g 20438 world medical journal 53no. 4, december …world medical journal vol. 53 no. 4, december...

WorldMMeeddiiccaall JJoouurrnnaall

Vol. No. 4, December 200753

OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.

G 20438

Contents

EEddiittoorriiaallThe challenge to medical care 85Make medicines child size 86

MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttssMedical Research on Child Subjects 87China affirms its commitment toWMA Transplantation policy 87World Health Professions Alliance Conferenceon Regulation of Health Professions display 90WMA Statement On The Ethics Of Telemedicine 91WMA resolution on the responsibilityof physicians 92WMA Resolution On Health And Human RightsAbuses In Zimbabwe 94

MMeeddiiccaall SScciieennccee,, MMeeddiiccaall PPrraaccttiicceeaanndd MMeeddiiccaall EEdduuccaattiioonnWMA Statement on Health Hazardsof Tobacco Products 95Avicenna Directories to replace World Directoryof Medical Schools 97Global Standards for Quality Improvementin Medical Education 97

PPooiinntt ooff vviieewwA Worldwide Tour of Medical Degreesand Qualifications 97

FFrroomm tthhee WWMMAA SSeeccrreettaarryy GGeenneerraallTrust me, I’m a Doctor! 99

WWMMAAWMA General Assembly 100Plenary Session of the Assembly6th October 2007 103Resolution in Support of the Medical Associations in Latin America and the Caribbean 104178th WMA Council meeting 107Inter-professional training seminar on infectioncontrol in South Africa 108

WWHHOO 108–110

RReevviieeww aanndd LLeetttteerr 111–112

Report on WMA General Assembly, Copenhagen 2007

Dr. Jon SnaedelWMA-President 2007-2008

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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. Yoram Blachar Dr. J. Snaedal Dr. N. ArumagamIsrael Medical Association Icelandic Medical Assn. Malaysian Medical Association2 Twin Towers, 35 Jabotinsky St. Hlidasmari 8 4th Floor MMA HouseP.O. Box 3566, Ramat-Gan 52136 200 Kopavogur 124 Jalan PahangIsrael Iceland 53000 Kuala Lumpur

Malaysia

Treasurer Chairman of Council Vice-Chairman of CouncilProf. Dr. Dr. h.c. J. D. Hoppe Dr. J. E. Hill Dr. K. IwasaBundesärztekammer American Medical Association Japan Medical AssociationHerbert-Lewin-Platz 1 515 North State Street 2-28-16 Honkomagome10623 Berlin Chicago, ILL 60610 Bunkyo-kuGermany USA Tokyo 113-8621

JapanSecretary GeneralDr. O. KloiberWorld Medical AssociationBP 63 01212 Ferney-Voltaire CedexFrance

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

ARGENTINA SConfederación Médica ArgentinaAv. Belgrano 1235Buenos Aires 1093Tel/Fax: (54-11) 4381-1548/4384-5036E-mail:[email protected]: www.comra.health.org.ar

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

AUSTRIA EÖsterreichische Ärztekammer(Austrian Medical Chamber)Weihburggasse 10-12 - P.O. Box 2131010 WienTel: (43-1) 51406-931/Fax: -933E-mail: [email protected]

REPUBLIC OF ARMENIA EArmenian Medical AssociationP.O. Box 143, Yerevan 375 010Tel: (3741) 53 58-68Fax: (3741) 53 48 79E-mail:[email protected]: www.armeda.am

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

BAHAMAS EMedical Association of the BahamasJavon Medical CenterP.O. Box N999Nassau Tel: (1-242) 328 1857/Fax: 323 2980E-mail: [email protected]

BANGLADESH EBangladesh Medical AssociationBMA Bhaban 5/2 Topkhana RoadDhaka 1000Tel: (880) 2-9568714/9562527Fax: (880) 2-9566060/9568714E-mail: [email protected]

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

BOLIVIA SColegio Médico de BoliviaCalle Ayacucho 630TarijaFax: (591) 4663569E-mail: [email protected]: colegiomedicodebolivia.org.bo

BRAZIL EAssociaçao Médica BrasileiraR. Sao Carlos do Pinhal 324 – Bela VistaSao Paulo SP – CEP 01333-903Tel: (55-11) 317868-00/Fax: -31E-mail: [email protected]: www.amb.org.br

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

CANADA ECanadian Medical AssociationP.O. Box 86501867 Alta Vista DriveOttawa, Ontario K1G 3Y6Tel: (1-613) 731 8610/Fax: -1779E-mail: [email protected]: www.cma.ca

Cabo Verde SOrdem Dos Medicos du Cabo Verde Avenue OUA N°6 – B.P. 421Achada Santo António, Ciadade dePraia, Cabo VerdeTel : (238) 262 2503Fax : (238) 262 3099E-mail: [email protected]

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

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85WMJ 53, December 2007

OFFICIAL JOURNAL OFTHE WORLD MEDICAL

ASSOCIATION

Hon. Editor in ChiefDr. Alan J. Rowe

Haughley Grange, StowmarketSuffolk IP14 3QT

UK

Co-EditorsProf. Dr. med. Elmar Doppelfeld

Deutscher Ärzte-VerlagDieselstr. 2

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Editorial

The challenge to medical careThe Tobacco Control Resource Centre, a resource supported by the British MedicalAssociation, the European Commission and the European Regional Office of the WorldHealth Organisation, published in 2000 a report in the context of Tobacco ControlProgramme under the title “Tobacco – Medicine’s Big Challenge.” Now at the end of 2007,while Tobacco remains a problem and the great scourges of disease still challenge medi-cine, a huge challenge (possibly “The Challenge” for the medical profession) faces thehealth professionals providing medical care, namely the problem of the supply and distrib-ution of health care workers. The 2006 World Health Report of WHO* highlighted theproblem, notably the huge discrepancies in the distribution of Physicians, Dentists, Nurses,Midwives and other Health care workers, not only within countries but more significantlybetween countries. Scientific advances have made great contributions in our knowledge ofthe nature and causes of many diseases, accompanied by discovery and development ofmany new drugs to cure or ameliorate the effects of disease. All of these call for increasingskills and increased demands on all sectors of the medical workforce in developed coun-tries It places increased demands on the sparse, sometimes almost non-existent supply ofhealth care workers in underdeveloped countries, where healthcare was already minimal,obstructing any implementation of advances in healthcare available elsewhere.

Hitherto the limited attempts to address manpower problems in the healthcare workforcehad, unsurprisingly, concentrated on workforce problems within national health care sys-tems, substantially disregarding the huge disparities between countries, regions and evencontinents. At the same time concern has been expressed by both the profession and bysome other authorities about the recruiting of physicians in developed countries from devel-oping countries who are already under-doctored, Codes of practice and statements of poli-cy to change this have been issued by the World Medical Association** and by some gov-ernments and authorities.

While a great tribute should be paid to those organisations and governments who, in oneway or another have, over many years, encouraged the provision of doctors, nurses andother medical assistance to those countries in need, and to those health professionals whoundertook to meet the needs, it was effectively only with the arrival of HIV/AIDS and,more recently the risk of pandemic disease, coupled with increasing political awareness ofthe need to deal with poverty, inequity and human rights, that the need to address the prob-lems associated with the global health workforce have been forced to the forefront of dis-cussion.

In previous editorials in the World Medical Journal, WMJ 52 (1) and (2) we have drawnattention to emerging trends not only in the changing or expanding role of individual healthprofessions, but also to problems of training, mobility and availability of health profession-als. Further problems complicating the whole issue relate to the changes in role and func-tions of health professionals, reflecting not only the increasing aspirations of the individualhealth professional, but also the increasing specialisation within individual health profes-sions.

In the first part of 2008 at least two conferences will address some of the issues involved.The first is a World Health Organisation Global Conference to be held in Addis AbabaEthiopia in January 2008, when the conference will address the topic of Task Shifting (seep. 90). “Task Shifting” is defined in a number of WHO documents as “the name given to a

* “Working together for health” The World Health Report 2006 WHO, Geneva, ISBN 92 4 156317 6 ** WMA Statement on Ethical Guidelines for the Recruitment of Physicians, Helsinki 2003

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86 WMJ 53, December 2007

process of delegation whereby tasks aremoved, where appropriate, to less spe-cialised health workers”.

The second conference, organised by theWorld Health Professions Alliance in theweek preceding the WHO Assembly, is theFirst World Conference the Role andRegulation of Health Professions whichwill be held in Geneva (see p. 90). BothConferences are of huge importance in rela-tion to the provision of health care acrossthe globe in both developed and developingcountries.

The conferences have great relevance to thefuture role and functions of the MedicalProfession. Whereas previously, physicians,when recognised for full registration as amedical practitioner, held the sole licence tocarry out certain specific acts such as theright to prescribe and to engage in the prac-tice of medicine, in an increasingly sophisti-cated and technical world it is clear thatsome of these reserved functions can be car-ried out by other health professionals underregulation, after appropriate technical spe-cialist training. This has substantial implica-tions for changes in the protected role thatphysicians have previously held in certainareas, while possibly calling for new roles inother areas, essentially calling for a reassess-ment of the role and functions of physiciansin society. In some countries such changeshave already occurred in areas such as theextension of limited prescribing rights toother health professionals such as nurses,and extending the acts carried out by otherhealth professionals By enhancing the roleof some health professionals, such changesincrease the provision of certain health ser-vices to a much wider population in bothdeveloped and developing countries.

Nevertheless, as indicated earlier, if there isa basic shortage of health care workers inall the health professions, the world is facedwith a major problem. This shortage doesnot only apply to underdeveloped countries.In more developed countries as scientificand technical knowledge and developmenthave increased there is also increaseddemand for the implementation of these dis-coveries and a consequent demand for morehealth workers. Thus the USA estimatesthat by 2020 they will require at least

200,000 physicians to meet their needs,more than the current need of the rest of theworld!

The WMA Secretary General in his columnrefers to another problem associated withthe changes in role and functions of physi-cians, namely the need for clarity in identi-fying the roles of health professionals andthe titles used to identify them to the public.The differences in titles used for physiciansacross the world are illustrated in an articleby Dr. Doren, to which Dr. Kloiber refers.(see p. 97).

The Health Workforce problem which the2006 World Health Report highlighted isnow being actively pursued and it is essen-tial that, as indicated in the editorialsreferred to above, both individual physi-cians and their representative organisationsactively address these issues. The distribu-tion of certain diseases has been radicallychanged as a result of greatly increasedinternational travel, with the potential forwider dissemination of communicable dis-eases including newly emerging diseases,and the risk of major pandemics need to bebalanced with attention to the global prob-lems of inequitable distribution of physi-cians, with such huge disproportions in

their distribution. With the calls for “taskshifting” as part of the solution, this mayalso call for radical changes in the careercycle of physicians, nurses, pharmacists,including professional practice in foreigncountries as a normal part of the profession-al career structure. All of these considera-tions require urgent attention at a time whenthe very nature of the regulation of thehealth professions in also under review,including the question of the degree towhich the professions themselves shouldplay a role in regulation, a matter of majorconcern to those professions whose proudrole has for millennia been that of “CaringProfessions”. It is to this end that the med-ical profession defends its position in self-regulation of standards of care and its ethi-cal code of conduct in the interests of bothpatients and profession. All of this must beurgently considered both in discussions atindividual, at national level and in the glob-al conferences referred to above. There isno time to be lost. Just as the profession hastaken a stand on Tobacco so it must face upto this Big Challenge to the professionitself. Both individual physicians and theirleaders must act. Time waits for no man!

Alan Rowe

Make medicines child size

On 6. December 2007, the WHO launcheda five years initiative to raise awareness andaccelerate action on medicines for children.This project is based on a document whichwas accepted at the 60th World HealthAssembly in May 2007. At the same timethe WHO released the first internationalList of Essential Medicines for Children(WMJ 53(2), 50). The list contains 206medicines that are deemed safe for childrenand address priority conditions. On this lista number of existing medicines are howev-er lacking because they have not beenadapted for childrens use.

It has been known for a long time that thereis a substantial gap between the availability

of childrens medicines and the actual needand that this gap is global even if it is mostevident in poor income countries. In indus-trialized societies more than half of the chil-dren are prescribed medicines authorisedand dosed for adults but not authorized ordosed for children. In developing countries,the problem is compounded by loweraccess.

In this project there are three main priori-ties.

1. To improve access where proper medi-cines for children exist but they are notreaching those in need due to cost andinefficient distribution systems.

Editorial

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2. To increase development of medicineswhich exist for adults but are either inunsuitible forms for children or have notbeen developed for children taken intoaccount the different pharmacokineticsin children of various ages.

3. To facilitate research into areas wherethere are very few or even no medicinesand where the efficacy of existing medi-cines is unknown. This applies speciallyto medicines for various infectious, trop-ical disease.

This project has received a wide acceptanceand backup from many stakeholders such asUNICEF, the pharmaceutical industry, regu-latory agencies and various NGO´s such asSave the children. WMA most certainly willdo its utmost to facilitate this project. Theproject starts at a time when WMA isadressing the special situation of children intwo areas. One is the upcoming revision ofthe existing document on Health ofChildren since 1998, by many consideredone of the best documents of the WMA.

This issue should also be kept in mind dur-ing the process of revision of theDeclaration of Helsinki and in conjunctionto that a new document on research of chil-dren which has been circulated to NMA´sfor comments. Lastly we should take thisopportunity to work closely with the WHOas this is one of many topics where it is ofobvious value that these Internationalorganisations join forces.

Jon Snaedal

President of the WMA

Editorial note:

The text of many of the statements etc.adopted by the WMA General Assembly,while referred to in the Report (see p. 103)have been printed in the appropiate sec-tions e.g. Ethics. Due to constraints onavailable space, those on Noise andFamily Planning will appear in the nextissue. They can also be accessed atwww.wma.net.

Medical Ethics and Human Rights

Medical Research on Child Subjects

Dr. James Appleyard, MD, FRCPCH,Past President WMA(see also pp. 86 and 109)

Children worldwide bear the greatest bur-den of disease. Medical research on childsubjects is essential to identify effective andsustainable action that will lead toimprovements in child health (1,2). Thereis a natural reluctance to involve children inany risk associated with such research.Testing in adults has rightly to precede anytrial of new approaches to treatmentamongst children.

