov-ernments and other authorities for theprovision of the infrastructure that isa prerequisite to health, includingpotable water, adequate food andshelter.

10. Where conflict appears to be imminentand inevitable, physicians should, asfar as they are able, ensure that author-ities are planning for the repair of thepublic health infrastructure in theimmediate post-conflict period.

11. In emergencies, physicians arerequired to render immediate attentionto the best of their ability. Whethercivilian or combatant, the sick andwounded must receive promptly thecare they need. No distinction shall bemade between patients except thosebased upon clinical need.

12. Physicians must be granted access topatients, medical facilities and equip-ment and the protection needed tocarry out their professional activities

freely. Necessary assistance, includ-ing unimpeded passage and completeprofessional independence, must begranted.

13. In fulfilling their duties, physiciansand other health care professionalsshall usually be identified by interna-tionally recognized symbols such asthe Red Cross and Red Crescent.

14. Hospitals and health care facilities sit-uated in war regions must be respectedby combatants and media personnel.Health care given to the sick andwounded, civilians or combatants,cannot be used for morbid publicity orpropaganda. The privacy of the sick,wounded and dead must always berespected.

Initiated February 2004

Approved by the WMA General Assembly, Tokyo 2004

A. INTRODUCTION1. In late 2002, an outbreak of a new

severe acute respiratory syndrome(SARS) began in southern China. Thedisease, which was caused by theSARS coronavirus, spread internation-ally in late February 2003. The mostseverely affected countries wereChina, Canada, Singapore andVietnam, all of which experienced out-breaks before the issue of global alertsby the World Health Organization(WHO). According to WHO data, alto-gether 8422 cases occurred in 29 coun-tries; in the four afore-mentionedcountries, 908 cases were fatal.

2. SARS was an especially difficult newdisease to diagnose and treat - it passedreadily from person to person, requiredno vector, had no particular geograph-

ic affinity, mimicked the symptoms ofmany other diseases, took its heaviesttoll on hospital staff, and spread inter-nationally with alarming ease. Thespread of SARS along the routes ofinternational air travel emphasizes thefact that pathogens know no bound-aries and reinforces the critical needfor global public health strategies.

3. The main outbreaks of SARS occurredin areas with well-developed healthsystems. If SARS had become estab-lished in areas with weak health infra-structure, it is unlikely that contain-ment would have been achieved soquickly. But even in well-developedhealth care systems, certain very sig-nificant flaws were demonstrated dur-ing this epidemic:

• Lack of effective real-time, two-waycommunication channels to front-line physicians;

• Lack of adequate resources, stock-piles of medication and supplies todeal with this type of catastrophe;

• Lack of surge capacity within acutecare and public health systems.

4. A gap between public health authori-ties (national and international) andclinical medicine was demonstratedduring this episode. At its September2003 General Assembly, the WMAadopted a Resolution on SARS that:„strongly encouraged the WorldHealth Organization to enhance itsemergency response protocol to pro-vide for the early, ongoing and mean-ingful engagement and involvement ofthe medical community globally.…“

B. BASIC PRINCIPLES

5. The international community must beconstantly alert to the threat of emerg-ing disease outbreaks and ready torespond with a global strategy. TheGlobal Outbreak Alert and ResponseNetwork (GOARN) of WHO has a sig-nificant role to play in global healthsecurity by:

• combating the international spread ofoutbreaks;

• ensuring that appropriate technicalassistance reaches affected statesrapidly; and

The World Medical Association Statement onhealth emergencies communication and coordination


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• contributing to long-term epidemicpreparedness and capacity-building. The WMA has been activelyinvolved in GOARN, where appro-priate. The role of GOARN must,however, be acknowledged andactively promoted within the med-ical profession.

6. Sovereign states have a responsibilityto address the health needs within theirborders. Today, however, many urgenthealth security risks are not confinedby national boundaries. Early detec-tion, through effective national sur-veillance systems, of unusual diseaseevents that threaten public health, andinternational cooperation betweenWHO, its member states, and non-governmental partners like the WMA,are required to effectively respond topublic health emergencies of interna-tional concern. A strengthening of theInternational Health Regulations tobroaden their scope to include newand future health emergencies andenable WHO to actively assist Statesin responding to international healthsecurity threats will provide additionaltools for global epidemic control.

7. Effective communication betweenWHO and the WMA, the WMA and itsmember National Medical Associations(NMAs), and NMAs and physicianscan strengthen the informationexchange between WHO and itsMember States during public healthemergencies.

8. Physicians are often the first point ofcontact with the emergence of newdiseases; therefore they are in a posi-tion to aid in all elements of diagnosis,treatment and reporting of affectedpatients and prevention of disease.Physicians with key expertise must beincorporated into the health emer-gency decision-making process so thatthe impact of national and internation-al directives on clinical settings andpatient care is understood.

9. WHO and its Member States must workwith the WMA and NMAs to proactive-ly address the safety of patients and of

health professionals involved in caringfor the sick during outbreaks of new dis-eases. Delays in identifying and distrib-uting supplies of protective equipment tohealth professionals and their patientsexacerbate anxiety and risk of spread ofinfectious disease. National and interna-tional systems that stockpile relevantand adequate supplies and rapidly movethem to affected areas should be createdor enhanced. All the principles employedin the safeguarding of patient safetyshould be respected and followed inemergencies such as SARS.

C. RECOMMENDATIONS

10. That the WMA and member NMAsshould work closely with WHO,national governments, and other pro-fessional groups to jointly promote theelements of this Statement.

11. That the WMA urge physicians to a) bealert to the occurrence of unexplainedillnesses and deaths in the community,b) be knowledgeable of disease sur-veillance and control capabilities forresponding to unusual clusters of dis-eases, symptoms and presentations,and assiduous in the timely reportingof suspicious cases of illness to appro-priate authorities; c) utilize appropriateprocedures to prevent exposure ofinfectious pathogens to themselves andothers; d) understand the principles ofrisk communication so that they cancommunicate clearly and non-threaten-ingly with patients, their families, andthe media about issues such as expo-sure risks and potential preventivemeasures (e.g., vaccinations); and e)understand the roles of the publichealth, emergency medical services,emergency management, and incidentmanagement systems in response to ahealth crisis and the individual healthprofessional’s role in these systems.

12. That the WMA encourage physicians,NMAs, and other medical societies toparticipate with local, national, andinternational health authorities in devel-oping and implementing disaster pre-

paredness and response protocols fornatural infectious disease outbreaks.These protocols should be used as thebasis for physician and public education.

13. That the WMA call on NMAs to pro-mote and support WHO’s GOARN asa control coordinating entity in com-bating global health security threats.

14. That the WMA call for the establish-ment of a strategic partnership agree-ment with WHO, so that in case ofepidemics, health communication canbe stepped up considerably and two-way flow of information ensured.

15.That WHO should coordinate thedevelopment of an inventory basedon existing stockpiles of supplies, sothat such supplies can be rapidlydeployed and accessed by physiciansinvolved in the care of victims.

16. That WHO should strengthen theInternational Health Regulations tobroaden their scope to include report-ing of new and future health emer-gencies, and to enable WHO toactively assist States in responding tointernational health security threats.

17. That international agreements shouldbe proactively explored to facilitatethe movement of health professionalswho are involved in the managementof epidemics.

18. That research in the field of emergencypreparedness should be enhanced bynational governments and NMAswhere appropriate, to better understandcurrent flaws in the system and how toimprove preparedness in the future.

19. That education and training of physi-cians should be modified to take intoaccount the realities and specific needsrequired in the event of emergencies,and to ensure that due diligence is paidto patient and health care worker safe-ty when managing patients with acuteinfectious diseases.

20. That physicians everywhere in the world,including those in Taiwan, have unlimit-ed access to WHO programs and infor-mation concerning health emergencies.


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Note of clarification on paragraph 30 of theWMA Declaration of Helsinki“The WMA hereby reaffirms its position that it is necessary during the study planningprocess to identify post-trial access by study participants to prophylactic, diagnostic andtherapeutic procedures identified as beneficial in the study or access to other appropri-ate care. Post-trial access arrangements or other care must be described in the study pro-tocol so the ethical review committee may consider such arrangements during its review.”

Medical Science, Professional Practice and Education

Account by Dr. James Appleyard of his Presidential year of office 2003–2004

It has been a great honour and privilege tohave represented the World MedicalAssociation over the last twelve months asyour President. My enduring memory hasbeen the warm, friendly and respectful wel-come from physicians worldwide. This wasa the reaffirmation of our Declaration ofGeneva that „my colleagues will be mybrothers and my sisters“. We all share acommon professionalism underpinned byour core values.

My main theme has been the Right of aChild to Health Care advocating our Declaration of Ottawa, highlighting thegap between the rich and poor both betweenand within the nations of the World, seekingto raise awareness and encouraging profes-sional links particularly in education and research. I was able to spread the messagefrom Africa (at the Ugandan MedicalAssociation and in South Africa), toAmerica (in Miami at the Academy ofPharmaceutical Physicians, New York, atthe Hispanic Development Foundation,Portland Oregon to the medical studentsduring their Global Health Week) and inMalta, where the theme was taken up in afour minute television feature augmentedby their own archives.

Emphasizing that Violence is a leading pub-lic health problem particularly impacting onthe lives and wellbeing of children, it waspossible to stress the message of the

Helsinki WMA statement on Violence atmeetings in the UK, Dominica, and notablyat the annual meeting of the InternationalFederation of Medical Student Associations(IFMSA) in Ohrid, Macedonia where themajor theme was “Violence and Health”.

Finally I addressed the Symposium on“The application of Children’s Rights” atthe 24th International Congress ofPediatrics in Mexico. At the Congress, Ms.Carol Bellamy from UNICEF emphasizedthat six out of the eight Millennium Goalswere Child focused and that these were thegoals of each government of the nations ofthe World. (UNICEF is publishing a Reporton “Progress for Children” this autumn),Joy Phumaphi from WHO stressed the“unfinished agenda” of the “Alive at Five”initiative also pointing out that 11 millionchildren are dying each year from pre-ventable and treatable conditions. Thuschildren are bearing 1/3 rd of the world’sburden of disease, 9/10ths of which wasaffecting the poorer countries who had theleast resources to cope with it. She said thatthe conference knew who was at risk, wherethey were, what must be done and how todo it. There are several concomitant initia-tives such as the “Child SurvivalPartnership” with UNICEF, WHO and theWorld Bank that WMA, as the Associationof the Worlds’ Physicians needs to join andthere are also two effective pilot projects“Child Watch Africa” and the Save the

Children’s “Saving New Born Lives”,which are physician driven.

I have contacted all our national medicalassociation members about the need todevelop the WMA Declaration of Ottawafurther, and am currently collating thereplies.

There were two other areas for which, asPresident, I sought your support. Firstly,action to stop the increasing health prob-lems of sub-Saharan Africa and to try andinclude more African National MedicalAssociations in our work; and secondly, theimportance of medical education in thismission. My first engagement was to attendthe “Strategies for Survival” Conference ofthe South African Medical Associationunder the inspired leadership of Dr. KgosiLetlape. In the very challenging timesahead, all the members of the profession inSouth Africa are united both in the ethicalvalues that underpin medical practice andin their quest for improved health servicesfor the underserved. At the Annual Meetingof the Ugandan Medical Association, therewas an opportunity to meet the Presidentsof the Kenyan and Tanzanian MedicalAssociations in conjunction with the WorldHealth Organization who were discussingthe setting up of an East African Medicaland Dental Association.