Children, however, have been subject toresearch studies in residential institutionsprior to any independent ethical review

being introduced . The most public and con-troversial research study on children duringthe second half of the 20th century was the‘Willowbrook Hepatitis Study’ started in1956 at a New York State Institution formentally defective persons. (3,4) Suchexamples led to the persistence of a pre-dominantly protective approach towardsresearch in children.. So much so that ,withthe increasing number of medications avail-able to adults in the last half century, chil-dren were increasingly being ‘left behind’.The market for new drugs amongst childrenwas much smaller and that a combinationof the inherent protective environment withthe increased cost of clinical trials meantthat pharmaceutical companies did not

undertake the relevant trials in children.Practicing pediatricians faced the dilemmaof knowing how effective a new chemicalsubstance has been found in adult studiesand feeling duty bound to try them on theirchild patients ‘off label’

In the 90’s this had reached such a propor-tion that pediatricians were pressing forchanges in the system. (5,6) The ‘Children’srule, evolved in the USA, has had a positiveeffect on promoting children’s research. (7,12) and Europe has followed with the E.U.Directive 2001/20/ECBoth the Food andDrug Administration and the E.U.Commission have been consulting furtheron their existing regulations

China affirms itscommitment toWMA Transplan-tation policyFollowing the visit of a WMA delegationearlier this year (see report in WMJ 53,2),the Chinese Medical Association, in a let-ter from the Secretary General, Dr. Wangaffirmed its commitment to WMA poli-cy and wrote as follows:

“… after discussions in the ChineseMedical Association, a consensus hasbeen reached, that is, the ChineseMedical Association agrees to theWorld Medical Association Statementon Human Organ Transplantation,which states that organs of prisonersand other individuals in custody mustnot be used for transplantation exceptfor members of their immediate family.The Chinese Medical Association will,through its influence, further promotethe strengthening of the management ofhuman organ transplantation and pre-vent possible violations of the regula-tions made by the ChineseGovernment. We also hope to workmore closely with the WMA andexchange information and views on themanagement of human organ trans-plantation”.


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Regulations are important within the legalframework of each country. Medicalresearch is increasingly a global imperativeand the relevant common ethical standardsneed to be international. (6)

The WMA’s Declaration of Helsinki (9)has underpinned the guidelines from theCouncil for International Organisations ofMedical Sciences (CIOMS) (7) and ICHGCP (8) It has also been the reference doc-ument for many national pediatric guide-lines. (5) The paragraphs specifically relat-ed to children are paras. 24 and 25, regard-ing consent and/or assent of ‘minors’

“24 For a research subject who is legallyincompetent, physically or mentally inca-pable of giving consent or is a legallyincompetent minor, the investigator mustobtain informed consent from the legallyauthorized representative in accordancewith applicable law. These groups shouldnot be included in research unless theresearch is necessary to promote the healthof the population represented and thisresearch cannot instead be performed onlegally competent persons”.

“25 When a subject deemed legally incom-petent, such as a minor child, is able togive assent to decisions about participationin research, the investigator must obtainthat assent in addition to the consent of thelegally authorized representative.”

In the WMA’s Declaration of Ottawa on theRight of a Child to Healthcare, a precau-tionary protective approach to research isadopted as one of the General Principles:

Para 4 V1 states “In particular every effort‘should be made to protect every child fromunnecessary diagnostic procedures, treat-ment and research”;

We need to change the emphasis about theneed for research on children for their ownbenefit while maintaining full protectionThe WMA should provide leadership forthe benefit of children worldwide. Most ofthe burden of disease affecting children isoutside the rich countries of the USA,Europe and Japan, where regulations andguidelines have moved to a more positiveapproach to research in children.Principles recognizing the importance ofresearch and the growing maturity of chil-

dren to assent and consent to the process,their need for special protection with theavoidance of harm, are essential.These areof particular importance in relation to mat-ters referred to ethical review committees,which must include in their membershipspecialist paediatric expertise in studydesign when considering paediatricresearch.

It is difficult to incorporate all these essen-tial points within the Declaration ofHelsinki even though there is an opportuni-ty to do so now that revisions are being con-sidered. The WMA has already acceptedthe special needs of Children in their previ-ous agreement to a separate Declaration onthe Right of a Child to Health Care, in addi-tion to the general rights of all patients. TheAssociate Members Meeting at the GeneralAssembly of the WMA, with the particularsupport of representatives from the USA,Germany and Nigeria, recommended that aseparate Statement on Medical Research onChild Subjects be considered by the WMAAssembly in Copenhagen with a view to itsbeing circulated for comment by nationalmedical associations (NMAs). TheAssembly agreed and the Statement hasbeen sent out to nmas by the WMASecretariat.

The Statement has been drafted from theprinciples underlying the key guidelines onpediatric research in Europe (10, 12)United States (11) and Japan (13) andrelates directly to the Declaration ofHelsinki. The Statement should form a tem-plate for the development of local nationalguidelines in each country to provide both apositive and protective environment for thepromotion of child health and welfare

The Preamble summaries the importance ofmedical research for children and the needto protect them from harm. The five mainparagraphs highlight issues which areeither specific to children or must be con-sidered in the context of childhood. Eachstatement underlines a principle and eachsentence is both self standing and to betaken in context. Further clarification ofthese principles need to be expanded inlocal national guidelines. Thus the docu-ment has been constructed to be a succinctas possible

Draft Proposed Statement

Preamble

Advances in medical care are based on thescientific evaluation of preventative, diag-nostic and therapeutic measures.

Children should share in the benefits fromscientific research relevant to their individ-ual age related health needs.

Research on children is essential for thedevelopment of scientifically based med-ical knowledge that will ensure the effectivepromotion of child health and the wellbeing of children worldwide.

Children involved in research need specialprotection. They differ from adults biologi-cally. –with their increased vulnerability,age specific needs and growth and develop-ment potential.

Children must be subject to the safeguardsapplicable to all research subjects in theDeclaration of Helsinki, together with para-graphs 24 and 25 concerning legally incom-petent minors.

The Declaration of Ottawa defines the rightof a child to health care, which includes theprinciples of consent and self determinationamongst children in paragraphs 9-13.

Physicians should respect internationaland national professional guidelines onresearch in children which conform tothese principles.

Need for Protection

Biomedical studies involving children asresearch subjects should be focused on theknowledge of epidemiology, pathogenesis,diagnosis and treatment of diseases or con-ditions of childhood.

A child should not be involved in researchthat can be carried out on laboratory mod-els, animal subjects or adult persons, or thatserves only a scientific interest The knowl-edge to be gained from the research mustform a necessary contribution to the health-care of children.

Different physiological, psychological andpathogenic features occur at the different


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ages and stages of the growth ,development,sex and ethnicity in childhood. from thepremature newborn infant through adoles-cence.

There is a need to balance the potential ben-efits to children against any risk involvedin the research.

Physicians must respect the integrity andrelative autonomy of a child and strive toattain the maximal achievable benefit, withthe avoidance of unnecessary risks, discom-fort and stress.

Avoidance of harm

Risks should be minimised and potentialharm leading to physical, psychological,social, spiritual impairment should beavoided

Minimal risk involves procedures, ques-tionnaires, observation and measurementseven being carried out in a child sensitiveway.

Greater than minimal risk is can be associ-ated with invasive procedures or therapies.These should be carried out only when theresearch is concerned with diagnosis andtreatment and the expected benefits to thechild participant outweigh the known oranticipated risks involved where theresearch is likely to yield justifiable gener-alisable knowledge of vital importanceabout the child’s disorder or condition andresearch that provides the only opportunityto identify, prevent or alleviate a rare dis-ease confined to childhood

Study Designs

Study protocols and study designs must bechild specific. In addition to including thesafeguards for adult subjects , they shouldjustify the necessity of the research on chil-dren

Preclinical safety and efficacy data are pre-conditions for the start of paediatric clinicaltrials.

The selection of children to participate in abiomedical research project should notdepend upon the child’s race, nationality,

gender or religion, except in cases whereone or more of these attributes relate to theobjective of the research

The performance of a study must be guaran-teed to be conducted by experts competentin childhood diseases and disorders, empa-thetic and truly conversant with children,parents, and all legal requirements wherethe interests of the child are paramount

Child specific protocols should be drawn upby experienced experts and the study shouldbe carried out under the supervision of pae-diatricians

Age specific informed consent/assent formsneed to be available for child subjects, theirparents and legal representatives.

The study protocols should be evaluated byindependent research ethics committees onwhich there are paediatric health profes-sionals.

Consent/Assent

Children are minors who have not reachedthe age for self responsible consent.

Informed consent means the approval of thechild’s parents or legal representative forthe participation of the child in a researchstudy, following sufficient information toenable them to make an informed judgment.

Informed Assent means the acquiescence ofthe child to participate in the research fol-lowing information being provided in aform understandable to their age group.

The consent of both parents should besought prior to enrolling a child in a bio-medical research project.

There must be no forced or undue influ-ence, financial or otherwise, on the child’sdecision to participate in the research or onthe parents/legal representative’s consent.

The refusal to participate in the research byan informed child must be respected .

Privacy

The privacy if the child must be fullyassured throughout the research project.

All personal and health related informationabout the child and the family, collected andstored, must remain confidential.

Research Ethics Committees

The interests of children should always berepresented on independent research ethicscommittees when research on children isbeing considered. The membership mustinclude children’s physicians experiencedin paediatric research and trained in the spe-cial needs of children. Other membersshould be well acquainted with the needs ofchildren .

Further work on this Statement

A detailed scrutiny by national medicalassociations and other interested ‘stake-holders’ is welcomed. The W.M.A has setup an electronic working group to receivecomments and suggestions both on the needfor a document such as this which is specif-ic for children and on the core principles inthe statement which can be used to developboth international and local national guide-lines.

Please send your comments to yourNational Medical Association or as individ-uals to the WMA office [email protected]

James Appleyard MD FRCPCHChildren’s PhysicianPast PresidentWorld Medical AssociationNovember 2007

References

1. Child Health Research – A foundation forimproving Child Health. World HealthOrganisation 2001

2. Global Forum for Health Research 2005World Health Organisation

3. Krugman S Experiments at theWillowbrook State School . Lancet 19711 966-967

4. Burns J.P. ‘Research in Children’ CritCare Med 2003 31 No 3 (Suppl)


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5. Guidelines for the Ethical Conduct ofMedical Research involving children.Royal College of Paediatrics and ChildHealth: Ethics Advisory CommitteeArch. Dis. Child. 2000 82 177-182

6. Appleyard W.J The Challenge of buildingan International Framework for Researchon Medicines for Children. The Joseph JHoet Lecture 2005 The European Forumfor Good Clinical Practice Bruxelles

7. International Ethical Guidelines forBiomedical Research involving HumanSubjects, Council for InternationalOrganisations of Medical Sciences withthe WHO Geneva 2002

8. Department of Health and HumanServices, Food and Drug Administration.Regulations requiring manufacturers toassess the safety and effectiveness of newdrugs and biological products in pediatricpatients; final rule Ref Reg 199863(231):666 32-72

9. Additional Safeguards for Children inClinical investigations of FDA-regulatedProducts – Interim Rule Food and DrugAdministration, Health and HumanServices 2007 www.fda.gov.

10. ‘Ethical Principles for MedicalResearch Involving Human Subjects’WMA Declaration of Helsinki 2002

11. Ethical Principles and OperationalGuidelines for Good Clinical Practice inPaediatric Research in Ethics WorkingGroup Confederation of EuropeanSpecialists in Paediatrics 2002

12. Committee on Drugs, AmericanAcademy of Pediatrics Guidelines forthe ethical conduct of studies to evalu-ate drugs in pediatric populationsPediatrics 1995 286-294

13. Ethical Considerations for Clinical tri-als performed in Children - Guidelinesby an Ad Hoc Group for E U Directive2001/20/EC 2006

14. International Ethical Guidelines forBiomedical Research Involving HumanSubjects Prepared by the Council forInternational Organizations of MedicalSciences (CIOMS) in collaborationwith the World Health Organization(WHO) CIOMS Geneva 2002

15. ‘Clinical Investigation of medicinalproducts in the paediatric population’.International Committee onHarmonisation E 11

16. Guideline on Ethical considerations forClinical Trials performed in childrenwithin the scope of the E.U ClinicalTrials Directive 2001/20/EC . TheEuropean Agency for the Evaluation ofMedicinal Products (EMEA) 2006

17. Improving Child Health : The role ofResearch Working Group on Womenand Child Health BMJ 2002 324 1444-7

18. Forest CB, Shipman SA , Dougherty D,Miller MR ‘Outcomes Research inPediatric Settings’ Pediatrics 2003 111171-8

19. Homan R ‘Problems with Codes’Research Ethics Review 2006 2 No398-103

20. Appleyard W.J.’ The Rights of Childrento Healthcare’ Medical Ethics 1998 24293-4

21. Ross L.F ‘Do healthy children deservegreater protection in Medical Research?’ J.Pediatr 2003 142 108-12

22. Ondrusek N., Abramovitch R.,Pencharz P and Koren G ‘Empiricalexamination of the ability of children toconsent to clinical research’ Journal ofMedical Ethics 1998 24 158-165

23. Steinbrook R Testing Medications inChildren N Eng J Med 2002 347 1642-1470

World Health Professions AllianceConference on Regulation of HealthProfessions displayThe World Medical Association will join with its partners in the World HealthProfessions Alliance (WHPA)* and the World Confederation for Physical Therapy inhosting a conference in the Regulation of Health Professions.

The Conference will be held in Geneva, Switzerland on May 17-18 2008 and discussthe role and future of health professions’ regulation. It will focus on models of healthprofessions’ regulation, examples of best practice in regulatory body governance anda discussion of trade in services and its implications for regulation.

The Conference, intended to bring together regulators, leaders of healthprofessions.policy makers, health system managers and administrators; researchersand scientists and other interested parties, will take place prior to the World HealthAssembly (19–23 May 2008).

For full details of speakers, programme, registration and submission of abstracts visit: www.whpa.org/reg/index.htm*The World Health Professions Alliance is a unique alliance of dentistry, medicine, nursing andpharmacy aiming to address global health issues and striving to help deliver cost effective qual-ity health care worldwide. The WHPA member organisations are: the International Council ofNurses (ICN), the International Pharmaceutical Federation (FIP), the World Dental federation(FDI) and the World Medical Association (WMA). WHPA will be joined by the WorldConfederation for Physical Therapy (WPTC).


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DEFINITIONTelemedicine is the practice of medicineover a distance, in which interventions,diagnostic and treatment decisions andrecommendations are based on data, doc-uments and other information transmittedthrough telecommunication systems.

PREAMBLE

The development and implementation ofinformation and communication technol-ogy are creating new modalities for pro-viding care for patients. These enablingtools offer different ways of practisingmedicine. The adoption of telemedicine isjustified because of its speed and itscapacity to reach patients with limitedaccess to medical assistance, in additionto its power to improve health care.

Physicians must respect the following eth-ical guidelines when practising telemedi-cine.

PRINCIPLES

Patient-physician relationship and confi-dentiality

The patient-physician relationship shouldbe based on a personal encounter and suf-ficient knowledge of the patient's person-al history. Telemedicine should beemployed primarily in situations in whicha physician cannot be physically presentwithin a safe and acceptable time period.

The patient-physician relationship mustbe based on mutual trust and respect. It istherefore essential that the physician andpatient be able to identify each other reli-ably when telemedicine is employed.

Ideally, telemedicine should be employedonly in cases in which a prior in-personrelationship exists between the patient andthe physician involved in arranging orproviding the telemedicine service.

The physician must aim to ensure thatpatient confidentiality and data integrityare not compromised. Data obtained dur-ing a telemedical consultation must besecured through encryption and othersecurity precautions must be taken to pre-vent access by unauthorized persons.

Responsibilities of the physician

A physician whose advice is soughtthrough the use of telemedicine shouldkeep a detailed record of the advice he/shedelivers as well as the information he/shereceived and on which the advice wasbased.

It is the obligation of the physician toensure that the patient and the health pro-fessionals or family members caring forthe patient are able to use the necessarytelecommunication system and necessaryinstruments. The physician must seek toensure that the patient has understood theadvice and treatment suggestions givenand that the continuity of care is guaran-teed.

The physician asking for another physi-cian's advice or second opinion remains

responsible for treatment and other deci-sions and recommendations given to thepatient.

A physician should be aware of andrespect the special difficulties and uncer-tainties that may arise when he/she is incontact with the patient through means oftele-communication. A physician must beprepared to recommend direct patient-doctor contact when he/she feels that thesituation calls for it.

Quality of care

Quality assessment measures must beused regularly to ensure the best possiblediagnostic and treatment practices intelemedicine.

The possibilities and weaknesses oftelemedicine in emergencies must beacknowledged. If it is necessary to usetelemedicine in an emergency situation,the advice and treatment suggestions areinfluenced by the level of threat to thepatient and the know-how and capacity ofthe persons who are with the patient.

RECOMMENDATION

The WMA and National MedicalAssociations should encourage the devel-opment of national legislation and inter-national agreements on subjects related tothe practise of telemedicine, such as e-prescribing, physician registration, liabili-ty and the legal status of electronic med-ical records.

WMA Statement On The Ethics Of TelemedicineAdopted by the WMA General Assembly, Copenhagen, Denmark, October 2007


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The World Medical Association,

1. Considering the Preamble to the UnitedNations Charter of 26 June 1945 solemn-ly proclaiming the faith of the people ofthe United Nations in the fundamentalhuman rights, the dignity and value ofthe human person,

2. Considering the Preamble to the UniversalDeclaration of Human Rights of 10December 1948 which states that disre-gard and contempt for human rights haveresulted in barbarous acts which have out-raged the conscience of mankind,

3. Considering Article 5 of that Declarationwhich proclaims that no one shall be sub-jected to torture or cruel, inhuman ordegrading treatment,

4. Considering the American Conventionon Human Rights, which was adopted bythe Organization of American States on22 November 1969 and entered intoforce on 18 July 1978, and the Inter-American Convention to Prevent andPunish Torture, which entered into forceon 28 February 1987,

5. Considering the Declaration of Tokyo,adopted by the World Medical Associationin 1975, which reaffirms the prohibition ofany form of medical involvement or pres-ence of a physician during torture or inhu-man or degrading treatment,

6. Considering the Declaration of Hawaii,adopted by the World PsychiatricAssociation in 1977,

7. Considering the Declaration of Kuwait,adopted by the International Conferenceof Islamic Medical Associations in 1981,

8. Considering the Principles of MedicalEthics Relevant to the Role of HealthPersonnel, Particularly Physicians, in theProtection of Prisoners and DetaineesAgainst Torture and Other Cruel,Inhuman or Degrading Treatment orPunishment, adopted by the UnitedNations General Assembly on 18December 1982, and particularlyPrinciple 2, which states: "It is a grosscontravention of medical ethics… forhealth personnel, particularly physicians,to engage, actively or passively, in actswhich constitute participation in, com-plicity in, incitement to or attempts tocommit torture or other cruel, inhumanor degrading treatment…",

9. Considering the Convention AgainstTorture and Other Cruel, Inhuman orDegrading Treatment or Punishment,which was adopted by the UnitedNations General Assembly on December1984 and entered into force on 26 June,1987,

10. Considering the European Conventionfor the Prevention of Torture andInhuman or Degrading Treatment orPunishment, which was adopted by theCouncil of Europe on 26 June 1987 andentered into force on 1 February 1989,

11. Considering the Resolution on HumanRights adopted by the World MedicalAssociation in Rancho Mirage, inOctober 1990 during the 42nd GeneralAssembly and amended by the 45th,46th and 47th General Assemblies,

12. Considering the Declaration ofHamburg, adopted by the World

Medical Association in November 1997during the 49th General Assembly, call-ing on physicians to protest individual-ly against ill-treatment and on nationaland international medical organizationsto support physicians in such actions,

13. Considering the Istanbul Protocol(Manual on the Effective Investigationand Documentation of Torture andOther Cruel, Inhuman or DegradingTreatment or Punishment), adopted bythe United Nations General Assemblyon 4 December 2000,

14. Considering the Convention on theRights of the Child, which was adoptedby the United Nations on 20 November1989 and entered into force on 2September 1990, and

15. Considering the World MedicalAssociation Declaration of Malta onHunger Strikers, adopted by the 43rdWorld Medical Assembly Malta,November 1991and amended by theWMA General Assembly, Pilanesberg,South Africa, October, 2006,

Recognizing

16. That careful and consistent documenta-tion and denunciation by physicians ofcases of torture and of those responsi-ble contributes to the protection of thephysical and mental integrity of vic-tims and in a general way to the strug-gle against a major affront to humandignity,

WMA resolution on the responsibility of physicians in the documen-tation and denunciation of acts of torture or cruel or inhuman ordegrading treatmentInitiated: September 2002, Adopted by the WMA General Assembly, Helsinki 2003 and amendedby the WMA General Assembly, Copenhagen, Denmark, October 2007


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17. That physicians, by ascertaining thesequelae and treating the victims of tor-ture, either early or late after the event,are privileged witnesses of this viola-tion of human rights,

18. That the victims, because of the psycho-logical sequelae from which they sufferor the pressures brought on them, areoften unable to formulate by themselvescomplaints against those responsible forthe ill-treatment they have undergone,

19. That the absence of documenting anddenouncing acts of torture may be con-sidered as a form of tolerance thereofand of non-assistance to the victims,

20. That nevertheless there is no consistentand explicit reference in the profession-al codes of medical ethics and legisla-tive texts of the obligation upon physi-cians to document, report or denounceacts of torture or inhuman or degradingtreatment of which they are aware,

Recommends that NationalMedical Associations

1. Attempt to ensure that detainees or vic-tims of torture or cruelty or mistreatmenthave access to immediate and indepen-dent health care. Attempt to ensure thatphysicians include assessment and docu-mentation of symptoms of torture or ill-treatment in the medical records usingthe necessary procedural safeguards toprevent endangering detainees.

2. Promote awareness of the IstanbulProtocol and its Principles on the EffectiveInvestigation and Documentation ofTorture and Other Cruel, Inhuman orDegrading Treatment. This should be doneat country level using different methods ofinformation dissemination; includingtrainings, publications and web docu-ments.

3. Disseminate to physicians the IstanbulProtocol.

4. Promote training of physicians on theidentification of different modes of tor-ture, in recognizing physical and psycho-logical symptoms following specificforms of torture and in using the docu-mentation techniques foreseen in theIstanbul Protocol to create documenta-tion that can be used as evidence in legalor administrative proceedings.

5. Promote awareness of the correlationbetween the examination findings,understanding torture methods and thepatients' allegations of abuse;

6. Facilitate the production of high-qualitymedical reports on torture victims forsubmission to judicial and administrativebodies;

7. Attempt to ensure that physiciansobserve informed consent and avoidputting individuals in danger whileassessing or documenting signs of tortureand ill-treatment;

8. Attempt to ensure that physicians includeassessment and documentation of symp-toms of torture or ill-treatment in themedical records using the necessary pro-cedural safeguards to prevent endanger-ing detainees.

9. Support the adoption in their country ofethical rules and legislative provisions:

9.1 aimed at affirming the ethical obligationon physicians to report or denounce actsof torture or cruel, inhuman or degrad-ing treatment of which they are aware;depending on the circumstances, thereport or denunciation would beaddressed to medical, legal, national orinternational authorities, to non-govern-mental organizations or to theInternational Criminal Court. Doctorsshould use their discretion in this mat-ter, bearing in mind paragraph 68 of theIstanbul Protocol.

9.2 establishing, to that effect, an ethicaland legislative exception to profession-al confidentiality that allows the physi-cian to report abuses, where possible

with the subject's consent, but in certaincircumstances where the victim isunable to express him/herself freely,without explicit consent.

9.3 cautioning physicians to avoid puttingindividuals in danger by reporting on anamed basis a victim who is deprived offreedom, subjected to constraint orthreat or in a compromised psychologi-cal situation

10. Place at their disposal all useful infor-mation on reporting procedures, partic-ularly to the national authorities, non-governmental organizations and theInternational Criminal Court.

Istanbul Protocol, paragraph 68: "In somecases, two ethical obligations are in con-flict. International codes and ethical princi-ples require the reporting of informationconcerning torture or maltreatment to aresponsible body. In some jurisdictions, thisis also a legal requirement. In some cases,however, patients may refuse to give con-sent to being examined for such purposes orto having the information gained fromexamination disclosed to others. They maybe fearful of the risks of reprisals for them-selves or their families. In such situations,health professionals have dual responsibili-ties: to the patient and to society at large,which has an interest in ensuring that jus-tice is done and perpetrators of abuse arebrought to justice. The fundamental princi-ple of avoiding harm must feature promi-nently in consideration of such dilemmas.Health professionals should seek solutionsthat promote justice without breaking theindividual's right to confidentiality. Adviceshould be sought from reliable agencies; insome cases this may be the national medicalassociation or non-governmental agencies.Alternatively, with supportive encourage-ment, some reluctant patients may agree todisclosure within agreed parameters."


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PREAMBLE

Noting information and reports of system-atic and repeated violations of humanrights, interference with the right to healthin Zimbabwe, failure to provide resourcesessential for provision of basic health care,declining health status of Zimbabweans,dual loyalties and threats to health careworkers striving to maintain clinical inde-pendence, denial of access to health carefor persons deemed to be associated withopposition political parties and escalatingstate torture, the WMA wishes to confirmits support of, and commitment to:

• Attaining the World Health Organizationprinciple that the "enjoyment of thehighest attainable standard of health isone of the fundamental rights of everyhuman being"

• Defending the fundamental purpose ofphysicians to alleviate distress ofpatients and not to let personal, collec-tive or political will prevail against suchpurpose

• Supporting the role of physicians inupholding the human rights of theirpatients as central to their professionalobligations

• Supporting physicians who are persecut-ed because of their adherence to medicalethics

RECOMMENDATION

Therefore, the World Medical Association,recognizing the collapsing health care sys-tem and public health crisis in Zimbabwe,calls on its affiliated national medical asso-ciations to:

1. Publicly denounce all human rightsabuses and violations of the right tohealth in Zimbabwe

2. Actively protect physicians who arethreatened or intimidated for actionswhich are part of their ethical and pro-fessional obligations

3. Engage with the Zimbabwean MedicalAssociation (ZiMA) to ensure theautonomy of the medical profession inZimbabwe

4. Urge and support ZiMA to invite aninternational fact finding mission toZimbabwe as a means for urgent actionto address the health and health needsof Zimbabweans

In addition, the WMA encourages ZiMA,as a member organization of the WMA,to:

5. Uphold its commitment to the WMADeclarations of Tokyo, Hamburg andMadrid as well as the WMA Statementon Access to Health Care

6. Facilitate an environment where allZimbabweans have equal access to qual-ity health care and medical treatment,irrespective of their political affiliations

7. Commit to eradicating torture and inhu-mane, degrading treatment of citizensin Zimbabwe

8. Reaffirm their support for the clinicalindependence of physicians treatingany citizen of Zimbabwe

9. Obtain and publicize accurate and nec-essary information on the state ofhealth services in Zimbabwe

10. Advocate for inclusion in medical cur-ricula, teachings on human rights andthe ethical obligations of physicians tomaintain full and clinical indepen-dence when dealing with patients invulnerable situations

The WMA encourages ZiMA to seek assis-tance in achieving the above by engagingwith the WMA, the CommonwealthMedical Association and the NMAs ofneighboring countries and to report on itsprogress from time to time.

WMA Resolution On Health And Human Rights Abuses In ZimbabweAdopted by the WMA General Assembly, Copenhagen, Denmark, October 2007


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PREAMBLE

More than one in three adults worldwide(more than 1.1 billion people) smokes, 80percent of whom live in low- and middle-income countries. Smoking and otherforms of tobacco use affect every organsystem in the body, and are major causesof cancer, heart disease, stroke, chronicobstructive pulmonary disease, fetal dam-age, and many other conditions. Five mil-lion deaths occur worldwide each yeardue to tobacco use. If current smokingpatterns continue, it will cause some 10million deaths each year by 2020 and 70percent of these will occur in developingcountries. Tobacco use was responsiblefor 100 million deaths in the 20th centuryand will kill one billion people in the 21stcentury unless effective interventions areimplemented. Furthermore, secondhandsmoke - which contains more than 4000chemicals, including more than 50 car-cinogens and many other toxins - causeslung cancer, heart disease, and other ill-nesses in nonsmokers.

The global public health community,through the World Health Organization(WHO), has expressed increasing concernabout the alarming trends in tobacco useand tobacco-attributable disease. As of 20September 2007, 150 countries had rati-fied the Framework Convention onTobacco Control (FCTC), whose provi-sions call for ratifying countries to takestrong action against tobacco use byincreasing tobacco taxation, banningtobacco advertising and promotion, pro-hibiting smoking in public places andworksites, implementing effective healthwarnings on tobacco packaging, improv-ing access to tobacco cessation treatmentservices and medications, regulating thecontents and emissions of tobacco prod-

ucts, and eliminating illegal trade intobacco products.

Exposure to secondhand smoke occursanywhere smoking is permitted: homes,workplaces, and other public places.According to the WHO, some 200,000workers die each year due to exposure tosmoke at work, while about 700 millionchildren, around half the world's total,breathe air polluted by tobacco smoke,particularly in the home. Based on the evi-dence of three recent comprehensivereports (the International Agency forResearch on Cancer's Monograph 83,Tobacco Smoke and InvoluntarySmoking; the United States SurgeonGeneral's Report on The HealthConsequences of Involuntary Exposure toTobacco Smoke; and the CaliforniaEnvironmental Protection Agency'sProposed Identification of EnvironmentalTobacco Smoke as a Toxic AirContaminant), on May 29, 2007, theWHO called for a global ban on smokingat work and in enclosed public places.

The tobacco industry claims that it iscommitted to determining the scientifictruth about the health effects of tobacco,both by conducting internal research andby funding external research throughjointly funded industry programs.However, the industry has consistentlydenied, withheld, and suppressed infor-mation concerning the deleterious effectsof tobacco smoking. For many years theindustry claimed that there was no conclu-sive proof that smoking tobacco causesdiseases such as cancer and heart disease.It has also claimed that nicotine is notaddictive. These claims have been repeat-edly refuted by the global medical profes-sion, which because of this is also res-olutely opposed to the massive advertis-ing campaigns mounted by the industry

and believes strongly that the medicalassociations themselves must provide afirm leadership role in the campaignagainst tobacco.

The tobacco industry and its subsidiarieshave for many years supported researchand the preparation of reports on variousaspects of tobacco and health. By beinginvolved in such activities, individualresearchers and/or their organizationsgive the tobacco industry an appearanceof credibility even in cases where theindustry is not able to use the resultsdirectly in its marketing. Such involve-ment also raises major conflicts of interestwith the goals of health promotion.