Concerning medical education, my aimwas to raise awareness of internationalissues in a sustainable way by encouragingall medical students to do a month’s elec-tive in a developing country and to suggest“exchanges” during residency training pro-grammes, with the support and encourage-ment of joint research initiatives. I visitedthe International Department of CornellMedical School where 40% of the studentsalready have international assignments,met the Dean of New York College ofMedicine and joined an inspired core ofdedicated medical students who hadarranged a Global Health Week at OregonHealth and Sciences University inPortland, Oregon. The energy and enthusi-asm apparent at the InternationalFederation of Medical StudentsAssociations (IFMSA) in Ohrid,Macedonia, where I participated in theimpressive opening ceremony held in the


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Roman Amphitheatre, bodes well for thefuture. Members of the IFMSA are givenfree associate membership of the WMAafter they graduate and have to move onfrom their own association. I hope as manyof these young and dedicated physicianswill attend our meetings and continue tohelp shape the future.

Our continuing work with other interna-tional professional associations is essentialif we are to get our important messagesacross to the wider world community. Iattended the excellent InternationalFederation of Dentist’s (FDI) first RegionalConference on Oral Health of the AfricanRegion, where the importance of includingthe major oral health problems within thecollaborative general health programs wasstressed in the presence of the Ministers ofHealth, WHO, representatives fromAcademia and dental practitioners. Thiswas an inclusive conference dealing withthe particular problems of the Region andone which we should be emulated in otherRegions. The European Forum for GoodClinical Practice held a Conference onClinical Research involving Academia,Industry, Medical Organizations, NGOs.,seeking to influence current European leg-islation The European Platform for PatientOrganizations also expressed a concern torescue reliable, ethical research initiatives on children.

The World Health Professions AllianceConference held in Geneva after ourCouncil Meeting in Divonne was a majorinnovation for the WMA. It is essential thatwe use such forums to join with otherhealth professional colleagues to help tack-le the global problems such as AIDS in acoordinated way. We must rise above theunnecessary turf battles that have belittledus all. The combined energy should be usedto advocate our own shared policies so thattogether we can have much greater impact.

We are also a Founder Member of OxfordVision 2020 dedicated to the prevention ofthe forecast pandemic growth of largelypreventable chronic diseases in the low andmiddle income countries and the poorersegments of society in the developed world.The forum includes academia, industry,professional and other non governmental

organization, patient groups and youngpeople. It focuses on three risk factorstobacco, diet and lack of exercise, and fourchronic diseases, diabetes, cardiovasculardisease, chronic lung disease and some can-cers, which lead to 50% of deaths globally.Our profession should set an example andfollow the lead of our American colleagueswith regard to diet, smoking, and exerciseand reduce our own BMI’s!

During a meeting of the Maltese MedicalAssociation, I had the opportunity toencourage policy development to imple-ment the Framework convention onTobacco Control in a meeting with theMinister of Health. Some progress has beenmade with regard to the hazards of passivesmoking on the island. Increasingly othercountries are following the example of theRepublic of Ireland. I wrote to the PrimeMinister in the UK but he has so far failedto respond to the lead of his own ChiefMedical Officer.

As the global representative body of some 7million physicians we have a duty to sup-port our “brothers and sisters” in times ofgreat difficulty. In conjunction with ourHuman Rights Unit I tried through contactsto help free Dr. Biscet who is still languish-ing in a Cuban Jail as a result of his endeav-ors to promote human rights. Some 10.000 doctors were on strike whenI visited the Dominican Republic. Theirconcerns were the deteriorating situation inGovernment Hospitals, and the catastrophiceffects of the fall in the value on the peso onbasic maintenance of hospitals and on theirown salaries. With the President of theColegio Medico Dominicano I visited theHospital General Materno Infantil and metthe faculty, residents and the administra-tion. The acute services budget was runningat 15% of the hospitals needs. Hospitalblackouts could last up to 13 hours, andsometimes the only available light duringemergency operations had been from theLCD display of a mobile phone.

The collapse of the health system inZimbabwe, whose government has ratifiedwith the other African Countries theWHO’s “Right to Health”, is a humanitari-an disaster with an additional 20.000 chil-dren dying each year in the year 2002 than

would have died ten years previously.Cuban doctors have been imported to tryand reverse the effects of the loss of physi-cians from the country but they are unableto provide a proper primary care servicebecause of language difficulties, and havesettled in the cities. I met a dynamic groupof non governmental organizations includ-ing the Amani Trust, AmnestyInternational, Zimbabwe Association andZADHR to be informed about the currentculture of repressive violence and torture inZimbabwe which is being reinforced by the“War Veterans” and Youth Militia.

At the BMA Annual Representative Bodyin Llandudno, I met Dr Raj Doolabh, whothen was Treasurer of the ZimbabweMedical Association, one of our memberassociations. He did not expect significantchange in Zimbabwe until Mr. Mugaberetired. Members of the opposition werebeing denied treatment for HIV/Aids. By-elections caused by their deaths allowedtheir replacement by ZANU members. RajDoolabh suggested that the main helpphysicians from outside Zimbabwe couldgive their colleagues in Zimbabwe wasthrough Continuing Medical Education,which is now mandatory in the Country. Itwas hoped that it would be possible toarrange a meeting with the ZIMA executiveduring a conference on AIDS which Dr.Letlape was organising in September butunfortunately this has not been possible.

Physicians in Iraq have started to developlinks with the WMA following the atten-dance of Dr. Brennan on their behalf at theCouncil Meeting in May. At a recent IraqiMedical Specialty Forum in Washington Imet some Iraqi physicians from Baghdadand several others who had emigrated to theUS. The security situation for physicianswas very serious. Dr Khalili, aNeurosurgeon, who had been kidnappedhimself, said the main problems were secu-rity, a regular supply of electricity andwater and the maintenance of medical sup-plies and provisions for GovernmentHospitals. On the other hand the budget forHealth had been increased from $16 millionin Saddam Hussein’s time to $905 million.600 extra medical facilities for essentialcare had been developed with 110 primaryhealth care centers. Certain areas of the


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country such as Kurdistan were peacefuland safe. It was suggested that a conferenceincluding all interested national medicalassociations in the region might be held tolook how the health problems in the Regionand in particular how those in Iraq could beaddressed. This is a contribution that theWMA might make with the WHO subjectto funding which I gather could be raised.

My last visit before handing over the badgeof office to the President-elect, Dr. YankCoble, was to talk about “Professionalism”at the annual meeting of the IcelandicMedical Association, a subject alreadytaken up by the Editor of the WMJ. Here itwas emphasized that we need to guard ourprofessional autonomy by ensuring the

highest standards of education, care andethics.

This last visit had a timely topic for reflec-tion and illustrates the importance of theWMA continuing to support the work ofphysicians worldwide.

“Wherever the Art of Medicine is loved,there is also the love of humanity”

Hippocrates 400 BC

James Appleyard MA (Oxon), MD (Kent),FRCP (Lon), FRCPCH (UK)President of the World Medical Association2003–2004

The future of medical technology – Implications for medical education and practice

Address to the World Medical Associa-tion (Tokyo, Japan)

Henry Haddad, MD, FRCPCPast PresidentCanadian Medical Association

Thank you very much for asking me tospeak to you today. It is indeed a great hon-our, and I would like to express my gratitudeto our Japanese hosts for having invited meto address this distinguished gathering.

As many of you know, medical technologyhas revolutionized both medical educationand the clinical practice of medicine in mostparts of the world. Some people may stillview advances in the field as a relativelyrecent development, and medical technolo-gy as a modern phenomenon.

However, medical technology as we under-stand it has been developing over manyyears, from the discovery of medical appli-cations of radioactivity by Roentgen to theisolation of insulin by our own Canadianresearchers Banting and Best. More recentdevelopments have included implantablemedical devices such as pacemakers andartificial valves, and the refinement of

organ transplantation techniques and antire-jection drug regimens.

Although medical technology is not new, itsdevelopment has certainly accelerated sig-nificantly, and keeping up with thesechanges has become a difficult challengefor many medical practitioners.

Before expanding on the concept of medicaltechnology, it may be useful to take a stepback and consider human achievementswhich are in today’s terms decidedly “low-tech”. Some of our most prominent medicalpractitioners, such as Pasteur, Burkett,Osler and Freud worked without the benefitof high technology.

It was in 1950 that Dicke suggested, in alandmark study, that certain dietary cerealgrains were harmful to children with acoeliac sprue – a malabsorbtion disorderthat is potentially fatal. He acutely observedthat the incidence of coeliac sprue in chil-dren in Holland during World War II wasmarkedly reduced and that previously diag-nosed coeliac patients improved during thewar years. During this period, grain produc-tion such as wheat and rye flour, were in

short supply in Holland. When cereal grainsagain became plentiful after the war, theincidence of coeliac sprue rapidly returnedto previous levels. It was subsequentelydemonstrated that the gluten moiety of wheatwas the offending agent. This simple obser-vation has improved the quality of life ofmany thousands of people, including some ofmy relations.

There are also other factors of determantsof health that have had a tremendousimpact on global health, these includepatient education, improved diet and recog-nition of environmental factors. Inventionsnot directly related to medicine have alsoplayed an important role. For example, theinvention of refrigeration may have savedmore human lives than any other. Havingsaid this, most people would still probablyagree that, on balance, medical technologyhas had a positive impact on patient healthand well-being. Life expectancy in mostcountries around the world has increasedsignificantly and other markers of health,such as neonatal and maternal mortality,have also improved.

In general, medical technology has enhanceddiagnostic accuracy and efficiency.

This has allowed physicians to see, diag-nose and treat more patients in a shorterperiod of time, an important developmentin those many places with insufficient med-ical human resources. Patients live longerand have higher quality of life because ofdevelopments such as insulin pumps, pros-thetic heart valves and artificial joints.However, in many parts of the worldincluding my own country, great advancesin medical technology have not generallytranslated into the large leaps in productiv-ity as witnessed in other industries.

It would now appear that what we oncereferred to as the “future” of medical tech-nology is nearly upon us.

Advances previously thought to be in therealm of science fiction are fast approach-ing reality. Among the numerous examplesof medical technology, the most widely dis-cussed is the genetic/genomic revolution.

Following the unravelling of the humangenome, we have been witness to wide-spread and diverse predictions regarding

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future applications of this new knowledge.The genomic revolution has raised manyquestions:

• Is the development of designer drugsbased on a person’s genetic makeup faroff?

• Is gene therapy for currently untreatableconditions on the horizon or will thepotential roadblocks prove insurmount-able?

And what of stem cell transplantation?

• Is it truly the answer we have been seek-ing to help cure diabetes, Parkinson’sDisease and spinal cord injury?

Along with these questions, which tend toprovoke much excitement and optimismamongst medical practitioners and theirpatients, are other, potentially more trou-bling ones, which also deserve some atten-tion and discussion.

Who will have access to these new tech-nologies?

Access to care remains a major concern inmany parts of the globe.

Access to care based on need rather thanability to pay, is still a pipe dream for most.It is certainly possible that as medical tech-nology advances further, inequities inaccess to care will become more rather thanless apparent and profound.

Wealthier nations who are able to fund thedevelopment of technologies will move fur-ther ahead, while those without theresources to compete will fall furtherbehind.

This also has to do with the broader issuesof resource allocation and priority setting.Hi-tech interventions tend to be relativelymore expensive, both in terms of initialcapital outlay and recurrent expenditures.

We need to ask ourselves how far weshould go in allocating scarce resources tomeeting increasing patient demands forthese more costly interventions, when theend result may be decreased availability ofsimpler, but often equally effective, treat-ments. For example, many countries,including Canada, devote inadequateresources to caring for the terminally ill. It

is difficult to compare results seen from theuse of medical technology to the benefits ofcompassionate care at the end of life. Butdecisions about where to allocate our pre-cious resources must be made, and we mustgrapple with the issue of what kind ofrationing in health care is morally acceptable.