RECOMMENDATIONS

The WMA urges the national medicalassociations and all physicians to take thefollowing actions to help reduce thehealth hazards related to tobacco use:

1. Adopt a policy position opposingsmoking and the use of tobacco prod-ucts, and publicize the policy so adopt-ed.

2. Prohibit smoking at all business, social,scientific, and ceremonial meetings ofthe National Medical Association, inline with the decision of the WorldMedical Association to impose a simi-lar ban at all its own such meetings.

3. Develop, support, and participate inprograms to educate the profession andthe public about the health hazards oftobacco use (including addiction) andexposure to secondhand smoke.Programs aimed at convincing andhelping smokers and smokeless tobac-co users to cease the use of tobacco

WMA Statement on Health Hazards of Tobacco ProductsAdopted by the 40th World Medical Assembly, Vienna, Austria, September 1988 amended by the49th WMA General Assembly, Hamburg, Germany, November 1997 and the WMA GeneralAssembly, Copenhagen, Denmark, October 2007

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products and programs for non-smok-ers and non-users of smokeless tobaccoproducts aimed at avoidance are bothimportant.

4. Encourage individual physicians to berole models (by not using tobacco prod-ucts) and spokespersons for the cam-paign to educate the public about thedeleterious health effects of tobaccouse and the benefits of tobacco-use ces-sation. Ask all medical schools, bio-medical research institutions, hospitals,and other health care facilities to pro-hibit smoking on their premises.

5. Introduce or strengthen educationalprograms for medical students andphysicians to prepare them to identifyand treat tobacco dependence in theirpatients.

6. Support widespread access to evi-dence-based treatment for tobaccodependence - including counseling andpharmacotherapy - through individualpatient encounters, cessation classes,telephone quit-lines, web-based cessa-tion services, and other appropriatemeans.

7. Develop or endorse a clinical practiceguideline on the treatment of tobaccouse and dependence.

8. Join the WMA in urging the WorldHealth Organization to add tobaccocessation medications with establishedefficacy to the WHO's Model List ofEssential Medicines.

9. Refrain from accepting any funding oreducational materials from the tobaccoindustry, and to urge medical schools,research institutions, and individual

researchers to do the same, in order toavoid giving any credibility to thatindustry.

10. Urge national governments to ratifyand fully implement the FrameworkConvention on Tobacco Control inorder to protect public health.

11. Speak out against the shift in focus oftobacco marketing from developed toless developed nations and urgenational governments to do the same.

12. Advocate the enactment and enforce-ment of laws that:

a. provide for comprehensive regula-tion of the manufacture, sale, distrib-ution, and promotion of tobaccoproducts, including the specific pro-visions listed below.

b. require written and pictorial warn-ings about health hazards to be print-ed on all packages in which tobaccoproducts are sold and in all advertis-ing and promotional materials fortobacco products. Such warningsshould be prominent and should referthose interested in quitting to avail-able telephone quit-lines, websites,or other sources of assistance.

c. prohibit smoking in all enclosed pub-lic places (including health carefacilities, schools, and educationfacilities), workplaces (includingrestaurants, bars and nightclubs) andpublic transport. Mental health andchemical dependence treatment cen-ters should also be smoke-free.Smoking in prisons should not bepermitted.

d. ban all advertising and promotion oftobacco products.

e. prohibit the sale, distribution, andaccessibility of cigarettes and othertobacco products to children andadolescents.

f. prohibit smoking on all commercialairline flights within national bordersand on all international commercialairline flights, and prohibit the sale oftax-free tobacco products at airportsand all other locations.

g. prohibit all government subsidies fortobacco and tobacco products.

h. provide for research into the preva-lence of tobacco use and the effectsof tobacco products on the health sta-tus of the population.

i. prohibit the promotion, distribution,and sale of any new forms of tobaccoproducts that are not currently avail-able.

j. increase taxation of tobacco products,using the increased revenues for pre-vention programs, evidence-basedcessation programs and services, andother health care measures.

k. curtail or eliminate illegal trade intobacco products and the sale ofsmuggled tobacco products.

l. help tobacco farmers switch to alter-native crops.

m. urge governments to exclude tobac-co products from international tradeagreements.

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Education

Avicenna Directories to replace World Directory of Medical Schools

Discussions have been taking placebetween WHO and the University ofCopenhagen with a view to replacing theWorld Directory of Medical Schools withthe establishment of a Global database ofhealth professions. It is planned is toinclude other academic health institutionsrelating to the other health professions suchas dentistry, midwifery, nursing, pharmacy,public health and will include information

on schools' accreditation, number of admis-sions, students, graduates , Faculty, educa-tional resources, address, and national offi-cial recognition. The database will be runby the University of Copenhagen in collab-oration with WHO, the World Federationfor Medical Education (WFME), theFoundation for the4 Advancement ofInternational Medical Education andResearch (FAIMER), the International

Pharmaceutical Federation and other part-ners.

The database will be based in the Facultyof Health Sciences in the University ofCopenhagen with the close collaborationof WFME. These electronic resources willbe called the Avicenna Directories. It is understood that the work has alreadystarted.

Global Standards for Quality Improvement in Medical Education

The World Federation of Medical Educationhas published European Specifications forBasic and Postgraduate Medical Educationand Continuing Professional Development.

These have been developed by a WFMA/AMSE international task force set up byMEDINE, chaired by WFME and ASME,sponsored by the European Commission,and provides a valuable tool adapting theglobal standards in medical education to the

European Region of WHO. It is directedtowards national and international authori-ties, institutions and organisations withresponsibility for medical education andrepresents a valuable tool in planning qual-ity improvement in medical education, set-ting out the essential elements which needto be considered in planning necessaryreforms in medical education. While this isan essential tool for authorities and institu-tions concerned with medical education it is

of value to all physicans who have respon-sibilities in medical education,

WFME Global Standards for QualityImprovement in Medical EducationEuropean Specifications.ISBN 978-87-989108-6-2Publication facilitated by WHO EURO

Information from:World Federation of Medical Educuationwww.wfme.org

Point of view

A Worldwide Tour of Medical Degrees and Qualifications Dr. Denis Doran MD

In recent years, attempting to recognise amedical degree or qualification can be chal-lenging With the reunification of East andWest Germany, the opening of the EuropeanCommunity to several new member states,the break-up of the Soviet Union and thefragmentation of Yugoslavia into severalindividual nations, medical degrees andqualifications which were not familiarbefore are now more commonly seen.

Another problem that Boards, MedicalCouncils and Colleges have had to deal withfor many years, is to differentiate and recog-nise which degrees relate to clinical prac-tice, which ones are linked to academiccareers and which ones are honorary. Theincrease in international migration has madethis problem even more pressing.

This article will review the broad range ofmedical degrees and evidence of qualifica-tion presented nowadays to licensing bod-

ies, dental committees and residency pro-gramme applications. It is not intended toprovide an official or exhaustive list ofmedical qualifications but merely to reflecton the great variety of titles for medicaldiplomas and qualifications.

EUROPEIn Europe, the medical degrees awardedvary from country to country (and also

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within countries), of which the followingare examples.

In Belgium, the French university diplomais Docteur en Medicine,Chirugie etAccouchement. The Flemish universitydegree is Aerts, Arts (Physician).

In the countries of the former Soviet UnionRussia, Ukraine, Moldova, Armenia andEstonia all issue a Doctor in MedicineDiploma; Uzbekistan awards a GeneralPractitioner diploma and the rest of the 15republics award a Vrach (Physician) diploma.

In the nations of the former Yugoslavia,Croatia and Macedonia award a Doctor ofMedicine diploma, while Bosnia-Herzegovina, Serbia and Slovenia formerlyissued a Lekar (or Zdravnik) diploma - nowa Doctor of Medicine diploma.

The graduates from medical schools inAustria, The Czech Republic and Slovakiareceive a Medicinae Universae DoctorDiploma.

In Scandinavia, Norwegian and Danishmedical schools award a CandidatusMedicinae diploma; Iceland - a CandidatusMedicinae et Chirurgiae diploma; Sweden -a Lakaexamen diploma and in Finland - a“Lisensiatti (Licence in Medicine). Thedegree Laaketieteen Tohtori (Doctor ofMedicine) is a traditional university doctor-ate, the highest degree and is a requirementfor the position of Professor..

In the Netherlands an Arts (or Artsexamen)diploma is awarded, in Luxembourg aBachelor Academique en Sciences de laVie-Medicine, and in Bulgaria, aMaster’s/Physician or State Examinationcertificate is awarded

A few degrees have unusual soundingnames: in Albania Mjek I Prerjithshem; inGreece, Psycho Iatrikes; Belarus currentlyKvaliifi Kaciya (Physician diploma ) for-merly a Vrach.)

Romania awards a Doctor-Medic diploma;Poland, a Lekarz diploma; Hungary – anOrvos doctor or MD diploma, and Turkey –a Doctor of Medicine diploma.

In the United Kingdom, the basic Britishmedical degree is the MB, BCh, (MedicinaeBaccalaureus, Baccalaureus Chirugiae).

Varieties of the same degree exist through-out Britain and the rest of theCommonwealth. These are BM BCh , MBChB, MB BChir, MB, BS. In the UK, anMD could be awarded to one who doesresearch and submits a thesis in the field ofmedicine, or as an honorary degree, to asenior or academic physician. Throughoutthe world, many countries with former edu-cational associations with Britain awarddegrees reflecting the British type of med-ical degree.

The Conjoint Diploma LRCP, MRCS , andthe LMSSA (Licentiate of the Royal Collegeof Physicians of London, Member of theRoyal College of Surgeons of England, andthe Licentiate in Medicine, Surgery of theSociety of Apothecaries) were registrablequalifications with the General MedicalCouncil (where all practising physicianshave to be registered if they wish to prac-tice) until 1999. The Scottish TripleConjoint Diplomas, LRCPE, LRCSE,LRCPSG are similar qualifications whichwere registrable with the GMC until 1999.

In Ireland, the basic medical degree is MB,ChB, BAO (Baccalaureus in ArteObstetrician). The LRCPI, LRCSI diplo-mas, unlike England and Scotland are stillregistrable with the Irish Medical Council.Also recognised is the LM (Licence inMidwifery)

For Germany there is a State ExaminationCertificate , either on passing a three partState exam (Dritter Abschnitt Certificate ) ora two part State exam, (Zweiter AbschnittCertificate).which are recognised for basiclicensing purposes. Italy awards a Laurea inMedecina e Chirurgia diploma) (Bachelor ofMedicine and Surgery), Portugal awards aLicenciatura em Medecina diploma andSpain, a Licenciado en Medecina y Cirurgia.

Switzerland awards a Diploma Federal.

LATIN AMERICABrazil awards a Medico (or MD) diploma;Bolivia a Titulo en Provision Nacional deMedico Cirujano; Costa Rica,Venezuelaand Chile, a Medico Chirujano diploma:Ecuador, Honduras and Nicaragua, aDoctor en Medicina y Chirugia; Mexico

and Peru, a Titulo de Medico Cirujano.Surinam awards an Arts or Geneesherendiploma.

NORTH AMERICAIn Canada, francophone universities awarda Docteur/ Doctorat en Médecine diploma:

Anglophone universities offer the MD diplo-ma. In the USA, most graduates of medicalschools receive an MD. Another medicaldegree awarded by 19 medical schools is theDoctor of Osteopathy or DO diploma.

ASIA

China and Taiwan offer a Bachelor ofMedicine degree. China also offers aBachelor of Traditional Medicine and Japanoffers an Igaku (Bachelor of Medicine). InMalaysia following the British system theMB,BS or MB,ChB are awarded as well asthe Doctor “Perubatan”. North Korea offersa Doctor diploma and South Korea, earlier aHak Sa diploma and now a Bachelor ofMedicine; Indonesia awards a Doktor diplo-ma and Mongolia a Physician diploma.

AFRICA

Angola and Mozambique ex-Portuguesecolonies offer the same diplomas asPortugal; the Democratic Republic ofCongo, an ex-Belgian colony, awards aDocteur en Med., Chir et Accouchementdiploma, as well as a number of others,which are accepted for basic medical licens-ing purposes. Gabon, Benin and IvoryCoast have a Doctorat d’Etat en Medicine.

Most other countries of the world issueeither an MD, Doctorat en Medecine orMBBS/MB ChB degree.

NON-MEDICAL QUALIFI-CATIONS

The PhD is a university awarded researchDoctorate, not necessarily associated withclinical practice, awarded after supervisedacademic research and the submission of a

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thesis. (Often Clinical Psychologists, whounlike Psychiatrists cannot prescribe med-ications have a PhD.).

MEMBERSHIP/FELLOW-SHIP OF COLLEGES ANDOTHER SPECIALISTINSTITUTIONS

Medical Colleges and Academic Institutions,many of which have existed many or forhundreds of years, award fellowships. TheColleges are normally concerned with spe-cialities, although, as, mentioned above,some conduct examinations related to theirown specialty which are recognised for basiclicensing purposes to practice medicine e.g.LRCPI, LRCPI. Fellowships, on the otherhand normally require the passing of a high-er examination or assessment and election by the College as Fellows. HonoraryFellowships are mostly awarded for excep-tional and distinguished practice in medicineSuch Colleges have as their aim the develop-ment of the specialty and the maintenance ofhigh standards and excellence, a conditionwhich their members are bound to fulfil as acondition of Membership or Fellowship. Theuse of titles varies greatly between countriesand institutions.

MEMBERSHIP

e.g MCCFP Membership of CanadianCollege of Family Physicians;

MACP Membership of American Collegeof Physicians;

MRCGP Membership of the Royal Collegeof General Practitioners.

Membership of these bodies, while notobligatory in some countries, often marksthe end point of specialist training and isawarded after an examination This type ofMembership is, in certain countries, recog-nised as achieving formal specialist qualifi-cation, notably in the UK where for exam-ple, the MRCP is the recognised basic spe-cialist qualification in medicine, whereasthe FRCS is the basic specialist qualifica-tion for surgery.

FELLOWSHIP

e.g FAAP Fellow of the American Academyof Paediatrics.

FRCP Fellow of the Royal College ofPhysicians.

Fellowships require a much higher distinc-tion and status. They are usually awardedafter passing a very difficult examination orare elected for distinction in the relevantbranch of medicine.

In many countries of Europe and to a cer-tain extent throughout the world, physiciansappointed as Professors prefer to be calledProfessor rather than Doctor and inEngland, Fellows of the Royal College ofSurgeons are referred to as Mister In fact allsurgeons are called Mister but “Obstetricand Gynaecologist” specialists if they holdan MD, may use the title Doctor.

CONCLUSION

It is not the purpose of this article to discussthe details of qualifications associated withthe great variety of medical degrees listedabove.

Nevertheless, licensing bodies have the roleof recognising (or not) these medicaldegrees and qualifications and to suggest,when necessary, updates to qualify for alicence to practice.

Accordingly, the public at large need toaccept the fact that physicians qualified topractice in their region may not necessarilyhave the usual MD after their name.

Address for communicationDr Denis DorenBox70 1 Hastings St N,Bancroft. KOL 1COCanada

From the WMA Secretary General

Trust me, I’m a Doctor!

Although you never should say this to yourpatients – you often will enjoy exactly thedesired high degree of confidence in whatyou do and what you are – a physician.However, we are about to lose this!

No, I am not referring to the sermon-likerepeated “doctor bashing” of politicians andmedia, I am referring to what may bethought to be advertising, but may be large-ly a lack of precision and carelessness incommunication, with which we are endan-gering our image.

More and more people are reaching outtheir hands to patients saying „Hallo! I amyour doctor.“ But what kind of doctors arethey? At best they may be scientifically

trained persons but they may well be doc-tors of podology. This not a joke! There isan economic war and we are about to lose it,because as it looks as if we have not evenunderstood that it is going on.

The battles our associations are fightingabout scope of practice and task shifting,are not an academic entertainment.Politicians and economists are trying to de-professionalize medicine and make it acheap commodity for the masses.

Why? Is it – at least partially – our faultbecause we have produced the confusion, orat least we let it happen? . Not only does anormal person already have a hard time tounderstand what an Endocrinologist is and

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does, we even top-up this non-communica-tion with academic degrees, titles andabbreviations that are cryptic, confusingand worst of all – misleading.

Appendices of titles, consisting of dozensof apparently randomly combined lettersmake us look like amateurs rather than seri-ous professionals. Yes, we may be proud tobe a fellow of a college or society and whynot talk about it. Yes, it is more than correctto display specialist qualifications. Buttitles that even our colleagues can onlydecipher when they hold exactly the sametitle could be considered vain advertising.Whom are medical titles good for? Shouldthey not serve our patients to find the rightphysician, to find the right treatment from aqualified physician?

In this issue, Denis Doren, MD, fromOntario (Canada) has taken a look at themedical degrees, qualifications and titlesthat are being awarded and used around theworld. One might attribute the wide variety

he found as a sign of pluralism, culturaldiversity and tradition. But let’s face it, forour patients it is simply a mess. To makethis more transparent, at least to the con-sumer (the patient), is there not some justi-fication for simplifying the whole thing to “Licensed Medical Practitioner”, with theaddition “and Licensed xxxxx Specialist”,where appropriate. If then, the letters indi-cating qualifications degrees e.g. MD, andFellowships of Colleges etc are added, theywill be less confusing.

In this day and age, access to the computersurely permits patients to find the meaningand significance of the letters.

And of course there are others who wel-come our own confusion. While we don’tdelivery clarity – they do it by simply clas-sifying us as “service providers” or “healthworkers”. Separating us from our patients ismade easy by our use of terms and abbrevi-ations and making physicians accede to thegeneric group of “service providers” in

health care, neglecting the additional quali-ties implicit in a practicing profession.

Do we want to maintain a special role inhealth care? Do we want to remains advo-cates for our patients? Do we want to keepour leadership role in healthcare teams? Ifthe answer is “yes” we should avoid theridiculous variety of titles and acronyms weare currently using and should make surethat patients can identify us as what we are:physicians. This still permits the nomina-tion of a speciality, provided the qualifica-tion has been earned and awarded, but weshould do it with the degree of transparencyand clarity we owe our patients and the pub-lic.

Only then we will be able to protect ourtitles. This will not be enough as a sufficientstrategy to protect our scope of practice, butwe have to realize that it is a necessaryrequirement.

Trust me, I’m a doctor!

Ceremonial Session 5th October2007

The President, Dr. N. Arumugam formallyopened the Session.

The Secretary General Dr. Otmar Kloiberreported the death on 10th of June of Dr.André Wynen, former Chair of Council andSecretary General Paying a tribute, he said”André Wynen was our friend, teacher andleader, serving the World MedicalAssociation and the whole medical profes-sion with dedication and passion.

The meeting stood in silent tribute.

The Secretary General, then took the RollCall, introducing the Delegates and theObservers of other organisations presentwhich included the International

Committee of the Red Cross, CIOMS,Confemel, the Danish Nursing Association,the Federal Council of Brazilian Doctors,the International Dental Federation, theInternational Federation of MedicalStudents, the International Federation ofPharmaceutical Manufacturers andAssociations, the Medical Women’sInternational Association, the StandingCommittee of European Doctors, the WorldFederation of Medical Education, theWorld Psychiatric Association, theInternational Rehabilitation Council forTorture Victims and the World Self-Medication Industry.

Dr. Jensen, President of the Danish MedicalAssociation welcomed World MedicalAssociation and all the participants to

Copenhagen. He congratulated Dr. Snædel,the incoming President on his election andpaid tribute to his work, notably for his con-tribution in the revision of the InternationalCode of Ethics. He thanked the outgoingPresident Dr. Arumugam for all is workover the past year.

The Chair of Council Dr. Hill warmlythanked Dr. Jensen and the Danish MedicalAssociation for the invitation to return toCopenhagen for this year’s Assembly andfor the hospitality, which was greatly appre-ciated. Proposing a vote of thanks to thePresident, he reminded the meeting that Dr.Arumugam, a cardiologist in Malaysia, wasa champion of Public Health, had played amajor role in the introduction of TobaccoLegislation in that country.

WMA General AssemblyThe General Assembly of the World Medical Association was held in the Marriott Hotel, Copenhagen on 5th and 6th October 2007

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Retiring President’s Address

Dr. Arumugam said that it had been a ter-rific year in which it had been an honourand a privilege to represent the WorldMedical Association. He had tried toadvance the views of WMA, had witnessedthe challenges facing Health Care Servicesand Medicine in different countries andmet fellow doctors across the world. Heexpressed his thanks both to Council andto his fellow Officers for their work andsupport during the past year. His main taskhad been to emphasise the work of theWMA and improve its visibility. He hadvisited and attended the Annual meetingsof many National Medical Associationsand referred to the problems of the profes-sion such as increasing regulation reducingthe time for professional work. Focusingon Continuing Professional Development,he noted that this had been a special prob-lem over the past 10 years where therewere many hurdles in developing coun-tries. Addressing the problems in SouthEast Asia in particular, he referred to thedevelopment of a points system for CPD inthat region.

Patient Safety was also an important prob-lem especially in hospitals. This had beenaddressed by the Hospitals Association inMalta which had recognised the WMAStatement on this issue. A Conference ofMedical Associations in SEA had includedCME on Ethics in Medicine and ClinicalPractice. Dr. Arugunam also referred tothe increasing problem of medical litiga-tion.

Turning to China he reported that the sevenpersons in the delegation had discussed theproblems of Organ Transplants and harvest-ing organs from prisoners, the shortage oforgans and other problems with the ChineseMedical Association and the Minister ofHealth. At the end of the meeting it wasconcluded that Trade in Organs must stop.He was encouraged by the recent accep-tance of the WMA Code on Transplantationof Organs by the Chinese MedicalAssociation. He commented that the prob-lems of transplantation, including ethicaland legislative aspects had been discussedby the German Medical Association whosemeeting he had addressed.

Obesity was a major problem and the loom-ing epidemic needed addressing with a pre-ventive healthy diet and food labelling.

The problems of tobacco continue. Whilethe Framework Convention on TobaccoControl was welcomed, he felt that it so farhad had a limited effect and the WorldMedical Association must continue itsefforts to encourage Tobacco Control activ-ities.

Turning to the World Health ProfessionsAlliance he commented that the Presidentsof these professions met to discuss the prob-lem of Health Personnel Migration andTask shifting, where areas of difference stillneed to be addressed.

The President referred to his presence inIndia, the Philippines and most recently at ameeting of CONFEMEL, finally comment-ing that at the recent AMA meeting therewas concern over the development of clin-ics in supermarkets and that in Australiathere was a need for vigilance over the issueof what is being called “Task Shifting“. Heclosed by stating that the most unforgettableevent for him had been the reading andaffirmation of the WMA Oath of theMedical Profession. The Assembly rose in a Standing Ovation.

Installation of the new President

Dr. Hill in thanking Dr. Arumugam for allhis work for the profession referred to thewisdom, care and understanding he hadshown as President. He then presented Dr.Arumugam with the Past President’s medal.

Introducing Dr. Snædel as the newPresident, Dr. Hill said he had been electedin recognition of his many services to theprofession and the WMA. Dr. Snædel tookthe oath on assuming the office of Presidentand was invested with the Presidents Badgeof Office.

Presidential Address by Dr. Jon Snædel

“Dear colleagues, distinguished guests.

During the last decades new discoveries inclinical research as well as in basic researchhave been stretching the ethical boundariesof medicine. The World MedicalAssociation has managed to be at the fore-front of this evolution and during the past

few years the WMA has revised many of itsold documents in ethics as well as in otherfields. It has been a privilege to participatein the solution of many of these dilemmas,not least when the International Code ofMedical Ethics was revised after a processof 2 years and finally finished in South-Africa last year. To take an example of hownew thoughts are integrated in such a docu-ment I will mention one paragraph of theCode.

One of the paragraphs has been unchangedsince its earliest version in 1949:“A PHYSI-CIAN SHALL always bear in mind theobligation to preserve human life.” In thelast revision one word was changed and theword preserve was replaced by the wordrespect and now it reads: “A PHYSICIANSHALL always bear in mind the obligationto respect human life.” The change of justone word reflects a fundamental change inour way of thinking of our duties. Our abil-ities to treat our fellow human beings havevastly increased as we are now able to pre-serve live for a long time even if this life iswithout any obvious quality. There is a say-ing that life is a disease with 100% mortali-ty, a saying that medicalises life itself. Wehave to acknowledge the fact that death isinevitable and that in its last phases it is ofmore value to the person to treat the symp-toms rather than the disease. In this phase oflife our obligation is thus to respect thepatient rather than to preserve his life.

There are many other ethical questions wehave to address and the WMA is workingconstantly on these. Just to mention twoissues we are dealing with in the comingmonths – a revision of the Helsinki declara-tion on research involving human subjectsand a new document on stem cell research.Every now and then we are faced with ethi-cal dilemmas we did not foresee. I will giveyou an example of such an issue whichunfolded in my country just 3 weeks ago. Aprivate company in genetic research hasnow offered those who wish for and arewilling to pay, an analysis of their geneticmakeup. The whole genome is analyzed byhalf a million markers and the person willget a report on his chances of getting a num-ber of diseases. But is it not just wonderfulthat we have a technique that can provide uswith such information of your health and

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health risks? In our view there are, howev-er, obvious problems with this type of infor-mation. One is clearly that you are not ableto change your genes, which means that ifyou know that your chances of getting say acertain type of cancer; you will not be ableto affect that chance. Another is that thistechnique will obviously be very interestingto insurance companies who could theninsist that you will go through such a testwhether you like or not. There are evenmore obstacles to this idea than I haveaccounted for and this is just one exampleof many of what medical ethics is about.

During my year of presidency of the WorldMedical Association my main concerns willtherefore be medical ethics and its manifoldtasks. I will build on the traditions of ourAssociation and work in harmony with theCouncil and the Secretariat, as it is of greatimportance that we work together for ourmutual cause even if I have chosen this spe-cific part of work of our Association for mymission. There are many means to achieveour goals. At this Assembly we will discussthe future of the World Medical Journal. Iwould like to see this Journal, and therebythe WMA itself, have a much greater role inmedical ethics and public health than it hashad up to now. When I asked the librarian inmy University hospital to take a look intothe accessible Journals of Medical Ethics itbecame clear to me that there is a place forone more. The Journals are far less in num-ber than in many specific fields of medi-cine, even subspecialties, and the distribu-tion of most of them seems to be confinedto the society they are published for. Thiscan be seen by their limited impact factor. Anew international journal on medical ethicsand public health published by the WMAwill in my mind not only be an asset to theassociation but more importantly, of clearbenefit to the clinical doctor which this newjournal should be aimed at.

Closely linked to ethics are human rights. Ifeel that the WMA is on the right track in its

collaboration with very important organisa-tions in this field such as the Red Cross,Amnesty International and not least theInternational Council for Torture Victimswhich actually have their main office herein Copenhagen. The important task of pre-venting torture by using a tool called theIstanbul Protocol in ten countries has nowbeen underway during the last 4 years. It ismy hope that the WMA will continue towork for this important human rights issuein all possible ways during the comingyears.

The WMA has during the last years dis-cussed advocacy because that is the meansby which the association will have effect.The WMA aims its work mainly towardsthree types of receivers, the individualdoctor, the association of doctors, mainlythe NMA’s of the WMA, and towardsinternational organisations. The mainreceivers of the work of the WMAthroughout the years have been theNMA’s. That is of course good, but to havea real effect on health issues, ethics andinternational politics of medicine ourAssociation needs more visibility. Byrevamping the WMJ we will increase ourvisibility towards the individual doctor.Doctors will hopefully go to our newJournal for advice and inspiration and wewill reach out with a printed version aswell as an electronic one to all parts of theworld in spite of language barriers.Another important and imminent task is toincrease our presence and influence ininternational organisations. One specifictask will be to work to preserve our educa-tion and training because it has been on theagenda of the WHO to solve the problemof shortage of doctors by proposing ashorter training, some kind of technicaldoctor trained for limited purposes. Evenif we can understand that some countriesneed to address this difficult problemurgently, we feel that in the long run thismethod will undermine the health servicein these countries. I would therefore like to

echo the words of our past president,Kgosi Letlape, when he said in his addressin South-Africa that the solution to thisproblem is to “keep the pastures green inour countries.”

Doctors are not working alone. Team workis an increasing issue in our daily routineand we are accustomed to work alongsideother health professionals, most often nurs-es and pharmacists. The WMA participatesin an international collaboration with therespective organisations of these two pro-fessions as well as the dentists. However,we need to address the collaboration ofthese professionals on the ground better.Another task of mine will be to work on thatin a task looking specifically at collabora-tion for better pharmacological treatment.More tasks of this kind are obvious and willmost likely be looked at in the near future.

Lastly I will mention the specific group ofpatients I care for and treat in my dailywork as a geriatrician, persons with demen-tia, more specifically Alzheimer’s disease.Even if I feel some urge to place their prob-lems on the agenda I realize that the prob-lems of specific group of patients are not anissue for the WMA. We work for all ofthem. However I will use this opportunityto correct a prevalent misunderstanding,that this is a specific problem for the devel-oped world. In fact most demented personsare found today in the developing world andthe greatest increase of this patient group iswithout question in Asia and Africa.

During the coming year I hope to bringsome benefit to the WMA but I acknowl-edge that one person will not be able toachieve much. It is therefore my sincerehope that I will be able to collaborate withas many of you as possible during my pres-idency. May the WMA continue to thriveand prosper for many years.”

The President then thanked the Assemblymembers and their guests for attending andformally closed the Ceremonial Session.

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Plenary Session of the Assembly 6th October 2007

Dr. Hill, Chair of Council, opened themeeting and the Secretary General, Dr.Kloiber referred to the sad death of Dr.André Wynen and informed the Assemblythat a Memorial Book was open for signa-ture.

He also reminded the Assembly that theWorld Health Professions Association’sLeadership would take place in November.There were 30 places on the course and 24applications had so far been received andapproved. There were still six vacancies andhe invited applications for these places,preferably female candidates.

Dr. Hill, after listing the apologies forabsence, stated that there were three nomi-nations for the Presidency of the WorldMedical Association for 1908-9 and openedthe floor for further nominations. In theabsence of any other proposals he declaredthe three candidates to be Drs. Blachar(Israel), Desai(India) and Boswell(NewZealand).