Will predictive genetic testing disadvantagethose with a genetic susceptibility to dis-eases for which there is no cure? For exam-ple, the development of a test could deter-mine with certainty that a person woulddevelop incapacitating and untreatable can-cer or a neurological disorder at a young agewould be likely to affect their insurabilityand employability if insurers and employerswere able to gain access to this information.Currently the insurance industry is lobbyingfor exactly this type of access.

This threatens to have a detrimental impacton the doctor-patient relationship.

Presently in Canada it is known that inapproximately 11% of medical encounters,the patient withholds relevant medicalinformation because of concerns about whowill have access to this data (includingemployers, banks and insurance compa-nies). In the United States this percentageappears to be about 15% of patients. Thisproblem is likely to become worse overtime, with the advent of predictive genetictesting and the use of electronic healthrecords, which could be accessed by otherparties. If more medical information iswithheld, and many experts estimate thatthe figure will rise to 20% of patients, thedoctor-patient relationship will be furthercompromised, and there can be little doubtthat patient care will suffer.

And what about the psychological impact ofthis type of information on these patients?

Just because we have the ability to uncovercertain medical information, does that meanwe should, especially when treatment orcures do not exist?

Does the benefit of planning for the futureoutweigh the potential burden of knowingwhen this future will end? Experts in thisimportant field are currently consideringthese questions and others.

Will those who bear the burden of medicalresearch ultimately reap the rewards of dis-covery? There are many examples of stud-ies done in populations which ultimately donot derive the primary benefits from theirresults. There is no reason to believe thattechnological research might be any differ-ent, and as physicians we must do whatev-er we can to guard against this, and toensure that the burdens and benefits ofmedical research are equitably distributed,– a major concern of the WMA:

Where is the line drawn between innovativemedical practice and medical research? If asurgeon is perfecting a new procedure suchas implantation of a new mechanical pump,does this qualify as standard medical prac-tice or as research? The distinction can be acritical one. If it is research, it wouldrequire review by a duly constituted resarchethics board and would be subject to a dif-ferent standard of informed consent.Oversight and monitoring of the procedurewould also be more stringent in many partsof the world if it were considered to beresearch rather than standard treatment.

Does the advance of medical technologyfurther skew the balance between art andscience in the practice of bedside medicinetowards science, and what impact will thishave on the education and development offuture physicians?

Over many centuries, medical practitioniersrelied on the art of medicine to help relievesuffering. This was true for both diagnosisand treatment. As a very famous Canadianphysician, Sir William Osler, once said:“Always listen to the patient, they will tellyou the diagnosis.” The point is that test-ing should never be used as a substitutefor a good history. The emphasis is today– and I see this every day at my UniversityHospital – on scan and blood test. Keeprepeating to your students that there is noth-ing more satisfying or more informativethan sitting down with the patient and real-ly considering what they are saying. SirWilliam Osler was right – “Technology isthere to complete the art of medicine – it isnot a substitute”!

However, in modern times, the thoroughbedside medical examination has oftengiven way to the full-body or MRI scan.The


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long and emotional discussion about theimpact of a person’s physical illness ontheir psychological well-being has beenreplaced by the prescription for the newestanti-depressant, often one the patient hasseen advertised on TV. These changes havealtered the physician-patient relationship,and usually not for the better.

Medical students today train in an environ-ment with a bias towards specialization ofcare, often driven by rapid advances intechnology.

Physicians cannot be expected to keep upwith every new development when thebody of medical knowledge is, by someestimates, doubling every year. These fac-tors have led to increasing subspecializa-tion and the gradual erosion of the role ofthe primary care practitioner, which is socrucial to the maintenance of overallpatient health and well being.

Students are also often attracted to the moreglamorous and higher paying specialities,which not coincidentally, are often thosewhich make the most use of technology.

Unless we are able to swing the pendulumback towards the art of medicine, anddemonstrate to a greater number of stu-dents the merits and rewards of primarypractice, we will see a further decline of thedoctor-patient relationship and a furtherdehumanization of the practice of medi-cine. This is not in the best interest of eitherthe physicians or their patients.

As we have focused more attention onacute care and life-saving technologies,have we neglected areas such as publichealth and health promotion? Certainlymuch of the attention and publicity tends tobe focused on those medical interventionsthat save individual lives – the coronarybypass, the new cancer treatment, the kid-ney transplant. And while this attention(and, not coincidentally, much of the fund-ing) has been focused on acute care and theimpact of new advances, the public healthand promotion infrastructure has beenslowly deteriorating.

We need look no further than SARS for anexample. Billions of dollars world-wide arecurrently being poured into the develop-ment of medical databases so that, for

example, emergency physicians can accesspatient information and test results at thetouch of a button. This we would all agreeis a positive development-improving healthcare and eventually hopefully reducingcost. In the meantime, public health careworkers in Toronto were faced with a com-pletely outdated and inadequate computersystem to try and track new cases of SARSand their contacts during the height of theepidemic. In many offices, sticky notes wereused instead of computer databases to keeptrack of new developments. While we mayhave learned a lesson from this example,whether or not we can apply it in a meaning-ful and ongoing way remains to be seen.

Finally, will the emphasis currently placedon technological research and its transla-tional application detract both attention andfunding from equally important basic sci-ence research?

Just as medical students are more likely tobe attracted to the more glamorous spe-cialities, so too will scientists in trainingoften follow their mentors as they pursuethe dollars and glory promised by the nexttechnological miracle. Let me conclude bysaying that, overall, we have been wellserved by advances in medical technology,and our patients in general are livinglonger and healthier lives because of thesedevelopments.

However, we must not push ahead blindlyor unquestioningly.

I have tried to raise several questions,which I think require further thought anddiscussion. Until we can answer these ques-tions, and others, the future of medical tech-nology is likely to remain uncertain at bestand troubling at worst.

Twin Studies

Blame your genes for a restless night’s sleep –new research revealed

New research carried out by doctors in theTwin Research Unit at St. Thomas’Hospital, London, U.K. indicates thatgenetic factors make a “substantial contri-bution” to common sleep disorders.

Professor Tim Spector, Director of the Unit,has revealed the results of a new study ofalmost 2,000 pairs of female twins during apress briefing at the Science Media Centre.

1,937 pairs of identical and non-identicaltwins from the Twin Research Unit data-base were asked questions on sleep disor-ders such as obstructive sleep apnoea(OSA) and restless legs syndrome (RLS).

Dr. Adrian Williams, a co-author of theresearch study and Consultant in the SleepDisorders Centre at St. Thomas’ Hospital,says: “Sleep disorders are surprisingly com-mon and it is increasingly recognised thatthey can have a devasting impact on suffer-ers’ everyday lives.”

“For example, OSA affects approximately24% of men and 9% of women aged 30 to 60.It even contributes to road traffic accidentswhen sufferers fall asleep at the wheel.”

Twins were asked, in connection with OSA,if they ever snored and, if so, how oftentheir snoring disturbed others or causedthem to wake up – they were also asked ifthey experienced daytime sleepiness.

In relation to RLS, twins were asked if theyever experienced an urge to move their legsduring the night to relieve tingling or numb-ness and also if they ever found their legsjerked involuntarily during the night.

Key findings of the research study include:

• Genes contribute significantly to sleepdisorders – approximately 50% of thevariance in liability to these symptoms isdue to genetic factors.

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• Heritability was estimated to be 42%(disruptive snoring), 45% (daytimesleepiness), 54% (restless legs) and 60%(legs jerking).

• An important strength of the researchstudy is that these heritability estimateshave been corrected to take into accountother influences on the symptoms ofsnoring and daytime sleepiness such assufferers being overweight or heavysmokers.

Professor Spector says: “These results sug-gest a substantial genetic contribution to thesymptoms of both obstructive sleep apnoeaand restless legs syndrome and that couldbe good news for people who suffer from

these conditions if the genes responsiblecan be identified.

“One reason the genes for disruptive sleepmay have persisted is that poor sleep pat-terns make people gain weight and retainfat. These genes may have helped ourancestors through periods of famine and theIce Age.”

The Twin Research Unit was originally setup at St. Thomas’ Hospital (London U.K.)in 1992 to look at the role that genes playin the development of rheumatic diseasesin older women and has now expanded tolook at most common diseases, behavioursand traits.


New tools and increased funds will beat malaria, say global leaders

Arusha, Tanzania – New technologies formalaria prevention and treatment, com-bined with an increase in available funding,are fuelling optimism in the fight againstmalaria. Global leaders gathered in Arushafor the launch of the Olyset® Net at A to ZTextile Mills – the first factory in Africa toproduce this long-lasting insecticidal mos-quito net – agreed that conditions were rightfor a massive scale-up in the battle againstthe disease, which claims more than a mil-lion lives each year and hampers develop-ment, especially in Africa.

The President of the United Republic ofTanzania, Benjamin W. Mkapa, delivered amessage of hope to a group of dignitariesincluding US Secretary of Health andHuman Services Tommy Thompson, RollBack Malaria Partnership ExecutiveSecretary Awa Marie Coll-Seck, and GlobalFund to Fight AIDS, Tuberculosis andMalaria Executive Director RichardFeachem, as well as representatives of the

Roll Back Malaria partners who had madethe A to Z technology transfer possible.

“Long-lasting insecticidal nets are Africa’sbest hope for preventing malaria, and weare very proud that Tanzania is the home ofAfrica’s first manufacturer of these nets,”said President Mkapa. “We hope that thisshining example of technology transfer andstrengthening of local industry will serve asa model for similar efforts, making the netsmore affordable and available to the mil-lions of Africans who need them.”

The technology for long-lasting insecticidalnets, which embed insecticide within thenet’s very fibres and therefore retain theirefficacy for up to five years without retreat-ment, was transferred to Tanzania last yearin a groundbreaking collaboration betweenprivate and public sector players includingthe Acumen Fund, Sumitomo Chemical, theWorld Health Organization, UNICEF,ExxonMobil, and Population ServicesInternational. A to Z Textiles now produces

nearly half a million of these new nets eachyear and hopes to ramp up production topass the one-million mark in 2005.

The latest generation of highly effectivemalaria treatments known as artemisinin-based combination therapy (ACT) offer acure that so far has met only minimal resis-tance from the malaria parasite. Derivedfrom the Artemisia annua (sweet worm-wood) plant traditionally used to treatmalaria in China, these medicines havebecome the drug of choice for more than 40countries (20 of them in Africa), anddemand for them has increased rapidly.

The factory visit took place in the contextof th 9th board meeting of the Global Fund,which was held in Arusha from 17–19November. “The Global Fund has commit-ted nearly US$ 1 billion over the comingtwo years and expects to scale up malariafunding substantially,” said Global FundExecutive Director Feachem. “These fundswill be used by countries to purchase bothpreventive and curative tools – includinglong-lasting nets, artemisinin-based combi-nation therapy, and insecticide sprayingwhere suitable – for maximum impactagainst malaria.” The Global Fund is alsoworking with Roll Back Malaria partners toprovide the financial incentives that willbring a new malaria vaccine to the market.

“This is a new era for malaria control,”declared the Roll Back MalariaPartnership’s Executive Secretary Coll-Seck. “Demand for this latest generation ofeffective malaria-control tools is increasingrapidly, and so is funding. If we can repli-cate the success of A to Z to ensure an ade-quate supply of long-lasting insecticidalnets, and work with pharmaceutical com-panies to ensure ACT supplies, we willdemonstrate the true power of public-pri-vate partnerships by dramatically reducingmalaria deaths.”

Background

To provide a coordinated global approachto fighting malaria, the Roll Back MalariaPartnership was launched in 1998 by theWorld Health Oarganization, the UnitedNations Children’s Fund (UNICEF), the

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United Nations development Programme(UNDP) and the World Bank. ThePartnership’s goal is to halve the globalburden of malaria by 2010.

The Partnership now includes malaria-endemic countries, their bilateral and multi-lateral development partners, the private sec-

tor, non-governmental and community-basedorganizations, foundations, and research andacademic institutions and has succeeded inraising global awareness of malaria, generat-ing increased resources and achieving con-sensus on the tools and priority interventionsrequired to control the disease.

Midwives/Gynaecologists

Skilled attendants vital to saving lives of mothers and newborns

Geneva – The number of skilled attendants indeveloping countries needs to be increased byat least 333,000 if the international communi-ty is to meet the Millennium DevelopmentGoal (MDG) of reducing maternal deaths bytwo thirds by 2015, according to a joint state-ment* issued by the World HealthOrganization, the International Federation ofGynaecologists (FIGO) and the InternationalConfederation of Midwives (ICM).

A skilled attendant is a health professionalwith the competencies for care during nor-mal birth and the capacity to recognize,manage and refer complications in thewoman and newborn. Skilled attendantsplay a pivotal role in reducing maternal andnewborn mortality and morbidity, says thejoint statement of WHO, ICM and FIGO.The statement calls for better monitoringand reporting on progress in achieving the

MDG target of increasing the proportion ofbirths attended by a skilled attendant to90% by 2015.

The shortfall is most acute in the developingworld. In developed countries and countriesin transition, the average rate is above 90%.The lowest levels are in Eastern Africa(33.6%), South-Central Asia (37.5%) andWestern Africa (39.6%), with much higherlevels in South America (84.8%). Globally,only 61% of all childbirths are attended by askilled birth attendant.

“Life-threatening complications occur in15% of all births,” says Joy Phumaphi,Assistant Director-General of Family andCommunity Health at WHO. “For a moth-er and her newborn, a skilled birth atten-dant can make the difference between lifeand death. Not only can they recognize andprevent medical crises on the spot, but theycan refer women for life-saving care whencomplications arise.”

The joint statement defines a skilled atten-dant, sets out what skills they should have,and the training and support they need. Intheir statement, WHO, ICM and FIGOjointly urge the international community,professional associations and donors tomake skilled care for all pregnant womenand their newborns a priority – focusing onincreasing the number of skilled birthattendants, strengthening their capacity andincreasing the resources available to them.

Aids

A globally effective HIV vaccine requires greater participation of women and adolescents in clinical trials

Geneva – Greater participation of womenand adolescents is needed in HIV vaccineclinical trials, according to a group of inter-national experts, who attended a consulta-tion on HIV vaccine trials in Lausanne,Switzerland.

The meeting, organized by the WorldHealth Organization and the Joint Unitednations Programme on HIV/AIDS(UNAIDS), brought together for the firsttime 40 experts from around the world toaddress the issues of gender and age in par-

ticular, as well as race in HIV vaccine-related research and clinical trials.

“We have identified measures aimed at recti-fying the injustice stemming from the fre-quent exclusion or low participation ofwomen and adolescents in HIV vaccine clin-ical trials. Clinical trial enrolment needs to bemore inclusive, so the benefits of researchare more fairly distributed,” said Dr. RuthMacklin, co-Chair of the meeting and abioethics professor at the Albert EinsteinCollege of Medicine in New York City.

Studies show that women, when exposed toHIV, are at least twice as likely to become

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of VaxGen’s AIDSVAX, the only candidatevaccine so far to reach Phase III efficacytesting in large numbers of people, foundthat although the vaccine was not effectiveoverall, non-whites and women possiblyhad some degree of protection. This findingmerits further investigation.

More than 30 promising, new candidateHIV vaccines are currently being tested inhuman clinical trials, the majority of whichbegan in the past four years. The number ofAIDS vaccine candidates in small-scalehuman trials has doubled since 2000. Thetrials are taking place in 19 countries. Asafe, effective and affordable vaccineagainst HIV would be a powerful armagainst the AIDS epidemic which continuesto infect five million adults and childrenand kill three million people every year.

The international HIV vaccine researchmission is to develop HIV vaccines that arelicensed, acceptable, available and accessi-ble by all populations regardless of theirgender, age, socio-economic status, race,ethnicity or country, and that are effectiveacross the board. Special attention must bepaid to ensure that vulnerable groups, par-ticularly women and girls, benefit from anHIV vaccine.

Recommendations – covering ethics, poli-cy, advocacy, community participation,

clinical trial design and research gaps –issued at the consultation will form thebasis of a policy document that will helpguide those designing and conducting HIVvaccine clinical trials. An important sug-gestion for future work was to study HIVclinical trial sites with enrolments thatinclude appropriate numbers of peoplefrom different sub-groups, and to try to bet-ter understand the barriers that have pre-vented wider participation.

The challenges to the creation of an HIVvaccine are mainly and economic, primari-ly due to the lack of incentive by the privatesector to engage in product development.However, new momentum has been gener-ated in the field of HIV vaccine research. InJune 2004, the G8 countries endorsed aGlobal HIV Vaccine Enterprise to acceler-ate efforts to develop an HIV vaccinethrough an expanded capacity to test andmanufacture vaccines, the establishment ofvaccine development centres around theworld and the development of an integratedglobal clinical trials system allowing labo-ratories to easily share data.

Represented at the consultation, co-spon-sored by WHO and UNAIDS, were govern-mental public health research institutions indeveloping and industrialized countries,medical schools, industry, foundations andnon-governmental organizations.

infected with HIV as their male counter-parts. In parts of sub-Saharan Africa, girlsand young women are up to six times morelikely to be infected than their male peers.Girls and young women aged 15-24 makeup 62% of the young people in developingcountries living with HIV or AIDS.“Women and girls are particularly vulnera-ble to HIV infection for biological, socialand economic reasons,” said Dr. CatherineHankins, Chief Scientific Advisor atUNAIDS, who spoke at the opening of themeeting.

Youth and young adults are also at high riskfor HIV: about half of new HIV infectionsin the developing world occur among 15 to24 year olds.

“In spite of the epidemiological reality,women and adolescents, especially girls,have often had minimal involvement inclinical trials of HIV vaccines, as comparedto men. This is in spite of the fact that theywould be major beneficiaries of a futureHIV vaccine,” said Dr. Saladin Osmanov,Acting Coordinator, WHO-UNAIDS HIVVaccine Initiative, WHO. The Initiativepromotes the development of an HIV vac-cine, including through the facilitation ofclinical trials.

Reasons for the lack of participation ofwomen and young people in HIV vaccinetrials to date are numerous and include:lack of empowerment, independent deci-sion-making and education in some set-tings; social isolation; discrimination; preg-nancy and the potential effects of a candi-date vaccine on a foetus; stigma associatedwith high-risk behaviour; trial enrolmentcriteria; and issues concerning confidential-ity and informed consent. For instance, theparticipation of a minor in a clinical trialwould require the parents’ or guardian’sconsent, and youth must fully understandwhat receiving a candidate HIV vaccinedoes or does not mean for their health.

Experts agreed that these obstacles couldand should be overcome because HIV vac-cines need to be tested in a heterogeneouspopulation, particularly in those most inneed of vaccine. Vaccines for several infec-tious diseases have shown varying levels ofefficacy in different gender, age and radicalor ethnic sub-groups. The 1998-2003 trial

Priority Medicines

Landmark report could influence the future of medicines in europe and the worldGaps in pharmaceutical research and innovation can be closed, says WHO report

Geneva – The World Health Organizationhas released a groundbreaking report whichrecommends ways in which pharmaceuticalresearch and innovation can best addresshealth needs and emerging threats inEurope and the world.

Priority Medicines for Europe and the World,commissioned by the Dutch Government ascurrent president of the European Union

(EU), identifies a priority list of medicinesfor Europe and the rest of the world, takinginto account Europe’s ageing population,the increasing burden of non-communica-bel illness in developing countries and dis-eases which persist in spite of the availibil-ity of effective treatments. The report looksat the gaps in research and innovation forthese medicines and provides specific poli-

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cy recommendations on creating incentivesand closing those gaps.

At present, pharmaceutical research anddevelopment are based on a market-drivenincentive system relying primarily onpatents and protected pricing as a primefinancing mechanism. As a result, a numberof health needs are left unaddressed.

The report identifies gaps for diseases forwhich treatments do not exist, are inade-quate or are not reaching patients. Threatsto public health such as antibacterial resis-tance or pandemic influenza, for which pre-sent treatments or preventive measures areunlikely to be effective in the future, alsorequire immediate action.

“This report identifies health gaps andpotential solutions. It is particularly timelyfor a continent where an ageing populationfaces increasing health problems, and for aworld where old and new threats no longerrespect national borders,” said Dr. LEEJong-wook, Director-General of WHOfrom the Ministerial Summit on HealthResearch, taking place in Mexico.

In addition, the report addresses obstacleswhere effective medicines could be betterdelivered to the patient. It emphasizes fixeddose combination medicines (medicineswhich include more than one active ingre-dient in one pill) as worthy of furtherresearch and development. Finally, it looksat particular groups such as children,women and the elderly, who have frequent-ly been neglected in the scientific or medi-cine development process.

The 17 priority conditions identified by thereport are:

Future public health threats: infectionsdue to antibacterial resistance; pandemicinfluenza;

Diseases for which better formulationsare required: cardiovascular disease (sec-ondary prevention); diabetes; postpartumhaemorrhage, paediatric HIV/AIDS,depression in the elderly and adolescents;

Diseases for which biomarkers areabsent: Alzheimer disease; osteoarthritis;

Neglected diseases or areas: tuberculosis;malaria and other tropical infectious dis-

eases such as trypanosomiasis, leishmania-sis and Buruli ulcer, HIV vaccine;

Diseases for which prevention is particu-larly effective: chronic obstructive pul-monary disease including smoking cessa-tion; alcohol use disorders; alcoholic liverdiseases and alcohol dependency.

The report suggests that Europe can andshould play a global leadership role in pub-lic health, as reflected by its history ofsocial services provision and social safetynets for all citiziens. In many developingcountries, the poor are increasingly affectedby the chronic diseases that are widespreadin Europe, including cardiovascular dis-ease, diabetes, tobacco-related diseases andmental illnesses such as depression.Moreover, the ten countries that joint theEU in 2004 have additional public healthchallenges.

For all number of diseases that effect peo-ple in all members of the EU, no effectiveand safe medicinal treatment is yet avail-able (e.g. Alzheimer diseases and severalcancers). For some diseases, potentiallylarge markets exist for medicines (e.g.breast cancer) and associated pharmaceuti-cal research is likely to be intensive for cer-tain therapeutic classes. For other cate-gories of medicines, the number of patientsis low (e.g. cystic fibrosis) or the market-driven pharmaceutical industry has failed topursue research and development (e.g. newmedicines for tuberculosis).

Innovative solutionsThe report suggests that efforts to shortenthe medicine development process withoutcompromising patient safety would greatlyassist in promoting pharmaceutical innova-tion. For instance, the EU could create andsupport a broad research agenda throughwhich the European Agency for EvaluatingMedicines (EMEA), national regulatoryauthorities, scientists, industry and the pub-lic would critically review the regulatoryrequirements within the medicine develop-ment process for their relevance, costing,and predictive value.

Health authorities are responsible for medi-cines reimbursement decisions that aim to

ensure safe and effective treatment for allpatients, while reconciling this with bud-getary constraints. Health and reimburse-ment authorities and manufacturers shouldagree on general principles for the evalua-tion of future medicines. For example, theEU Commission and national authoritiesshould support a research agenda on thevarious methods of rewarding clinical per-formance and linking prices to nationalincome levels. The report authors believethat these measure will help encourageindustry to invest in the discovery of inno-vative medicines that address priorityhealth care needs.