Dr. Hill then referred to the presence as anobserver of the President of theInternational Dental Federation (FDI), Dr.Michéle Aerden, and invited her to addressthe meeting.

Dr. Aerden referring to the FDI as one of thepartners in the World Health Professions’Alliance (WHPA), said that it was the thirdoldest health professional organisation inthe world. As a worldwide independentorganisation representing 140 DentalAssociations FDI it was the voice of den-tistry and was represented at the UN, WHOand ISO. Recognising that Health was afundamental human right she pointed outthat this included the need for Oral Health.In 1981 WHO recognised the goal of glob-al oral health. In 2007 Oral Health was onthe Agenda of the World Health Assemblyand the important role of prevention in OralHealth was recognised, including the role ofFluoride.

Dr. Aerden said that it was important to col-lect data on oral health because of its value,particularly in developing countries whereprojects had been set up.

Turning to the importance of ethics shestressed that this was also true of Dentistry.She spoke of the importance of defendingthe position of the profession in recognisingthe dignity of individual and the well-beingof patients. Speaking of the effects of oraldisease on morbidity and mortality, shereferred the effects of pain on the quality oflife and to the link between oral disease andthe rest of the body

A proposal was being made in WHPA foraction to make things HAPPEN. There wasa “Health in Africa” Vision. In Africa,where there were major gaps in health care,conferences were planned in Africa in 2007and in America in 2008, to address the prob-lems of health access policy and also educa-tion in health promotion and disease pre-vention. Action by the WHPA would makea difference.

Dr. Hill thanked Dr. Aerden and remindedthe meeting that Dr. Letlape had been sit-ting on the working group in WHPA for thepast year.

Dr. Haikerwald presented the report of theCredentials Committee. 45 Delegationswere present of which 43 had the right tovote.

The Standing Orders and the Minutes of thePilanesberg meeting were both adopted,following which each of the three candi-dates in the presidential election addressedthe meeting. At the conclusion of these pre-sentations delegations proceeded to a for-mal ballot for the electing the President-elect 2008-2009.

President-elect

The Secretary General declared the result ofthe ballot was that Dr. Yoram Blachar had

been elected to the office of President-electfor the year 2008-2009.

Dr Blachar, responding to this said that hewas deeply touched by the trust place inhim and thanked those who had electedhim, expressing in particular his thanks tohis wife and to Ms. Leah Wapner for theirgreat continuing support and help.

Report of Council(Much of the written report of Council cir-culated before the November meetingappears in the report of the 176th Councilmeeting in WMJ52(2): matters other thanthe statements and resolutions adopted bythe Assembly which are set out below, areset out in the account of the 178th Councilmeeting (see page 107).

Finance and Planning

Dr. Hill presenting the report, turned first torecommendations arising from the Financeand Planning Committee business.

Cabo Verde

The application for constituent membershipof the Ordem dos Medical de Capo Verdewas approved.

Scientific Session, Seoul 2008

The theme of “Health and Human Rights”was approved for the 2008 scientific meet-ing in Seoul.

Treasurer’s Report

The Treasurer, Dr. J.D. Hoppe presentinghis report reviewing the period 2005-2006,referred to the Financial Statement preparedwith Mr. Hallmayr which had beenapproved by the auditors KPMG, and thenspoke to the document in some detail. Hereported that the net balance, reversing thedeficit of the years 2004-5 which had beenovercome through the efforts and actions ofthe Secretary General, had continued to

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improve, both from Dr Kloiber’s continuingactions, from the improvement in incomefrom members dues and other financialearnings.

The Financial Statement for 2006 was unan-imously approved.

Dr. Hoppe then presented the Budget for2008 which, in the absence of any questionsfrom the floor, was approved unanimously.

Dr. Hill expressed his thanks both to Dr.Hoppe and to Mr Hallmayr for their workduring the year.He reminded delegates that

the new dues categories had been approvedand sent to delegations.

Before turning to Medical Ethics Dr. Hillput to the Assembly the following CouncilResolution which was adopted unanimous-ly by the Assembly.

Adopted by the WMA General Assembly,Copenhagen, Denmark, October 2007

There are credible reports that arrange-ments between the Cuban governmentand certain Latin American and Caribbeangovernments to supply Cuban healthworkers as physicians to these countriesare bypassing systems, established to pro-tect patients, that have been set up to ver-ify physicians’ credentials and compe-tence.

The World Medical Association is signifi-cantly concerned that patients are put atrisk by unregulated medical practices.

There exist already duly constituted andlegally authorized medical associationswithin this region that are charged withthe registration of physicians and whichshould be consulted by their respectiveMinistries of Health.

Therefore, the WMA:

1) Condemns any actions by governmentsin policies and practices that subvert orbypass the accepted standards of med-ical credentialing and medical care;

2) Calls upon the governments in LatinAmerica and the Caribbean to work

with the medical associations on allmatters related to physician certifica-tion and the practice of medicine and torespect the role and rights of thesemedical associations and the autonomyof the medical profession.

3) Urges, as a matter of utmost concern,that the governments in Latin Americaand the Caribbean respect the WMAInternational Code of Medical Ethicsand the Declaration of Madrid thatguide the medical practice of physi-cians all over the world.

Resolution in Support of the Medical Associations in Latin America and the Caribbean

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Medical Ethics and HumanRightsDr. Hill then put to the Assembly the fol-lowing statements and resolutions arisingfrom Medical Ethics Committee business.Telemedicine

A proposed Statement on the Ethics ofTelemedicine (see medical ethics page 91 )was unanimously approved.

Human Tissue for Transplantations.

A proposed Statement on Human Tissue forTransplantation was approved unanimous-ly

Documentation and Denunciation of Actsof Torture

Dr. Hill asked Britte Sydhoff, SecretaryGeneral of the International Rehabilitation

Council for Torture Victims (IRCTV) toaddress the meeting.

Britte Sydhoff, introducing the IRCTV asan international NGO said that it was a plea-sure to stand before the WMA and thankthem for their support. She explained thatthe ICRTV had 130 rehabilitation centres in78 countries.

She was very pleased with the WMA standon Torture, as exemplified by the Tokyo andHamburg Statements. The proposedimprovements in the Statement onDocumentation of Torture constituted astrong supplement to the existing statement.The need for proof of torture is vital andspecific training in how to note and providesuch documentation is important, as physi-cians do not know how to do this. She com-mented that often victims are detained untilthe evidence is gone.

The Istambul Protocol and Guidelines helpin producing good reports to be used incourt. IRCTV is carrying out advocacy andtraining activities and she stressed thatPrevention through documentation can helpboth the Health and Legal professions. Thecollaboration of National MedicalAssociations has been a real part of the suc-cess of the training about the IstambulProtocol.

Dr. Hill thanked the IRCTV for its work andcooperation, in which Dr. Snaedel had beendeeply involved.

The proposed revision of the WMAResolution on the Responsibility ofPhysicians in the Documentation andDenunciation of Acts of Torture or Cruel orInhuman or Degrading Treatment (seeMedical Ethics p. 92) was approved unani-mously.

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Socio-Medical AffairsDr. Hill put to the Assembly the followingrecommendations arising from the Socio-Medical committee business:

Noise Pollution

The proposed revision of the WMAStatement on Noise Pollution was adoptedunanimously.

Family Planning and Right toContraception

The WMA Statement on Family Planningand the Right of a woman to Contraceptionwas adopted.

Health Hazards of Tobacco Products

The proposed Statement on Health Hazardsof Tobacco Products (see page 95) wasadopted unanimously.

Dr. Hill announced that in the Spring, anexciting new project on Tobacco will beannounced.

Health and Human Rights Abuses inZimbabwe

The proposed Resolution on Health andHuman Rights Abuses in Zimbabwe (seeHuman Rights (see page 94).

The rest of the Council report wasapproved.

Associates MeetingIn the absence of the Chair, Dr. DuMont,Dr. D. Johnson gave the report of theAssociate’s meeting. He indicated that therewere very spirited discussions althoughonly one Resolution was adopted. This wasa Statement on “Ethical Principles forResearch on Child Subjects” which, itrequested, should be referred to Council forprocessing.

Dr. J. Appleyard who had made the originalproposal said he appreciated the support ofthe Associates’ meeting in referring it to theAssembly with the suggestion of referral toCouncil. He also urged the Assembly andNMAs to take this matter forward. It wasparallel to Helsinki and reflected the con-cern about child subjects and research inAmerica, Europe and Japan.

The Chair drew attention again to the rec-ommendation that this be referred toCouncil and Dr. Kloiber commented that itcould be considered by Council at its post-Assembly meeting and then be processed.

The proposal that the Statement be referredto Council for processing was approved.

Dr. Johnson further reported that theAssociates meeting had appointed two rep-resentatives and deputies to the Assemblyexpressed the hope that this would be to theadvantage of the Associates, requesting thattheir role be examined when the analasysAssociates’ Membership is considered Thereport was adopted.

Open sessionDr. Siguero wished to propose a resolutionthat the writing of prescriptions must belimited to physicians. He was concernedthat with pending elections in Spain thenurses asked that they might prescribe.Currently there was a fear of a nurses strikeand Dr. Siguero pointed out that theInternational Council of Nurses supportedthe concept of nurse prescribing. He con-siders that prescribing must be limited tophysicians exclusively, as only physicians,because of their education, can diagnoseand ensure the quality of the appropriatedrug prescription. Only the qualified physi-cian has the knowledge of both the appro-priate drug and of the risks associated withtheir prescription. He appealed to theWMA to defend the right to prescribe forphysicians. There was a need to appeal tohealth authorities to ensure this throughappropriate legislation. Dr. Nathansen(UK) said that a number of physician’s sup-port nurse prescribing from a Limited Listand that the UK is about to move to nurseprescribing from the National Formulary.The BMA is opposed to this. There is aneed for very great care in the drafting oflegislation to ensure that the intended nurseprescribing is restricted to a LimitedFormulary. There are many problemswhich are related to “Task Shifting”.Prescribing by non-physicians is a worldwide trend. WMA must express its posi-tion, we have generally enough physiciansto deal with prescribing needs.

Dr. Letlape considered the matter to be verycomplex. It would be difficult to produce aresolution to cover the whole area of needsfor prescribing, as we have to consider thechallenges of areas in which there are noqualified physicians and patients need carethere; people are specially trained to diag-nose and prescribe in such areas.

The responsibilities which go with prescrib-ing need to be included in the training. ThePresident, Dr. Snaedel, thanked the SpanishMedical Association for raising this issue.While Dr. Nathansen had indicated that “theball was lost”, he felt that it was not lost – wecan dialogue with the professions and rele-vant authorities. The International Federationof Pharmacists was looking at this issue andwe must dialogue with them. The matterwould be on the agenda of Council.

Dr. Haikerwal (Aust) expressed sympathyfor Spain, stating, however, that” the trainhas moved on”. In Australia physicians,nurses and optometrists are moving in thisdirection. Dialogue is vital. Task substitu-tion must be avoided and medical supervi-sion was essential in any such job substitu-tion. Dr. Mckie (Canada) reported that inAlberta and some other provinces, alliedhealth professionals have the right to pre-scribe. The Alberta Medical Association setout generic guidelines for allied health pro-fessionals including provisions on conflictof interest. There was a need to ensure ade-quate records. Collaborative care was basedon the skills of the provider. The CMAwould provide further information to theWMA. A speaker from the Japanese delega-tion agreed with others that this was a fun-damental issue. Dr. Montgomery (Germany)agreed with others that the train had left. Hefelt that the Ministry of Health was usingthis concept as a means of breaking downphysicans’ domination. While he understoodthe situation in some countries he felt that aCouncil Working group should be set up.The Adminstrators think that by using thismechanism they will save money. Dr.Lemye (Belg.) also agreed that “the trainhad left”. Such extension of the right to pre-scribe could be useful in, for example,Disaster Medicine, but these powers shouldbe provided by the use of exemption mech-anisms. Governments, however, do not only

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consider the lack of qualified physicians asthe problem. but also look at curtailing theprerogatives of physicians. Dr. Figueredo(Uraguay) supported this. There was no lackof qualified physicians in South America butnevertheless the other health professionalswere being used to treat some sections of thepopulation even where patently there wereenough physicians, and he proceeded toquote a case illustrating this situation.

Dr. Blachar (IMA and President-elect) feltthe situation to be both fundamental andthreatening. He strongly supported settingup a Working Group to produce a paper forthe May meeting of Council.

Dr. Siguero (Spain) thanked contributorsfor their support and said that he supportedDr. Montgomery’s proposal. He had a feel-ing that some physicians were helping thetrain to leave! There was no lack of quali-fied physicians in Spain, politics and someprofessionals were behind this move. WHOshould not be promoting it.

Dr. Hill said this had been a good debateand the issue would be placed on theCouncil agenda.

Dr. Sabilli (Philippines) referred to a recenttelevision broadcast in which commentswere made about Philippine doctors inderogatory chauvinistic terms. He pointedout that his country was spending its ownmoney training physicians who then wentabroad to assist in providing healthcare. Atthe same time, he thanked those countrieswho had assisted his country with sec-ondary care. However he appealed to otherNMAs to assist in stopping the derogatoryremarks being made suggesting that diplo-mas of Philippine physicians could not bechecked etc. Such remarks were deplorable.Philippine physicians are asking for anapology from those who do this.

Dr. Hill assured the speaker that the AMAhad found the TV statement distasteful.Yesterday the AMA had approached the TVprogramme supporting the PhilippineDoctors in their desire for an apology.

Dr. Chan (Hong Kong) thanked Dr. Kloiberfor supporting a small survey on the regula-tion of the Profession in South East Asia andwelcomed the article on MedicalProfessional in the WMJ. He would like it tobe translated into other languages, notablyChinese, and would also like it to be fol-lowed up by a survey, perhaps by otherNMAs, concerning the right to prescribe. Healso felt that it would be most helpful if wecould see the results of follow-up ofResolutions and Statements issued by WMA.Finally he suggested that the effects of airpollution should be studied in the profession,both in developed and developing countriesconsidering that this would also need bothmid and long term surveys.

The Secretary General commented thatthere were strict limitations on what WMA,with a limited staff of seven could do.Speaking of Resolutions and Statementsetc, he said that implementation was in thehands of NMAs. Developing this he saidwould like feedback, giving as examples:

a) Work on Task-shifting. (He had beenasked by WHPA to seek this.)

b) Discussion of the White Paper onRegulation (WMJ 53(3) p. 58).

Dr. Kloiber then referred to the forthcomingWHPA conference next year onInternational Regulation of HealthProfessions. It was essential that we achievea common understanding on SelfRegulation. Some of the problems he hadreported to the WHO. NMAs must also takeup this issue. At the Chief ExecutiveOfficer’s conference concerns over issuesof regulation and licensing were expressedand he was looking to NMAs to act on this.

Dr. Hill, closing the session, thanked allthose who had contributed to what had beena very valuable session.

General Assembly – 2008

Dr. Shin then presented a film on Korea andthe forthcoming General Assembly, 15-18October 2008, thanking WMA for agreeing

to come to Seoul and extending a warminvitation to delegates to go to Korea.