The report maintains that where the marketis strong and the problem is poor under-standing of the basic biology of the disease,investment in basic research and in faciliat-ing innovation by the pharmaceuticalindustry will be needed. Where the biologyis well understood but the market is weak,public support for breaching the gapbetween basic and clinical research – possi-bly through public-private partnerships andother not-for-profit development initiatives– will be the preferred solution. Where thebiology is not well understood and there isalso a weak market, then biologicalresearch can be supported while marketincentives are created for the pharmaceuti-cal industry, through reducing barriers toinnovation and through improving reim-bursement rewards.

The report points out that major pharma-ceutical gaps have been closed in the past.For example, until 1975 the main treatmentfor severe peptic ulcer – a common ailment– was surgery. Following a long period offocused research in biological mechanismsunderlying ulcer disease, effective medicaltreatments werde discovered. These break-through discoveries, combined with the dis-covery that most ulceration was caused by abacteria treatable with antibiotics, madesurgery unnecessary.

The recommendations contained in thereport could have a significant impact onresearch innovation and policy, with sup-port from Europan leaders. The report wasdiscussed further at a High Level Meetingin the Hague on November 18th 2004.


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Geneva – The first international standardfor a human genetic test has been approvedby the World Health Organization. Use ofthe standard will help to improve the accu-racy and quality of laboratory results world-wide from a frequently used genetic test.This test identifies a genetic predispositionto thrombosis – a potentially life-threaten-ing blood condition – and could thereforeenable people to take preventive measures.

“Establishment of the first internationalstandard for a genetic test is an importantmilestone. Genetic testing procedures areplaying a vital and growing part in clinicalmedicine. This new standard will help toensure that the tests are giving accurateresults worldwide,” said Dr. Davie Wood,Coordinator of Quality Assurance andSafety of Biologicals at WHO.

The newly established standard, formallycalled an international Reference Panel,relates to the testing of patients for a partic-ular genetic mutation known as Factor VLeiden. Discovered in 1994, this mutationis one of the most common genetic risk fac-tors for venous thrombosis (blood clot), andis involved in 20–40% of all cases. Factor VLeiden induces a defect in the natural anti-coagulation system.

The test for Factor V Leiden is one of themost frequent genetic tests carried out inclinical laboratories. It determines the pres-ence or absence of the mutation, which hasbeen shown to result in a seven-fold to 80-fold higher risk of thrombosis depending onwhether the individual carries one or twocopies of the gene respectively.

The new standard was agreed at the 55thsession of one of WHO’s longest-standingcommittees, the WHO Expert Committee onBiological Standardization (WHO ECBS)which met from 15 to 18 November inGeneva. It is composed of ten global expertsfrom academia, industry and national regu-latory authorities, as well as 25 advisors.

One of WHO’s key functions, specified inits Constitution, is to develop, establish andpromote international standards withrespect to biological and other products.WHO is the world authority on biologicalstandards, and has established more than300 standards covering vaccines; bloodproducts; therapeutic biological products,such as insulin; and diagnostic tests, such asthose that detect HIV in a blood product.

Researchers are currently investigatingwhether or not there is a link between airtravel and deep vein thrombosis. This is oneexample of a condition which may be morelikely as a result of the Factor V Leidenmutation. Having information about theirgenetic make-up could allow travellers atrisk to take additional precautions.

The standard for Factor V Leiden was devel-oped by WHO partner and the leading inter-national laboratory for biological standards,the National Institute for Biological Standardsand Control (NIBSC) in the United Kingdom,in collaboration with colleagues from the clin-ical National Quality Assessment schemes for Blood Coagulation and the RoyalHallamshire Hospital in Sheffield, UK.

“This is an important step in genetic medi-cine. I am delighted that the NIBSC hastaken the international lead in developing thefirst WHO standard for a genetic test. Thiswill provide information on susceptibility tovenous thrombosis, and ultimately willdeliver clinical benefits for people atincreased risk of developing thrombosis,”said Professor Gordon Duff, Chairman of theNIBSC Board. NIBSC is currently develop-ing several other new reference standards tosupport testing for a range of other clinicallyimportant genetic characteristics.

DNA-based genetic testing offers enor-mous promise for improved disease man-agement by giving doctors better informa-tion about patients on which to base diagno-sis and decisions about treatment or coun-selling. It also offers the potential for bettertargeting of therapies and drugs to thosepatients most likely to benefit. Hundreds ofdifferent genetic tests are currently available.

A recent study estimated that in the EuropeanUnion alone more than 700,000 genetic testswere performed in 2002; and found that at

least 700 laboratories and 900 clinical centresin Europe were carrying out genetic tests.1Though the exact number is unknown, it islikely that millions of genetic tests are beingcarried out worldwide each year.

Setting standards is particularly critical asgenetic testing has expanded to more andmore laboratories throughout the world.Genetic testing must be done consistentlyin all laboratories around the world and tohigh standards in order to give confidencein the results.

A standard for a biological product is essen-tially a yardstick (either on paper or in anampoule, in which there is a specially pre-pared reference material) which enableslaboratories around the world to compareresults. The work of the WHO ExpertCommittee on Biological Standardizationcontributes to global public health in a fun-damental way since the written guidanceand reference preparations established onits recommendations define internationaltechnical specifications for the quality andsafety of biological medicines and in vitrodiagnostic procedures.

Once a WHO collaborating laboratoryphysically creates a standard, it is typicallyevaluated by 15 other top laboratories. TheWHO ECBS reviews all the laboratory dataand decides to approve or not the proposedstandard for international use. The rigorousassessment of the standard for the Factor VLeiden genetic test was carried out by aninternational panel of investigators in con-junction with the International Society onThrombosis and Hemostasis (ISTH).

The announcement of the first internationalstandard for the genetic diagnosis of theFactor V Leiden mutation is a significantstep forward in the assurance of high quali-ty genetic testing. In the future, the WHOECBS will likely approve standards forother genetic tests, the increasing use ofwhich will enable prevention and earlytreatment of genetic disorders, improvingquality of life.1 Ibarreta, D., Elles, R., Cassisman, J-J.,

Rodriguez-Cerezo, E., and Dequeker, E.Towards quality assurance and harmoniza-tion of genetic testing services in theEuropean Union. Nature Biotechnology, 22,1230–1235 (October 2004).

Common Genetic TestFirst standard adopted by WHO

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Geneva – The World Health Organizationis awarding a US$ 1 million contract to aglobal consortium of people living withHIV/AIDS and treatment activists to helpprepare people living with HIV/AIDS(PLWHA) for antiretroviral (ART).

Following a competitive process, theCollaborative Fund for HIV TreatmentPreparedness consortium – a programmecreated in 2003 to channel funds for com-munity-based education, managed by theUS-based organization Tides Foundation –was awarded the contract through WHO’s‘Preparing for Treatment’ programme.

The WHO initiative supports community-based treatment preparedness activities aspart of the drive to increase access to treat-ment and prevention in line the “3 by 5”target to get three million people livingwith AIDS on antiretroviral treatment bythe end of 2005.

“People living with HIV/AIDS need toknow about antiretroviral medicines. Thosewho currently have access to treatment needthis knowledge to be informed about theirtreatment and to ensure they know how andwhen to take their medicines. Those withoutaccess need this knowledge in order tobecome active in advocating for scale up intheir countries,” said Dr. LEE Jong-wook,WHO Director-General.

In implementing the million dollar grant,Tides Foundation-Collaborative Fund issupporting more than 30 networks ofPLWHA around the world in treatment pre-paredness activities, including treatment lit-eracy projects and civil society advocacyinitiatives.

The Collaborative Fund distributes fundingto regional networks of people living withHIV/AIDS who then establish grants initia-tives and tendering processes at the commu-nity level. In each of these regions, work-shops are already under way to help devel-

op the treatment preparedness agenda.Supporting the ‘Preparing for TreatmentProgramme’, UNAIDS has contributedover US$ 100,000 over the past year tothese regional meetings and will be provid-ing a ‘best practices’ document based onexperiences of programmes in late 2005.

“UNAIDS is pleased to support WHO inthis innovative movement to expand treat-ment access. Providing people living withHIV with the necessary tools to accesstreatment is vital to improving their qualityof life and engaging them in expandingaccess to treatment and care,” said Dr. PeterPiot, UNAIDS Executive Dirctor.

“This proposal ensures the participation ofpeople living with HIV/AIDS in all aspects ofthe programme and at all levels of decision-making and activity,” said Dr. Jim Yong Kim,Director of the HIV Department at WHO.

Treatment preparedness activities aim to givepeople on or in need of antiretroviral treat-ment easy-to-understand information aboutissues such as how HIV works in the body,HIV testing, opportunistic infections, the dif-ferent treatment types available and how theywork, how to take treatment correctly and thesupport services that are available.

This information can be conveyed in manyways, including through workshops, publica-tions and other activities designed to educatecommunities about obstacles to accessingtreatment and enable them to contribute tolocal treatment policy development andadvocacy efforts. All treatment preparednessactivities aim to ensure the meaningfulinvolvement of people living with AIDS andtheir communities in decisions regardingtheir care, including the distribution ofresources.

“This is perhaps one of the greatest UN-ledexamples of implementation of the GIPA(Greater Involvement of People with AIDS)principle [established in 1994]. The con-

tract award shows a commitment to a com-munity-driven model, relying on the exper-tise of people living with AIDS and com-munity-based groups to developing projectsthey need to do. It also acknowledges thattreatment preparedness is as important acomponent of the “3 by 5” success as isreceiving the drugs”, said David Barr,Senior Philanthropic Advisor for TidesFoundation.

In addition to WHO, the Collaborative Fundis supported by a growing number of donorsfrom around the world including RockefellerFoundation, Ford Foundation, Open SocietyInstitute, the Stephen Lewis Foundation, andAIDS Fonds Netherlands. To date, US$ 3.4million has been raised to support activitiesthrough the end of 2005 and fundraising forcontinued activities is on-going.

The concept of treatment preparedness wasdefined at the international treatment pre-paredness summit, held in Cape Town,South Africa in March 2003 and was basedoriginally on examples of activists prepar-ing for their own treatment. The summit ledto the creation of the Collaborative Fund togenerate funding for such activities.

WHO’s ‘Preparing for TreatmentProgramme’ was initiated in July 2004 whenWHO called for applicants with global reachand local capacity in the world’s most affect-ed countries to submit tenders to design andoperate programmes. With over 140enquiries, some 30 tenders were reviewed bya WHO panel before the award of the contractto Tides Foundation-Collaborative Fund.

“Making this happen has been a dream forWHO and underlines the recognition thatthe future of health belongs as much in thehands of those affected as those who carefor them. Treatment preparedness is key to“3 by 5” and a first instalment towardsreaching universal access for all who needit,” said Dr. Kim.

The million dollar contract is the first ofwhat WHO hopes will be an ongoingprocess within the Preparing for TreatmentProgramme with the aim of supporting addi-tional community-based treatment prepared-ness activities as funding becomes available.

The Tides Foundation has a long history ofadministering community-based grant pro-

Aids

Who awards million dollar contract for global treatment preparedness activities

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grammes in countries worldwide includingBrazil, Afghanistan, Sierra Leone, Peru,Russia, Ukraine and Croatia, as well asacross the United States.The Foundationmanages over 300 donor advised funds andover the past decade has administered morethan $235 million in grants to not-for-profitorganizations. To help countries achieve thisgoal, WHO provides normative guidanceand direct technical support in country.

The World Health Organization aims tohelp people attain the highest possible level

of health by providing leadership on nor-mative issues and technical assistance to its192 Member States. In 2003, WHO joinedUNAIDS in declaring the lack ofHIV/AIDS treatment to be a global publichealth emergency and jointly launched the“3 by 5” target to get 3 million people ontreatment by 2005. To help countriesachieve this goal, WHO provides norma-tive guidance and direct technical supportin country.

During February 2005 I will leave the officeof WMA Secretary General. After eightsyears of service to the WMA and the med-ical profession, I can only say that it was atremendous privilege and an outstandingexperience. May I use this opportunity tothank you all from the bottom of my heartfor your support and care during my tenure.At the same time I would like to expressmy sincere congratulations to my succes-sor, Dr. Otmar Kloiber from Germany.Otmar has a wealth of experience and theWMA is fortunate to have such a championof medical ethics and sound health carepolicy join our team.

The last four months have been a particular-ly impressive period in the existence of theWMA, and I would like to mention threereasons why:

WMA General Assembly in Tokyo, Japan Medical leaders from around fifty countriesof the world gathered, during October 2004,in the Imperial Hotel, Tokyo for our annualAssembly. Most fittingly, it was theEmperor and Empress of Japan themselveswho wished to welcome the leaders to thishistoric occasion. Having started the meet-ing in such an auspicious way, the rest ofthe meeting followed suit with high quality

discussions and content. The Japan MedicalAssociation excelled in developing a world-class scientific session on the relationshipbetween advanced medical technology andmedicine. Dr. Yank Coble was inauguratedas the new WMA President and had theopportunity to officially launch the “CaringPhysicians of the World” project (www.car-ingphysicians.info). This is the most ambi-tious Presidential project to date, with thedevelopment of a book on examples ofphysicians from around the world whovividly display the traditional values ofmedicine – science, ethics and care. In addi-tion, he will be visiting most of the WMAMember Associatons during regional meet-ings planned for 2005.

World Ocean Forum in New York, USA

The WMA identified the important linkbetween water and health as one of the pri-ority areas for the organization some 3years ago. It was decided to develop a morecomprehensive policy on this subject,which was completed when the WMAGeneral Assembly in Tokyo adopted theWMA Statement on Water and Health(www.wma.net – see “Policy”). In addi-tion, a two-day symposium was plannedwith the World Ocean Observatory to fur-

From the Secretary General’s Desk

ther investigate and debate some of themore pressing water and ocean issues suchas sanitation, ocean preservation, the bio-medical potential of the oceans and accessto water. Several high- level leaders attend-ed the event, including the ExecutiveDirector of the World Health Organizationtasked with Environmental Health, Dr.Kerstin Leitner. It is tragic and propheticthat this event preceded the tsunami disas-ter. In the aftermath of the tragedy, all thewater- and ocean-related issues discussedduring the meeting came into play in themost dramatic fashion. Please read the fullreport on the symposium, including slidesand speeches, at www.worldoceanfo-rum.org.

Launch of the WMA EthicsManual

It is incredible to think that despite the factthat medical ethics is more than 2000 yearsold, there is no one universally used train-ing manual for the teaching of medicalethics. The WMA had adopted a Statementon the Inclusion of Medical Ethics andHuman Rights in the Curriculum ofMedical Schools Worldwide (www.wma.net – see “Policy”) during 1999, andit was therefore quite fitting that the WMAdevelop a simple and concise ethics train-ing manual for use by medical students andphysicians. The WMA Director of Ethics,Dr. John Williams, did a splendid job inputting this manual together along with acommitted team of advisors. At a launchevent in January 2005, the first edition ofthe manual was released to the press andsome partner organizations. The launchwas a huge success, as we are confident thedistribution and use of the manual will be.The manual can be downloaded from theWMA website at www.wma.net.

Looking at the huge strides the WMA hasmade over the last quarter, it bodes well forthe future growth and expansion of theWMA and the profession. It gives me greatjoy to see this happen as I leave the WMAstage. Thank you and au revoir.

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The meeting was opened by the President,Dr. James Appleyard, who welcomed theMr. Assodo Chief Secretary of the Cabinet (representing the Prime Minister who wasabroad), the Minster of Health and theGovernor of Tokyo.

The Secretary General, Dr. Delon Humanintroduced the delegations of the NationalAssociation Members of the WMA, and theofficial observers from other internationalorganisations.

Dr. Uematsu, President of the JapaneseMedical Association expressed his pleasureat being able to welcome the members of theWMA to Tokyo once again after 29 years.He was delighted to see 500 people presentduring the Assembly and considered thatthere had been very valuable exchanges ofinformation at the Scientific Sessions duringwhich various aspects of Advanced MedicalTechnology had been discussed, includingMedical Ethics, IT and Healthcare. Therewas much valuable information whichwould contribute to the advance of WorldPeace. The JAMA looked forward to suc-cessful conclusions at the end of theAssembly. Referring to the earthquake theprevious day and to the tornado to beexpected later, he expressed the view that,no doubt, these were part of the globalweather changes.

The President then thanked Dr. Uematsuand the Japanese Medical Association fortheir excellent organisation and hospitalduring the Assembly. He then introducedMr. Assodo who extended the good wishesof the Prime Minister who had planned tobe present but had had to travel to Vietnam.He informed the assembly that theapproaching Typhoon was unusually largeand warned delegates not to leave the hotel.However, he then cheered them with newsof expected good weather the next day.Japan had been challenged by new infections such as SARS and AIDS.

Expectations of the population were rising.On the other hand, after referring to theincreasing role of the Japanese MedicalAssociation, he drew attention to the rise inlife expectancy between 1997 and 2003from 76,68 to 85. Infant mortality had fall-en from 1 to 3 per 10.000. All of these weredue to the efforts of the nation and of thedoctors. Health Care reform was a universalchallenge, notably with the increase in theelderly population and the diminishing birthrate, also the economic and environmentalenvironments. Safety is a key to health care.The discussions of the Assembly onMedical Healthcare Technology an MedicalEthics was particularly timely. TheJapanese were trying to introduce safety ofhealth technology into health care. Hehoped that the outcome of the meetingwould enlarge the understanding of theseissues. He felt that the World MedicalAssociation is an organisation which con-tributes to the world’s good future.

Mr. Ossuchio the Minister of Health, congrat-ulated the Assembly. WMA had a fifty yearhistory of engagement in major problemsaffecting health care globally. The WMAworks with the World Health Organisationand other international organisations toenhance the health of the peoples of theworld.

In Japan, Healthcare Services and advancedtechnology have improved the health of thepeople. The major challenges were Safety,Quality, and higher efficiency in Health Care,he looked forward to benefiting from the con-clusions of the discussions on Health CareTechnology. Finally he also expressed histhanks to the Japanese Medical Associationfor their work in organising this meeting.

The governor of Tokyo Mr. Ishiharo pointedout that medicine in Japan was referred to asWestern Medicine. However there was also aschool of Oriental Medicine which, contraryto belief, was a schematic system of care.

Recently there had been an evaluation of thistype of medicine by members of theJapanese Medical Association and nowAcupuncture had been included in theJapanese Healthcare system. He personallyvalues the work of experts in acupuncturewhich, he noted, was appreciated also in theUSA. He quoted various examples of natur-opathy applied successfully to various condi-tions ranging from obstetric complications todiseases of the liver and of the kidney. Hespecifically referred to CHI and toChiropractic and stressed that they were notSharmatic. It was important that there shouldbe co-operation between both systems ofmedicine. He urged physicians to be gener-ous in their approach to oriental medicineand closed by referring to the fact that theJapanese enjoyed the greatest longevity inthe world.

Dr. Blachar, Chairman of Council,expressed the appreciation of the Assemblyto the three high representatives of govern-ment and authority in Japan for kindlyattending and addressing the Assembly. Hethen paid tribute to Dr. James Appleyard, theretiring 54th President who had served theAssocation with great distinction. Dr.Appleyard had many accomplishments.Personally Dr. Blachar had enjoyed theassociation with a fellow paediatrician whoalso had three children. Dr. Appleyard hadbrought to fruition the Declaration if Ottawaon the Rights of the Child and had consis-tently lobbied for childrens’ rights to healthand for child health services. In addition hehad promoted Oral health and had supportedthe ICRC project on notification of tortureand the treatment of torture victims. He hadbeen chairman of the Ethics committee1995-99, and oversaw the Declaration ofHelsinki changes, speaking in New York,

The Ceremonial session of the World MedicalAssociation General Assembly was held in The Imperial Hotel, Tokyo 9th October 2004

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Japan, Malta, Uganda and many otherplaces.

Dr. Appleyard had enhanced the image ofWMA. He had been most a helpful personto work with and had greatly assisted theChairman in promoting the changes withinthe organisation. Dr. Blachar looked for-ward to his playing a further role in thefuture.

Dr Appleyard in response expressed hisenjoyment of the work in his past year asPresident. ----(see text of speech page 95) Dr.Blachar then presented Dr. Appleyard withthe Past President’s medal and conferred onhim lifelong membership of the WMA.

The Secretary General then invited theincoming President Dr. Coble, to take thePresidential Oath, following which he wasinvested as President and delivered hisPresidential address (see page 86).

Dr. Moon, retiring Vice Chair of Councilthen briefly addressed the Assemblyexpressing his pleasure at being invited tomake some closing remarks. The WMA wasfounded in 1947 by a group of idealisticphysicians, to build something better out ofthe ashes of World War II. WMA has donethis by issuing declarations over the years

and helping to define Medical Ethics andstandards in a changing world. It had workedto promote idealistic ideas and continue theethical tradition of the medical profession.WMA now includes 84 National MedicalAssociations and millions of doctors. Hugestrides have been made in health care and inhuman rights. For all. Tokyo is very memo-rable because Advanced MedicalTechnology and related issues promisetogether with IT to improve global health.He could think of no better way to addressthe agenda of global health care and Healthfor All. He expressed his appreciation of Dr.Uematsu and the leaders of JAMA for thehospitality enjoyed by all during theAssembly. Thanks to this he had been able towitness the Tokyo Assembly as a great occa-sion. He gave a special tribute to the work ofDr. Tsuboi for his leadership over manyyears to millions of doctors. Finally he paida tribute to Dr. Delon Human for his workover the past seven years, for his toleranceand patience and devotion to the WMA. Hethanked him and expressed the best wishesof everyone his future. The audience roseand endorsed this appreciation.

Dr. Coble thanked Dr. Moon for his addressand closed the meeting.

Dr. Begenholm reported that the Credential’sCommittee had verified that there were 35Members present who were in good stand-ing. This amounted to a total of 87 votes, andthat 65 would be necessary to adopt any pro-posal relating to Medical Ethics.

After the Annual Report of Council and theStanding Orders had been adopted, Dr.Letlape (South Africa) was unanimouslyelected President-elect.

Dr. Letlape expressing his appreciation ofthe responsibility of this office and thankingthe Assembly, said this was the time of thenew President and his remarks would bebrief. He referred first to the very few

Junior doctors present and speculated that ifthe age of the President was linked to lifeexpectancy, for South Africa the age wouldbe 39. He intended to carry forward thework of Drs. Millymakki, Appleyard andCoble, not only in advocating “patientsfirst” but also “patients’ rights”. This wouldfit the theme of “Access to Medical Care”in Chile 2005 and would be most appropri-ate. There was inequality in South Africa,where, with finite resources, privatisationwas a key issue.

Dr. Otmar Kloiber, Secretary General-elect, then addressed the Assembly, thank-ing Council and those who supported himfor the trust they had placed in him. He

Meeting of the WMA General Assembly, Tokyo, 9th October 2004

referred to earlier remarks about themeaning of service, namely “helping doc-tors doing a good job and to save ourpatients”. He thanked Dr. Delon Humanfor his work in restructuring the secretari-at, and opening new networks and newavenues to explore. He was proud to behere also as a successor to Dr. AndreWynen who had been designatedSecretary General 29 years ago in Tokyo.For Dr. Kloiber the commitment of therepresentative members of the Assemblywas most important and gives power tothe WMA. National MedicalAssociations’ commitment is what counts.If the members did not carry this out,WMA would be nothing. His primary jobwas to ask for this and to service theircommitment. The first priority was theDues, and the second was to participateand work in the WMA. Continuing thereconstruction was dependant on mem-bers’ support and participation leading to astrong, visible organisation for the future.