Closure

There being no other business theSecretary General, Dr. Otmar Kloiber,expressed his appreciation of the supportreceived from NMAs, notably in payingtheir Dues on time. He said that the changein the Dues structure had gone smoothly.We have never had such strong representa-tion from some parts of the world. We needto continue to strengthen this. In thankingNMAs, he particularly mentioned the out-standing commitments of Japan and ofIndia in responding to the increases indues. He expressed warm thanks to allNMAs who had supported projects onAdvocacy including the AMA and theBAK, also the DMA for acting as hosts tothe Assembly – observing that this impos-es costs on the host NMAs. He remindedthe Assembly that the WMA office was asmall one and had to depend on membersfor support.

Turning to direct support, he particularlymentioned the CMA’s engagement inAdvocacy, Information Technology, andEthics. He continued that, while it wasnot possible to identify all contributions,he had to mention the Officers, Chairs ofcommittees etc and the Chair of Council –all of whom contribute a great deal. TheBMA, Norwegian MA, SAMA and BAKhad all supported projects or given techni-cal support, such as the legal advice pro-vided by the Israel MA. Finally, hethanked most warmly Dr. Jensen and hisVice Chair Dr. Buhl, the DMA and itsstaff for the splendid organisation,arrangements and hospitality we hadexperienced during the meeting inCopenhagen.

Dr. Hill finally gave a warm thanks to theinterpreters and to delegates for all theirenthusiasm and hard work and formallyclosed the Assembly.

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The Chairman, Dr. Hill opened the meetingwith business arising from the GeneralAssembly and sought the views of Councilon the subject of “task shifting” which wasa matter of major concern to NMAs. Hesaid that there were considerable differ-ences in the degree to which this was occur-ring in different parts of the world andcalled for expressions of interest in mem-bership of a working group on this topic.

Prof. Nathanson was interested, in particu-lar because this was a matter of specialimportance in the UK and members fromCanada, Israel, Belgium, Germany,Norway, Brazil, Korea, Spain, Iceland indi-cated an interest. After the Chair pointedout that working groups were limited to sixmembers and it was agreed that the Chairwould select the group of six.

Dr. Davis (AMA) wondered whether it wastoo late to set up a working group. Had thetrain not already left the station?

Council considered a proposed Statementon “Research and Children” from theAssociates’ group, referred to the Councilby the Assembly. Dr. Kloiber pointed outthat the Assembly’s wish was that this bereferred to NMAs, was there a need for aworking group? Dr. Nathanson said that thiswas an important area, it overlappedHelsinki. She wondered whether thereshould be a self – standing group or that thisbe included in the Helsinki group remit. Dr.Appleyard, a Past President, who had madethe original proposition agreed that this wasimportant -a feeling which was reflected atthe Associates’ meeting. Helsinki was an“umbrella” declaration. The concerns aboutchildren were difficult to incorporate inHelsinki. The proposal was specificallygeared to the needs of children it would notinterfere with Helsinki. He would welcomethis going to NMAs for their comments and

178th WMA Council Meeting178th Council took place in the Marriott Hotel, Copenhagen on 6th October 2007

also for them to take this forward”. Dr.Bagenholm, Chair of Ethics, thought thatthis should be a separate statement,although it might eventually be part ofHelsinki. She supported its referral toNMAs for their comments.

The Council agreed that the proposed state-ment should be circulated to NMAs fortheir views and that the Helsinki workinggroup should co-ordinate the comments ofNMAs for the next Council meeting.Amongst the views expressed thereappeared to be a consensus that the state-ment should be a separate one but should belinked to the Helsinki Declaration.

Dr. Williams (Ethics consultant) said thatthe issue had not been dealt with adequate-ly in Helsinki up to the present. Now therewas a new interest in research ethics.Helsinki set out the principles but WMAdid not want to go any further than that. Itwas a question of why stop here with chil-dren? Suggestions had been receivedwhich included vulnerable populations,concerns about women etc – would we notbe asked to include the aged and deprivedpopulations? Dr. Hill expressed his per-sonal view that the issues relating to chil-dren were really different. Dr. Kloiberpointed out that the request before Councilwas whether to include something, excludeit or include other areas. The WorkingGroup could come back with a consideredview, taking into account the views ofNMAs.

Mr Tholl pointed out that the CanadianMedical Association already had a state-ment. The issue could go into Helsinki or,as in Canada, be a separate document. Itshould be left to the working group to comeforward with a suggestion.

Dr. Bagenholm felt that it might be better tohave separate working groups rather than

making Helsinki larger while Dr. Vilmarconsidered that we should concentrate onchildren first. We “lack knowledge aboutresearch in children. It might in the endhave to be taken up in the general review”.

In response to a call by Dr. Hill, expressionsof interest in working on this were made byIsrael,Brazil, Canada, South Africa and theUK.

Under Any Other Business, Dr. Hakerwal(Aust) raised the issue of corporate gover-nance. He asked who were directors –which countries? Dr. Hill said that WMAwas a USA state registered organisation andthat Council members are directors.

Dr. Plested (AMA) referred to the newadvocacy adviser’s contract needed for thenew Advocacy position, which would haveto be in France. He pointed out that if theperson was hired in another country thismight be illegal in France. He wonderedwhether it would be possible for a thirdmember association to do the hiring or if hecould be made a 90 day adviser, as we haveto use French rules. Dr. Davies queriedwhether he could be hired in Geneva, or anNMA could second someone.

Dr. Kloiber indicated that similar problemswould arise in Geneva as in France and thathe had sought legal advice on how to dealwith the employment in the most efficientand legal manor

Finally the Council considered how theWMA in its activities could be more inclu-sive and how the Associate members couldparticipate in a more productive way..TheChair said that he would look into all issuesconcerning the Associates, and refered tothe valuable Open Session of the Assemblywhich we had experienced earlier. In theabsence of any other business the meetingwas closed.

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Inter-professional training seminar on infection control in South AfricaHealth care workers safety in the context of drug resistant TB in low and middle-income countries

The World Medical Association (WMA)initiated together with the InternationalCouncil of Nurses (ICN), the InternationalHospital Federation (IHF) and theInternational Federation of Red Cross andRed Crescent Societies (IFRC)/SouthAfrican Red Cross Society, members of theLilly MDR-TB Partnership, a workshop inCape Town, South Africa, on health careworker safety and infection control, in thecontext of drug-resistant TB in low andmiddle income countries. The 2-day work-shop,12-13.November 2007, brought

together South African community supportworkers, hospital managers, nurses andphysicians working in the context of drug-resistant TB to jointly examine and addressthese issues. This common seminar for allfour health care professions was the firstone held in South Africa.Given the already critical shortage of healthproviders and the generally weak health sys-tems in the regions most affected by XDR-TB and MDR-TB, particularly in southernAfrica, anxiety about safety in the healthcare environment runs high and can dis-

suade health providers from acceptingassignments in these settings. The workshopprogramme, therefore addressed administra-tive, environmental and personal respiratoryprotection with the objective of identifyinggood practices and challenges to the imple-mentation of joint recommendations forfacilities and health workers It drew up rec-ommendations for implementing guidelinesin their hospitals and suggested establishinga common working group with a plan ofaction to communicate the identified prac-tices and recommendations.

WHO publishes new standard for documenting the health of children and youth

GENEVA/VENICE – WHO published thefirst internationally agreed upon classifica-tion code for assessing the health of chil-dren and youth in the context of their stagesof development and the environments inwhich they live.

The International Classification ofFunctioning, Disability and Health forChildren and Youth (ICF–CY) confirmsthe importance of precise descriptions ofchildren’s health status through a methodol-ogy that has long been standard for adults.Viewing children and youth within the con-text of their environment and developmentcontinuum, the ICF–CY applies classifica-tion codes to hundreds of bodily functionsand structures, activities and participation,and various environmental factors thatrestrict or allow young people to function inan array of every day activities.

The rapid growth and changes that occur infirst two decades of life were not sufficient-ly captured in the International

Classification of Functioning, Disabilityand Health (ICF), the precursor to theICF–CY. The launch of the ICF–CYaddresses this important developmentalperiod with greater detail. Its new standard-ized coding system will assist clinicians,educators, researchers, administrators, poli-cy makers and parents to document andmeasure the important growth, health anddevelopment characteristics of children andyouth.

Children who are chronically hungry,thirsty or insecure, for example, are oftennot healthy and have trouble learning anddeveloping normally. This classificationprovides a way to capture the impacts of thephysical and social environment so thatthese can be addressed through social poli-cy, health care and education systems toimprove children’s well-being.

“The ICF-CY will help us get past simplediagnostic labels. It will ground the pictureof children and youth functioning and dis-

ability on a continuum within the context oftheir everyday life and activities. In thisway it enables the accurate and constructivedescription of children’s health and identi-fies the areas where care, assistance andpolicy change are most needed,“ said RosMadden, Australian Commission on Safetyand Quality in Health Care, and, Chair ofthe Functioning and Disability ReferenceGroup of the WHO Family of InternationalClassifications (WHO-FIC) Network.

The ICF–CY has important implicationsglobally for research, standard setting andmobilizing resources. “For the first time, wenow have a tool that enables us to track andcompare the health of children and youthbetween countries and over time,“ saidNenad Kostanjsek of WHO’s Measurementand Health Information team. “TheICF–CY will allow countries and the inter-national community to take informed actionto improve children’s health, education andrights, by treating their health as a functionof the environment that adults provide.“

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The classification also covers developmen-tal delay. Children who achieve certainmilestones later than their peers may be atincreased risk of disability. Using this clas-sification, health practitioners, parents andteachers can describe these delays preciselyin order to plan for health and educationalneeds and frame policy debates. The chil-dren and youth version of the InternationalClassification of Functioning, Disability

and Health (ICF-CY) was launched inVenice, with international praise:

“The publication of the ICF-CY by theWHO provides, for the first time, a standardlanguage to unify health, education andsocial services for children,“ said Dr.Margaret Giannini, Director of the Office ofDisability, U.S. Department of Health andHuman Services.

For further information, please contact:

Lina ReindersCommunications OfficerWHO, GenevaTel.: +41 22 791 1828Fax: +41 22 791 1967E-mail: [email protected]

First List of Essential Medicines for Children released – WHO increases efforts to ensure appropriate medicines for children

WHO launched a new research and devel-opment campaign entitled “MakeMedicinces Child Size”, launched inLondon intensifies efforts to ensure thatchildren have better access to medicineswhich are appropriate for them.

The campaign also coincided with therelease by WHO of the first InternationalList of Essential Medicines for Children.The List contains 206 medicines deemedsafe for children and addresses priority con-

ditions. More than half of the medicinesprescribed for children in industrialisedcountries are medicines prescribed anddosed for adults and are not authorised forchildren. Lower access to medicines indeveloping countries adds to the problemsthere.

Dr. Hans Hogerzeil, Director of MedicinesPolicy and Standards at WHO emphasizedthis saying “A lot more needs to be done.There are priority medicines that have not

been adapted for childrens’ use or are notavailable when needed”.

WHO will also work with governments topromote changes in their legal and regula-tion requirements for childrens’ medi-cines.

Information contact:WHO Geneva:Daniela Bagozzie-mail: [email protected]

Projected supply of pandemic influenza vaccine sharply increases

23 OCTOBER 2007 | GENEVA – Recentscientific advances and increased vaccinemanufacturing capacity have promptedexperts to increase their projections of howmany pandemic influenza vaccine coursescan be made available in the coming years.

Last spring, the World Health Organization(WHO) and vaccine manufacturers said thatabout 100 million courses of pandemicinfluenza vaccine based on the H5N1 avianinfluenza strain could be produced immedi-ately with standard technology. Expertsnow anticipate that global productioncapacity will rise to 4.5 billion pandemicimmunization courses per year in 2010.

“With influenza vaccine production capaci-ty on the rise, we are beginning to be in amuch better position vis-à-vis the threat ofan influenza pandemic,“ Dr Marie-PauleKieny, Director of the Initiative for VaccineResearch at WHO, said today. „However,although this is significant progress, it isstill far from the 6.7 billion immunizationcourses that would be needed in a six monthperiod to protect the whole world.““Accelerated preparedness activities mustcontinue, backed by political impetus andfinancial support, to further bridge the stillsubstantial gap between supply anddemand,“ she said.

This year, manufacturers have been able tostep up production capacity of trivalent(three viral strains) seasonal influenza vac-cines to an estimated 565 million doses,from 350 million doses produced in 2006,according to the International Federation ofPharmaceutical Manufacturers &Associations. According to experts workingin this field, the yearly production capacityfor seasonal influenza vaccine is expectedto rise to 1 billion doses in 2010, providedcorresponding demand exists.

This would help manufacturers to be able todeliver around 4.5 billion pandemicinfluenza vaccine courses because a pan-

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demic vaccine would need about eight timesless antigen, the substance that stimulatesan immune response. Vaccine productioncapacity is linked to the amount of antigenthat has to be used to make each dose of thevaccine. Scientists have recently discoveredthey can reduce the amount of antigen usedto produce pandemic influenza vaccines byusing water-in-oil substances that enhancethe immune response.

The progress was reported at the first meetingof a WHO Advisory Group on pandemicinfluenza vaccine production and supply. TheGlobal Action Plan Advisory Group, an inde-pendent, international committee of 10 mem-bers, met at WHO headquarters one year aftereight new strategies to increase pandemicinfluenza vaccine were identified and pub-

lished in the WHO Global pandemic influen-za action plan to increase vaccine supply.

At the Advisory Group meeting, otherprogress on the Global Action Plan was dis-cussed. WHO reported it is setting up atraining hub that would serve as a source oftechnology transfer to developing countries.

The Advisory Group also discussed a newbusiness plan which assessed options forfurther increasing vaccine productioncapacity and reviewed priority next steps.The three most valuable options includecontinuing to promote seasonal influenzavaccine programmes, supporting the indus-try to sustain production capacity beyondseasonal demand and enabling some vac-cine production facilities to change, at theonset of a pandemic, from producing inacti-

vated vaccines to live attenuated vaccines.Due to the higher yields obtained with liveattenuated influenza vaccine technology,facility conversion could, by 2012, bridgethe expected supply-demand gap and pro-duce enough vaccine to protect the globalpopulation within six months of the declara-tion of a pandemic.

For further information, please contact:

Hayatee HasanDepartment of Immunization, Vaccines andBiologicalsWHO, GenevaTel.: +41 22 791 2103Mobile: +41 79 351 [email protected]

Protecting health from climate change – World Health Day 2008

WHO has announced that the topic forWorld Health Day 2008 will be “ProtectingHealth from climate change”. Sixty yearsago WHO was founded as part of the inter-national commitment to build global secu-rity and peace In the same spirit of univer-sal solidarity, WHO is seeking to unite thenations of the world in combating the threatto public health safety from climatechange.

In parallel with the increasing internationalemphasis on the need to place the reductionof environmental climate change high onthe international agenda to maintain sus-tainable development, the need to alsoaddress the environmental effects on public

health is essential. Dr. Chan, DirectorGeneral of WHO comments “Health profes-sionals are on the front line in dealing withthe impacts of climate change. The mostvulnerable populations are those who live incountries where the health sector alreadystruggles to prevent, detect, control andtreat diseases and health conditions includ-ing malaria, malnutrition and diarrhoea.Climate change will highlight and exacer-bate these weaknesses by bringing newpressures on public health, wit h greater fre-quency.”