The Assembly then adopted the following:

• A note of clarification on paragraph 30of the Helsinki Declaration (see 95)

• A Statement on Physicians andCommercial Enterprises (see 91)

• A statement on Water and Health

• Amendment to the Regulations in timesof Armed Conflict (see 92)

• A statement on the World Federation ofMedical Education

• A statement on Health EmergenciesCommunication and Co-ordination (see 93)

An Addition to Section M of the WMASchedule of Functions and OperationPolicies also was adopted.

Applications from the Vietnamese MedicalAssociation and the Estonian MedicalAssociation were unanimously approvedwith acclamation.

The Assembly also approved the themes ofthe 2005 Santiago General Assembly scien-tific meeting “Health Care system reform”and “Access to Medicine”.

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Approval was also given for the meeting in2008 to take place in Seoul, in the anniver-sary year of the Seoul Medical Association.

Following the Treasurer’s report, theFinancial Statement for the year 2003 andthe budget were adopted.

The report of the Associates meeting, whichincluded their resolution concerning Enfor-ced Sterilisation, was approved.

The Assembly then proceededto an open session

The first speaker from the Frauenarzte-Verlag (Germany), referring to the lack ofrepresentation of women both in theAssembly and on the platform, pleaded forthe enlistment of more women doctors whocare about the medical profession andpatients. It should be possible for the organ-isations of women doctors and the WMA towork together.

Dr. Arumugam (Malaya) was concernedthat the topic of “Oriental medicine” hadbeen raised during the formal ceremonialsession of the Assembly and asked whetherWMA had any policy on this. Ministers didnot know whether or not medically-quali-fied doctors should be involved in this. Hereferred to “over the counter” sales and tra-ditional medicine treatments now compris-ing 50% more than Western medical activi-ty in the East. Dr. Blachar respondingasked whether this was controllable. He feltthat WMA should have a policy and hopedthat an NMA would produce a backgroundpaper for discussion. Dr. Human, theSecretary General, hoped that the MalayMedical Association would send a consul-tation paper. He commented that WMA hada position on this. There were no controlson this type of medicine. He would send apaper to the MMA. Then Dr. Haikerwal(Australia) informed the meeting that legis-lation governing this issue in Victoria,Australia was the first in the world.

Dr. Adu-Gyanfi (Ghana) spoke about theimportance of student exchanges and also,in relation to human resources, mentionedthat while in 1969 there were 5500 doctorsfor a population of 7 million, now there wereonly 6500 for a population of 20 million.

Dr. Millymakki (Past President) drewattention to the absence of delegates fromTurkey, although they sent their greetings.Recently there had been three strikes byTurkish doctors, respectively of one, one,and two days duration, during which doc-tors saw all emergencies and any sick chil-dren. The strike related to the need for morefinancing of health care. She also reportedthat 85 doctors were in court, includingmembers of the doctors’ Chamber. Doctors,who were classified as civil servants, hadthe right to be members of a Union, but notthe right to strike. NMAs should be in touchwith the Turkish Medical Association toassist their colleagues. Dr. Human reportedthat he had spoken to the Vice-President ofthe Turkish Medical Association to givesupport to their leaders. He had written tothe Ministers of Health, of Justice and ofForeign Affairs concerning the unfair trial of85 doctors, including their leaders. Therewas a conference of the Turkish doctors dur-ing this week. The WMA would try to senda WMA leader to be present at the trial.

Dr. Montgomery (Germany) referring tothe comments from Ghana, said that doc-tors’ workload in much of the world wasrising to such an extent that some couldwork no more. There was a problem con-cerning the Worktime Directive in the EU,and in the USA doctors were working 90hours a week. WMA could define a safe-guard mechanism when the workload wastoo great. The Secretary General said thissuggestion was useful and asked the BAK toproduce paper on physician “burn-out” etc.

In response to a question from Dr. Massonconcerning the doctor and other healthworkers condemned to death in Libya, Dr.Human reported that the WMA and ICNhad met the Libyan delegation during theWorld Health Assembly. They received apoor reception from the delegates whodespite offering to send them a reply, had notresponded so far despite three reminders. Asan NGO, WMA would continue to seek dis-cussions with the government.

Dr. Chan Yee Shing (Hong Kong)observed that Chinese Medicine is notalternative medicine, it is mainstream.There is a need to deal with question of itsrecognition and registration. There is a

problem concerning the difficulties withstandardisation. There were major medico-legal problems. For example in the case ofcoronary heart disease treated under bothwestern and eastern medicine, when there isa lawsuit how can the court rules on theproblem. In the scientific discussion of theprevious day the medical professionseemed to be moving in the direction ofMedical Technology. Physicians wereworking as members of a team. If the twoprofessions were to be treated equally thiswas very difficult as there was no scientificbasis for Traditional Medicine. He won-dered whether WMA could help.

Dr. Appleyard (the President), referring tothe problem raised by Ghana mentioned theimportance of links with MedicalInstitutions in the West to help developingcountries. He cited as an example a Surgeonfrom Germany who went for three monthsto work in a hospital in which there was nosurgeon. Such a three months period couldnot only provide much needed assistancebut also a valuable experience. Other alter-natives were Fellowships linked withMedical Academic Institutions, or for indi-vidual doctors just to go and assist. He urgedNational Medical Associations to take thismessage back to their own countries andstressed the importance of such links beingestablished as between equal partners.

Dr. Harma from the InternationalRehabilitation Council for Torture Victims,referred to the real problem for doctors whohave been treating victims of torture inTurkey. The work of the WMA both in con-nection with the Tokyo declaration andmore recently with the new initiative ontraining doctors in connection with theIstanbul Protocol was very valuable. Healso referred to the recent Lancet article on

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possible involvement of physicians inMiddle Eastern prisons and the NorwegianMedical Association/WMA programme oftraining for prison doctors and others inHuman Rights. IRCT sought a WMA part-nership.

Dr. Blachar (chairman of Council) spokeof the visits to Morocco, Uganda andGeorgia in connection with theIstanbul/EU project of training in how torecognise victims of torture.

Dr Grewin, (President of CPME), hadwritten to the relevant EU Commissionerconcerning the Turkish situation.

Dr. Letlape (South Africa) informed theAssembly that in South Africa legislationrecognising traditional medicine is produc-ing problems, as there is competition forlimited resources, which were already ingreat difficulty. One part of traditional med-icine is spiritual – there was a family tradi-tion of training its members who were initi-ated into healing. If patients don’t recoverthe blame lay with their ancestors!

A speaker from the Thai delegation report-ed that they had 30,000 doctors for a popu-

lation of 63 million people. Herbal medi-cine has been known for 200 years and doeswork in a limited context. Currently theMinistry of Health and the University wereconducting a trial under the Professor ofMedicine from Hong Kong. He pointed outthat because of the very few physicians inrural areas the population has to useTraditional Medicine.

The Vietnamese delegation commented thatthe discussion was really about orientalmedicine. There was a need for a carefullook at the evidence. If the evidence is pos-itive we should accept it.

Dr. Blachar, summing up, welcomed thediscussion. There was clearly a need to lookinto the problems and he welcomed theMalayan lead.

After a presentation by the Chilean delega-tion in preparation for next year’sAssembly, Dr. Blachar thanked theJapanese Medical Association for theirgreat organisation and hospitality in theorganisation of the Assembly, and extend-ed his thanks to the Council, the SecretaryGeneral and to the staff of WMA.

By Donald J. Palmisano, MD, JD

Immediate Past President, American Medical Association

The United States is not alone in con-fronting the deleterious effects of overzeal-ous personal injury lawyers who seek mil-lion-dollar awards and settlements thatresult in scores of physicians restricting theirservices and patients losing access to care.

Reports from the United Kingdom statehow negligence claims against physiciansare rising1 as are the expected payouts –E150m by 20102. In Australia, increasedconcern has led to “several of the country’s

states and territories taking action to limitdamages for non-economic loss and capeconomic loss,”3 among other measures.And in New Zealand, health officials arealarmed by the large increases in payouts.In Wales, for example, claims haveremained relatively steady, but payoutshave seen from £63.3 million to £117.8 mil-lion from 1999-2000 to 2002-20034.

In the United States, the costs are even moresevere. Medical liability tort costs haveincreased from $9.5 billion in 1991 to morethan $21 billion by 20015. But rather thanthe money going to compensate injured par-ties, the U.S. tort system is so grossly inef-

Regional & NMA News

Patients’Access To Care At Risk With America’s Broken Medical Liability System

ficient that only 22 cents in the dollar actu-ally goes toward compensating thoseinjured for economic losses, and 24 centsgoes toward non-economic damages6.Consider, too, that in most jurisdictions,personal injury lawyers can receive asmuch as 50 percent of a jury award, and itbecomes more clear why personal injurylawyers fight tooth-and-nail to defeat rea-sonable measures at limiting non-economicdamages in state legislatures and the U.S.Congress. The U.S. medical liability tort sys-tem is the personal injury lawyers’ cash cow.

The bitterness of the dispute can be traceddirectly to personal injury lawyers’ desireto maintain the status quo of a civil justicesystem where multimillion-dollar juryawards benefit a very few, but have nega-tive ripple effects that affect many.Blockbuster medical liability cases in 2003in the United States have included verdictsand settlements of $112 million, $70 mil-lion, $50 million, $40.4 million and 10 thatwere $20 million or more7.

The broken system becomes obvious whenyou consider that 70 percent of all casesfiled against physicians are closed withoutany payment8. As a surgeon, I don’t operateon demand. There must be valid indica-tions. And surgeons get instant peer review.Every appendix I remove for the preopera-tive diagnosis of appendicitis is examinedby a pathologist. If it was found that 70percent of my operations were on normalappendices, I would not be allowed to oper-ate. Shouldn’t attorneys also be subject topeer review for the cases they file? Why isthat personal injury attorneys are not heldto a similar standard? Why is that theseattorneys rarely – if ever – sanctioned forfiling a suit without merit?

This lack of accountability is very expen-sive. Even though 70 percent of claims aredropped or dismissed, they still incur legalcosts that average $16,743. Expense costsfor settled claims average $39,891 andclaims in which the defendant wins at trial,$85,718.9 Now consider that on any givenday, there are 125,000 suits active in theU.S. court system, and the costs growexponentially.

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Snapshot of a Crisis

There are 20 states which the AMA believesare in a full-blown medical liability crisis10.We define this crisis after careful analysisof several key factors, including:

• The magnitude of patients losing accessto health care.

• What type of medical liability reformlegislation currently exists in a state – andfor how long the reforms have been inplace.

• The actions of a state court system touphold or overturn medical liabilityreforms.

• The affordability and availability of pro-fessional liability insurance.

• The actions of a state’s legal community,particularly the trend of increasing fre-quency and severity of jury awards.

Medical liability reform has been theAMA’s top legislative priority for severalyears. Our fight has been on two simultane-ous fronts: namely the U.S. Congress andthe state legislatures throughout the coun-try. We also have supported state medicalsocieties in their efforts to protect existingreforms before state supreme courts11.

Unfortunately, the U.S. Congress and statelegislatures have become the battlegroundsfor deciding whether patients will haveaccess to care. Because of a runaway legalsystems, patients have suffered as physi-cians have been forced to relocate, retireearly, or restrict their services – such asdelivering babies or performing traumasurgery12.

In my travels across the United States, Ihave personally spoken with scores ofphysicians who have given up part of theirpractice because of excessive lawsuits andskyrocketing liability insurance premiums.It is distressing to hear a young paediatricspecialist tell the story of how he moved tothe Mississippi Delta as part of “a calling”to treat rural patients, but he was forced toleave the state after being sued by patientswho did not even realize they were suinghim. One patient who hoped to earn a fewthousand dollars said “I’m kind of upset. I

do not want him leaving because of all thesuits. If we run off all the doctors, what arethe people gonna do?”13

It is even more distressing to be speaking toa group of America’s top surgeons aboutthis crisis and learn from a young surgeonthat he “understood the crisis all too wellbecause he recently lost his son becausethere was no neurosurgeon available.”Mississippi surgeon John Lucas, III, MD,told me that his son was in a car accidentand needed immediate neurosurgical inter-vention, but the area’s neurosurgeons hadalready either quit doing head trauma casesor had moved away. His son had a cor-rectible problem if immediate attention by aneurosurgeon could be given. Dr. Lucas dideverything he could to expedite the transferand find a neurosurgeon. Unfortunately hisson John Lucas IV died despite the subse-quent transfer.

A Solution ExistsExperience tells us that there are a fewstates that have had long-term medical lia-bility reforms: California, Colorado,Indiana, Louisiana, New Mexico andWisconsin. They all have in common a rea-sonable limit on damages. California, inparticular, places a $250,000 limit on non-economic damages, and there is no limit foreconomic damages. If a patient is harmedby negligence, the AMA strongly believesthat the patient should be able to receivefair and quick compensation. The modelthe AMA has advocated for the UnitedStates Congress to pass into law is theCalifornia model which gives all medicalexpenses, lost wages and benefits, futurewages and benefits, child care costs andmore, but limits non-economic damages to$250,000. Without a proven performer suchas the California $250,000 limit on non-economic damages, the system breaksdown. The majority of individuals in theUnited States House of Representatives andthe Senate as well as President Bush favorsuch a law but a minority of Senators fili-buster it and currently there are not the nec-essary 60 votes to overcome the filibuster.

California’s reasonable reforms alsoinclude limits on attorney contingency fees,

allocating responsibility for damages fairly,providing for periodic payment of damagesover time, and more. California’s law – for-mally known as the Medical InjuryCompensation and Reform Act (MICRA) –was enacted in 1975. Between 1976 and2002, medical liability insurance rates haveincreased in the United States by 750 per-cent. In California, they only haveincreased 245 percent. MICRA is the rea-son why an obstetrician pays about $69,000per year for professional liability insurancewhile the same physician would pay morethan $277,000 per year in Southern Florida,which does not have MICRA-style reforms.MICRA provides the predictability and sta-bility for the liability insurance market thatmoderates physicians’ insurance rates andprotects patients’ access to care.14

Recent State Actions Causefor Optimism

In the recent November elections, fourstates had constitutional ballot measuresregarding different medical liabilityreforms. In each case, the AMA stood side-by-side with our state medical societies topresent the facts. In each case, our opposi-tion tried to suggest that there was no needfor reform, that the status quo worked justfine to protect patients.

In Florida, where women have been forcedto wait as long as six months for a mammo-gram because radiologists are scared to readthem, the physicians won a great victory.Despite personal injury lawyers and theirsupporters spending an estimated $24 mil-lion, voters enacted new limits on contin-gency fees. Now, patients will be assured toreceive at least 70 percent of the first$250,000 of a jury award; and 90 percent ofany amount more than $250,000.

In Nevada, where Jim Lawson died in cir-cumstances similar to Dr. Lucas’ son, andscores of women searched for months tofind a doctor to deliver their babies, themedical community also had a great victo-ry when voters amended the state constitu-tion to eliminate all exceptions to the state’s$350,000 limit on non-economic damages.Previously, a crafty personal injury lawyer

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could use rhetorical arguments to circum-vent the cap.

In Oregon – despite the fact that more than 40percent of the state’s neurosurgeons and near-ly one quarter of its obstetricians havealready stopped providing certain services orwill soon do so – voters narrowly defeated(50.7 percent to 49.3 percent) a measure thatwould have restored a $500,000 limit on non-economic damages. The AMA is deeply con-cerned Oregon’s crisis will become worse.

And in Wyoming, where rural health care isthe norm, the loss of even one physician canhave negative consequences. But despitewidespread examples of physicians restrictingtheir practices and patients being forced todrive an hour or more to find care, voters nar-rowly defeated a measure designed to allowthe legislature to enact a limit on non-eco-nomic damages. However, voters did approvea measure that could lead to legislation enact-ing medical review panels to weed out thefrivolous cases currently choking the system.

Clearly, these results are mixed, but theyshow forward momentum, building on theoutstanding win in Texas in 2003 where thelegislature passed reforms and the citizensvoted to change the state constitution to becertain the new law would allow caps onnon-economic damages. Since enactment ofthe Texas law, the largest insurer of physi-cians in Texas lowered the medical liabilitypremiums 17%. The AMA plans on carryingthat momentum into 2005. We will continueto work with our champions in Washington,D.C., as well as in the halls of state legisla-tures across the country. We stand ready tosupport our international colleagues in theirefforts as well, including the efforts to enactpatient safety legislation akin to the success-ful Aviation Safety Reporting System ofvoluntary confidential reporting of errors or“near-misses” for review by experts, withfeedback for a system change to enhancesafety and then communicate the lessonlearned to all in a “no shame, no blame” de-identified manner. Such a proposed law,entitled the Patient Safety and QualityImprovement Act, has passed both theHouse and Senate in the United StatesCongress but it is questionable whether itwill get out of the conference committeeduring the few days left in the 2003-2004

Congress. We also continue to support theNational Patient Safety Foundation (NPSF)that we founded with others. To date wehave contributed $7.3 million to it and arevery proud of its extensive patient safetybibliography and teaching modules.15

In my 40+ years as a physician, I have wit-nessed the miracles of organ transplants, vac-cines, chemotherapy, and more. Today, wecan treat birth defects with the baby still in themother’s womb. We can perform microsurg-eries on the brain. We can re-attach severedlimbs. Tomorrow holds great promise here inthe United States and abroad, but we mustsafeguard our future. The rising threat ofunchecked lawsuits and out-of-control coststhreatens us all, which is why we must sharethe commitment to be relentless in the fight toenact reasonable reforms that protect patients’access to the courtrooms without sacrificingour patients’ access to medical care.

1. “Hospital awards bill to cost E400m,” The Sunday Tribune, Dec. 7, 2003.

2. Ibid

3. “Liability insurance: a global concern,” Insurance Day, Sept. 9, 2003.

4. “Claims now cost NHS trust more,” South Wales Evening Post, Sept. 2, 2003.

5. U.S. Tort Costs: 2002 Update. Trends andFindings on the Costs of the U.S. TortSystem. Tillinghast-Towers Perrin.Appendix 5.

6. Id at 17.7. VerdictSerach:

http://www.verdictsearch.com/news/top100/(note: page last accessed June 8, 2004)

8. Physician Insurers Association of America,PIAA Claim Trend Analysis: 2002 edition(2003), exhibit 1-2.

9. Physician Insurers Association of America(PIAA) testimony United States House ofRepresentatives Committee on Energy andCommerce Subcommittee on Health,February 23, 2003

10. For an extensive look at America’s medicalliability crisis, please visit www.ama-assn.org/go/crisismap

11. The AMA filed amicus briefs in support ofexisting medical liability reforms inWisconsin and West Virginia in 2004.

12. Several patient-specific examples of the lossof care can be found in theNovember/December 2004 issue of theSaturday Evening Post. See: Open Forum:“Why Your Doctor Might Quit,” by DonaldJ. Palmisano, M.D.

13. Clarion-Ledger, July 29, 2002 14. To ensure an accurate and extensive discus-

sion of MICRA and other types of reforms,including action in the U.S. Congress andstate legislatures, the AMA has prepared aresearch compendium, Medical LiabilityReform – Now!, which is regularly updated.See www.ama-assn.org/go/mlrnow for themost recent version.

15. Visit the NPSF at www.npsf.org

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Tobacco Control Capacity BuildingAt the British Medical Asociation’s TCRC* meeting, held in Edinburgh during the 50thanniversary year of the 1954 paper by Doll, participants heard a keynote address by itsauthor. Sir Richard Doll, after outlining the latest evidence of the health effects of tobac-co stressed that the important messages were that in Europe half of all smokers are killedby their smoking, a quarter of whom are killed by middle age, stopping smoking extendslifespan, and that doctors must become involved. He suggested that the choices open todoctors were to make a commitment to reduce smoking rates, or to do nothing and seetobacco related illnesses increase! Presentations were also made by Sir Richard Peto andDr. Carolyn Dressler, Head of Tobacco Control at WHO’s IARC and many others.

Participants each outlined their individual priorities for action and in a joint resolutionagreed to make every effort to persuade member states to ratify the WHO FrameworkConvention of Tobacco control and also welcomed the WHO Code of Practice forHealth professionals’ organisations *The Tobacco Control Resource Centre (TCRC) the global first such institution – was founded in1998 by the British Medical Association, WHO Europe ,and supported by the EuropeanCommission Commission.

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

COLOMBIAFederación 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 CONGOOrdre des Médecins du ZaireB.P. 4922Kinshasa – GombeTel: (242-12) 24589/ Fax (Présidente): (242) 8846574

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

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

CZECH REPUBLICCzech 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] Website: www.cls.cz

UNITED STATES Colegio Médico Cubano LibreP.O. Box 141016717 Ponce de Leon BoulevardCoral Gables, FL 33114-1016Tel: (1-305) 446 9902/445 1429Fax: (1-305) 4459310

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

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

ECUADORFederación Médica EcuatorianaV.M. Rendón 923 – 2 do.Piso Of. 201P.O. Box 09-01-9848GuayaquilTel/Fax: (593) 4 562569E-mail: [email protected]

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

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

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

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

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

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

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

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

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

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

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

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

HUNGARYAssociation 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

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

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

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

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

ISRAELIsrael 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

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

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

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

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

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

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

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

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

MALAYSIAMalaysian 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

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

MEXICOColegio 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

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

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

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

NIGERIANigerian 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

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

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

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

PHILIPPINESPhilippine Medical AssociationPMA Bldg, North AvenueQuezon CityTel: (63-2) 929-63 66/Fax: -6951E-mail: [email protected]

POLANDPolish Medical AssociationAl. Ujazdowskie 2400-478 WarszawaTel/Fax: (48-22) 628 86 99

PORTUGALOrdem 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

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

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

SLOVAK REPUBLICSlovak Medical AssociationLegionarska 481322 BratislavaTel: (421-2) 554 24 015

Fax: (421-2) 554 223 63E-mail: [email protected]

SLOVENIASlovenian Medical AssociationKomenskega 461001 LjubljanaTel: (386-61) 323 469Fax: (386-61) 301 955

SOUTH AFRICAThe 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

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

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

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

TAIWANMedical Association201, Shih-pai Rd., Sec. 2P.O. Box 3043Taipei 11217Tel: (886-2) 2871-2121, ext 7358Fax: (886-2) 28741097E-mail: [email protected]

THAILANDMedical 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.

TUNISIAConseil National de l’Ordredes Médecins de Tunisie16, rue de Touraine1082 Tunis Cité JardinsTel: (216-1) 792 736/799 041Fax: (216-1) 788 729E-mail: [email protected]

TURKEYTurkish Medical Association

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

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

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

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

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

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

VIETNAMVietnam General Associationof Medicine and Pharmacy (VGAMP)68A Ba Trieu-StreetHoau Kiem districtHanoiTel: (84) 4 943 9323Fax: (84) 4 943 9323

ZIMBABWEZimbabwe Medical AssociationP.O. Box 3671Harare Tel: (263-4) 791/553Fax: (263-4) 791561E-mail: [email protected]

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