She added “We need to put public health atthe heart of the climate change agenda. Thisincludes mobilising governments and stake-

holders to collaborate on strengthening sur-veillance and control of infectious diseases,safer use of diminishing water supplies, andhealth action in emergencies”.

On World Health Day, 7th April 2008, mark-ing the Sixtieth anniversary of the WorldHealth Organisation, communities andorganisations around the world will hostactivities to create greater awareness andpublic understanding of the health conse-quences of climate change and the impactand interdependency of health with othermeasures taken to reduce and control theeffects of climate change in policy deci-sions and policies taken at national andinternational level.

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New Internet course on multidrug-resistant tuberculosis MDR-TB Multi Drug Resistant Tuberculosis is difficult to treat and knowledge about it is scattered around the world. Thanks to WHO thereis not only a strategy to treat tuberculosis the “DOT Strategy” but now there are also WHO guidelines on how to prevent and treatMDR-TB using the existing evidence in the world.

Guidelines however are theoretical knowledge that doesn’t easily transfer into practice in the real world. The WMA therefore volun-teered, together with its member organizations, the South African Medical Association, the Norwegian Medical Association, to pro-duce a learning programme for the MDR-TB Guidelines and offer it electronically though the Internet.

This course is a free self-learning tool allowing physicians in all parts of the world to learn and test their knowledge about MDR-TBusing the Internet. The Foundation for Professional Development of South Africa wrote the learning programme, which subsequent-ly has been reviewed by an international advisory committee and then transformed into an Internet-based course by the NorwegianMedical Association. A first testing phase with an evaluation was implemented in South Africa. The CME accredited MDR-TB onlinetraining course is now accessible from the WMA web page www.wma.net.

The course is free of charge and is available in English. Soon it will be translated into French, Spanish, Chinese and Russian.

Review

Human Rights and Prisons – a training programme on human rights for prison officialsProfessional Training Series No. 11, UN Publications, UN New York and Geneva 2005, ISBN 92-1-15416-3

Prisons are places where a higher propor-tion of people with significant physical andmental health problems are incarcerated,but also where the health care they receiveis likely to be substandard. Pressures onmedical staff, lack of funding, uncertaintyabout the ethical duties of doctors and thepotentially restrictive attitude of prison gov-ernors can all reduce access to good qualityand impartial healthcare.

Although the rights of prisoners, and theduties of those who supervise them are wellestablished, and comprehensively set out ina variety of declarations, treaties, covenantsand conventions, these are often poorlyunderstood by prison officials. Either theyare not seen as applicable to a particularinstitution, or inflexible procedures that

undermine human rights are not reviewedor changed.

It is therefore welcome that the EuropeanRegional Office of WHO has published amodular course on human rights training forpeople who have a responsibility fordetainee care. While its focus is prisondetention, it is equally applicable to otherforms of custody, such as police stationsand detention centres. It has direct rele-vance to doctors, but unfortunately does notsuggest that prison medical staff, who areoften as much in need of human rights andethics teaching, should be exposed to theprinciples that the document promotes.

Designed in modular form, and backed by amanual, listing standards, sources and sys-tems, a compilation of relevant humanrights instruments, and a condensed pocketguide, the training is designed to be deliv-ered over a period of five days. While aspir-ing to a variety of aims, a key purpose is toequip students with a broad knowledge ofhuman rights practice in relation to prisons,

and to relate these to their day-to-day expe-rience. An important and measurable out-come must be to change attitudes, so thatprejudice is replaced with an understandingof the need to protect the dignity of the vul-nerable.

Much of the success of the courses that arebased on these documents will depend onthe quality of those delivering the training.It is not suggested that these should includedoctors, and this is a gap that should befilled, since the relationship between doc-tor, prisoner and institution is fertile groundfor highlighting human rights and ethicaldilemmas that are real and practical.Through their relevance and familiaritythey can provide a good basis for the groupdiscussions that form a major part of thetraining.

The section on health is adequate, but notfully complete. There is little reference toassessment of self-harm risk – a majorcause of death in custody being suicide -and the monitoring of prisoners with psy-

*

* This is the first of two reviews on PrisonHealth. The second will review a recentpublication by the WHO European Officeon Health in Prisons and will appear inthe next issue WMJ 54 (1).

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chiatric problems. In any prison in theworld, there will be a relatively high pro-portion of inmates with alcohol and/or drugdependence, and a range of psychiatric dis-orders. Prison staff can be very influentialin helping patients to develop a willingnessto address their addiction, and more couldbe taught on the often simple and accessibleservices that prisons can provide. Alcoholand drug misuse are common causes ofrecurrent, often petty crime, and moreunderstanding about the nature of the dis-ease of addiction, and the capacity for theaddict to change, would be welcome. Thesections on drug misuse are written in disci-plinary, rather than therapeutic terms.

Backed by high-level declarations, andwritten in the language of rights, the start-ing point for the training module on healthis that prisoners, like other members of theirsociety, deserve access to the highest avail-able standard of health. Given that a prisonpopulation is disproportionately unhealthy,and that resources, particularly in secondarycare are limited, the realisation of that rightis often a distant aspiration. Prison staffwho carry an attitude that equates a loss ofliberty with a removal of basic rights, addfuel to the fires of resentment and stigmati-sation, thereby increasing a sense of help-lessness in those for whom they are respon-sible. An institution run on principles thatacknowledges rights is more likely to beone in which staff have a higher level ofwork satisfaction and esteem. Training inhuman rights may not turn them into advo-cates for change, but may help them tooperate in a way that promotes decency anddignity.

For doctors who access the training manual,there is much to challenge attitudes that inmy experience have developed more as aresult of a lack of knowledge than throughoutright discrimination. Prison medicalstaff frequently assume that the "dual rela-tionship" that exists in their specialty (andin others), implies a reduction in their fun-damental medical ethical duties. While theneed to consider the interests of the prisonis ever-present in the doctor's mind, itshould only rarely lead to breaches of con-sent and confidentiality. A relationship oftrust between the detained patient and thedoctor has therapeutic value, allowing the

doctor more opportunities to provide care,along with reassurance that confidentialitywill usually be kept.

Welcome elements in the training packageare the need for prisoners to undergo a med-ical examination as soon as possible afterarrival, respect for cultural beliefs, and therisks that HIV/AIDS sufferers will be iso-lated through ignorance and fear of infec-tion. However, more could be said about theneed to be alert to signs of abuse and inap-propriate restraint measures, and on theduty of medical staff to report abuse.Doctors have the benefit of independenceand an ethical duty to report abuse, so arewell-placed to speak out when theyencounter abusive behaviour. They alsohave an obligation to record, not just thenature of the abuse and the injuries sus-tained, but also the action they take as aresult.

The training manual will not help doctorslooking for more certainty on the issue ofgross abuse. Definitions of torture anddegrading treatment are not sufficientlyrobust or clear, leaving the student in somedoubt as to where the involvement of a doc-

tor begins and ends. While there is a clearcondemnation of physician involvement intorture, current examples such as force-feeding and the provision of advice oninterrogation should be illustrated. At a timewhen the ethical duties of doctors have beenredefined in the interests of national securi-ty, these contemporary situations deservemore reflection.

An essential part of training is evaluating itseffect, and the course recognises that thisshould be built in over the long-term, usingattitudes and system change as key markersof progress. As the manual states, there is alot more to the teaching of human rightsthan a “lecture and a wave”. Participantsneed to be challenged, and their attitudesand behaviour changed, if our prisons are tobecome more humane places.

Michael Wilks

Michael Wilks is a forensic physician, andChairman of the Rehabilitation of AddictedPrisoners Trust in the UK. He is Presidentof the Standing Committee of EuropeanDoctors (CPME) for 2008/9.

Letter

CorrespondenceHon. EditorWorld Medical Journal

Sir,

The September 7th, 2007 issue of theMedical Journal of the World MedicalAssociation is carrying a story about “pre-sumed Consent” for the removal of organsfrom dead for transplantation.

The U.K. Chief Medical Officer, Sir LiamDonaldson is quoted as saying that the prac-tice of “presumed Consent” would increasethe number of organs available for trans-plantation to the betterment of the health ofthe recipients.

I am troubled by the apparent violation ofthe first tenet of the Nuremberg Code ofMedicas Ethics which clearly states that

“Freely Given Informed Consent” is thesine quo non of all activities by physiciansin dealing with patients.

I would suggest that this practice be stoppedimmediately.

I would also suggest that physicians all overthe world should sign the donor card andcarry it in their wallets and stipulate to theirloved ones that they want their organs har-vested for transplantation.

Unless we, physicians show by example theimportance of the donation of organs thereis little chance that there will ever beenough organs available to help the living.

Michael J. Franzblau MD, FAADClinical Professor of Dermatology (emeritus)University of California

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

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

CROATIA ECroatian Medical AssociationSubiceva 910000 ZagrebTel: (385-1) 46 93 300Fax: (385-1) 46 55 066E-mail: [email protected]: www.hlk.hr/default.asp

CZECH REPUBLIC ECzech Medical AssociationJ.E. PurkyneSokolská 31 - P.O. Box 88120 26 Prague 2Tel: (420-2) 242 66 201-4 Fax: (420-2) 242 66 212 / 96 18 18 69E-mail: [email protected] Website: www.cls.cz

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

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

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

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

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

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

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

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

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

FINLAND EFinnish Medical AssociationP.O. Box 4900501 HelsinkiTel: (358-9) 3930 91/Fax-794E-mail: [email protected]: www.medassoc.fi

FRANCE FAssociation Médicale Française180, Blvd. Haussmann 75389 Paris Cedex 08Tel/Fax: (33) 1 45 25 22 68

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

GERMANY EBundesärztekammer (German Medical Association)Herbert-Lewin-Platz 110623 BerlinTel: (49-30) 400-456 369/Fax: -387E-mail: [email protected]: www.bundesaerztekammer.de

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

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

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

HUNGARY EAssociation of Hungarian MedicalSocieties (MOTESZ)Nádor u. 36 – PO.Box 1451443 BudapestTel: (36-1) 312 3807 – 311 6687Fax: (36-1) 383-7918E-mail: [email protected]: www.motesz.hu

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

INDIA EIndian Medical AssociationIndraprastha MargNew Delhi 110 002Tel: (91-11) 23370009/23378819/23378680Fax: (91-11) 23379178/23379470E-mail: [email protected]

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

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

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

JAPAN EJapan Medical Association2-28-16 Honkomagome, Bunkyo-ku

Tokyo 113-8621Tel: (81-3) 3946 2121/3942 6489Fax: (81-3) 3946 6295E-mail: [email protected]

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

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

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

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

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

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

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

MACEDONIA EMacedonian Medical AssociationDame Gruev St. 3P.O. Box 17491000 SkopjeTel/Fax: (389-91) 232577E-mail: [email protected]

MALAYSIA EMalaysian Medical Association4th Floor, MMA House124 Jalan Pahang53000 Kuala LumpurTel: (60-3) 40413740/40411375


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Fax: (60-3) 40418187/40434444E-mail: [email protected]: http://www.mma.org.my

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

MEXICO SColegio Medico de MexicoFenacomeHidalgo 1828 Pte. D-107Colonia Deportivo Obispado Monterrey, Nuevo LéonTel/Fax: (52-8) 348-41-55E-mail: [email protected]: www.cmm-fenacome.org

NAMIBIA EMedical Association of Namibia403 Maerua Park – POB 3369WindhoekTel: (264) 61 22 44 55/Fax: -48 26E-mail: [email protected]

NEPAL ENepal Medical AssociationSiddhi Sadan, Post Box 189Exhibition RoadKatmanduTel: (977 1) 4225860, 231825Fax: (977 1) 4225300E-mail: [email protected]

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

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

NIGERIA ENigerian Medical Association74, Adeniyi Jones Avenue IkejaP.O. Box 1108, MarinaLagosTel: (234-1) 480 1569, Fax: (234-1) 492 4179E-mail: [email protected]: www.nigeriannma.org

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

PANAMA SAsociación Médica Nacionalde la República de PanamáApartado Postal 2020

Panamá 1Tel: (507) 263 7622 /263-7758Fax: (507) 223 1462Fax modem: (507) 223-5555E-mail: [email protected]

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

PHILIPPINES EPhilippine Medical AssociationPMA Bldg, North AvenueQuezon CityTel: (63-2) 929-63 66/Fax: -6951E-mail: [email protected]: www.pma.com.ph

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

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

ROMANIA FRomanian Medical AssociationStr. Ionel Perlea, nr 10Sect. 1, BucarestTel: (40-1) 460 08 30Fax: (40-1) 312 13 57E-mail: [email protected]: ong.ro/ong/amr

RUSSIA ERussian Medical SocietyUdaltsova Street 85119607 Moscow Tel: (7-095)932-83-02E-mail: [email protected]: www.russmed.ru

SAMOA ESamoa Medical AssociationTupua Tamasese Meaole HospitalPrivate Bag – National Health ServicesApiaTel: (685) 778 5858E-mail: [email protected]

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

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

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

SOMALIA ESomali Medical Association14 Wardigley Road – POB 199MogadishuTel: (252-1) 595 599Fax: (252-1) 225 858E-mail: [email protected]

SOUTH AFRICA EThe South African Medical Associa-tionP.O. Box 74789, Lynnwood Rydge0040 PretoriaTel: (27-12) 481 2036/2063Fax: (27-12) 481 2100/2058E-mail: [email protected]: www.samedical.org

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

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

SWITZERLAND FFédération des Médecins SuissesElfenstrasse 18 – C.P. 1703000 Berne 15Tel: (41-31) 359 –1111/Fax: -1112E-mail: [email protected]: www.fmh.ch

TAIWAN ETaiwan Medical Association9F No 29 Sec1An-Ho RoadTaipeiTel: (886-2) 2752-7286Fax: (886-2) 2771-8392E-mail: [email protected]: www.med.assn.org.tw

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

TUNISIA FConseil National de l’Ordredes Médecins de Tunisie16, rue de Touraine1002 Tunis Tel: (216-71) 792 736/799 041Fax: (216-71) 788 729E-mail: [email protected]

TURKEY ETurkish Medical AssociationGMK Bulvary

Sehit Danis Tunaligil Sok. N° 2 Kat 4Maltepe 06570AnkaraTel: (90-312) 231 –3179/Fax: -1952E-mail: [email protected]: www.ttb.org.tr

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

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

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

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

VATICAN STATE FAssociazione Medica del VaticanoStato della Città del Vaticano 00120 Città del Vaticano Tel: (39-06) 69879300Fax: (39-06) 69883328E-mail: [email protected]

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

VIETNAM EVietnam Medical Association(VGAMP)68A Ba Trieu-StreetHoau Kiem DistrictHanoiTel/Fax: (84) 4 943 9323

ZIMBABWE EZimbabwe Medical AssociationP.O. Box 3671Harare Tel: (263-4) 791553Fax: (263-4) 791561E-mail: [email protected]

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