World Medical Journal Vol. No. 2, June 2006 52 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 173 rd WMA Council Meeting Contents Declaration of Geneva 29 Editorial Human health resources 30 Trust in Physicians 31 Dr. LEE Jong-wook 33 Medical Ethics and Human Rights The World Medical Association Declaration of Tokyo 34 The World Medical Association regulations in times of armed conflict 35 WMA Declaration of Malta – A background paper on the ethical management of hunger strikes 36 From the Secretary General’s Desk “What do we expect from the next WHO Director General?” 43 WMA 173 rd WMA Council Meeting held in Divonne 44 Secretary General’s Report to the 173 rd WMA Council Session 49 WHO Health workforce crisis is having a deadly impact on many countries’ ability to fight disease and improve health 53 Global access to HIV therapy tripled in past two years, but significant challenges remain 54 Developing country access needed to existing and new medicines and vaccines 56
Transcript
WorldMMeeddiiccaall JJoouurrnnaall
Vol. No. 2, June 200652
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
“What do we expect from the next WHO Director General?” 43
WWMMAA
173rd WMA Council Meeting held in Divonne 44
Secretary General’s Report to the 173rd WMA Council Session 49
WWHHOO
Health workforce crisis is having a deadly impact on many countries’ ability to fight disease and improve health 53
Global access to HIV therapy tripled in past twoyears, but significant challenges remain 54
Developing country access needed to existing and new medicines and vaccines 56
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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 N. Arumagam Dr. Kgosi Letlape Dr. Y. D. Coble Malaysian Medical Association The South African Medical Association 102 Magnolia Street4th Floor MMA House P.O Box 74789 Lynnwood Ridge Neptune Beach, FL 32266124 Jalan Pahang 0040 Pretoria USA53000 Kuala Lumpur South AfricaMalaysia
Treasurer Chairman of Council Vice-Chairman of CouncilProf. Dr. Dr. h.c. J. D. Hoppe Dr. Y. Blachar Dr. K. IwasaBundesärztekammer Israel Medical Association Japan Medical AssociationHerbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome10623 Berlin 35 Jabotisky Street Bunkyo-kuGermany P.O. Box 3566 Tokyo 113-8621
Ramat-Gan 52136 JapanIsrael
Secretary GeneralDr. O. KloiberWorld Medical AssociationBP 63 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
Titlepage: Title page: Robert Koch Institute, Berlin, Germany. Photo courtesy of Robert Koch Institute. On top: RKI aerial view(Source: RKI / Ossenbrink). At the bottom: Foyer of the Robert Koch Institute (Source: RKI / Schnartendorff)
This was founded as the “Prussian Institute for Infections Diseases” of which Koch was the Director. His name was added to the title in 1912 and the Institute finally re-titled the “Robert Koch Institute” in 1942.
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OFFICIAL JOURNAL OFTHE WORLD MEDICAL
ASSOCIATION
Hon. Editor in ChiefDr. Alan J. Rowe
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DECLARATION OF GENEVA
Adopted by the 2nd General Assembly of the World Medical Association, Geneva,Switzerland, September 1948 and amended by the 22nd World Medical Assembly,
Sydney, Australia, August 1968 and the 35th World Medical Assembly, Venice,Italy, October 1983 and the 46th WMA General Assembly, Stockholm, Sweden,
September 1994 and editorially revised at the 170th Council Session, Divonne-les-Bains, France, May 2005 and the 173rd Council Session, Divonne-les-Bains,
France, May 2006
AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to consecrate my life to the service of humanity;
I WILL GIVE to my teachers the respect and gratitude that is their due;
I WILL PRACTISE my profession with conscience and dignity;
THE HEALTH OF MY PATIENT will be my first consideration;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession;
MY COLLEAGUES will be my sisters and brothers;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnicorigin, gender, nationality, political affiliation, race, sexual orientation, social
standing or any other factor to intervene between my duty and my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely and upon my honour.
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Editorial
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Editorial
Human health resources
Over the past two years we have drawn attention to the increasing problems facing not onlythe medical profession but also all the health professions. These have related both to thechanges and expectations of society globally and the remarkable increases in scientificknowledge and technological developments which have increased the potential and actualability to control and treat many diseases. At the same time the journal has reported theother side of the picture, the continuing existence of poverty and the inequity in access toeven the most basic, let alone the more sophisticated medical advances which result fromit. Over the past few years these issues have been placed on the international agenda andwe have witnessed increasing public acknowledgement of the need to reduce the gapbetween economically successful developed countries and developed or under developingcountries. This has been acknowledged by summits such as those of the G7 and individualgovernmental aid programmes, by generous non-governmental donors, and by worldwidefund raising movements directed towards specific major diseases or natural disasters suchas we have witnessed in the past few months. Nevertheless these international aid contri-butions still fall far short of the estimated need.
However attention is now being drawn to another major threat to healthcare, the relief ofsuffering and the reduction of morbidity and mortality from major diseases and this at atime when there is increasing concern and awareness of the risk of a new global pandem-ic. The WHO World Health Report 2006 launched in April 2006 is entitled “Workingtogether for Health”(1) and marks the beginning of the WHO year of “Human HealthResources“, to be followed by a decade of action to deal with the global shortage of healthworkers. This shortage applies to most groups of personnel working in the health sector andcalls for a radical reappraisal of the activities of the recognised main stream health profes-sions, doctors, nurses and midwives, pharmacists and dentists etc and for assessment of thepotential for limited training for carrying out specific tasks for some professionals and oth-ers, as opposed to the wider basic and specialist knowledge and skills training consideredessential for certain professionals to practice in health care professions.
While the report highlights the compelling and urgent need in some of the world’s poorestcountries, where the WHO estimates that some 57 countries (36 in Africa alone) have adeficit of 2.4 million doctors, nurses and midwives, reflecting the problems of AIDS, skillsdrain, rural/urban drain etc. in addition to the factors mentioned above, developed countriesare also experiencing or anticipating a shortage in these professions. The latter is exempli-fied by a suggestion made in a recent meeting that the anticipated needs of the USA forphysicians in 2020, will be for 200,000 new doctors (half the current estimated global num-ber of physicians available in the year 2020).
In another part of the WHO report, emphasis is also placed on the need for strong leader-ship - an issue which is being addressed by the World Health Professions Alliance of whichthe World Medical Association is a member. The late Director General Dr. LEE Jongwook’s opening overview of the Report referred to “Acquiring critical capacities bystrengthening core institutions for sound workforce development. Leadership and manage-ment development in health and other related sectors such as education and finance isessential for strategic planning and implementation of workforce policies. Standard setting,accreditation and licensing must be effectively established to improve the work of workerunions, educational institutions, professional associations and civil society”.
Later the report calls, amongst other things, for increased licensing and accreditation andexamination of cost and labour efficiency of health professionals, pointing out the evidence
of the better rates of immunisation in thepopulation when using nurses rather thandoctors in countries where most of theimmunisations are normally given by nurs-es. In this context the report cites three“Cochrane” reviews (2) of the results ofsubstituting nurses for doctors in primarycare. These showed no difference in qualityof care and outcomes between appropriate-ly trained nurses and doctors and showedthe nurses giving more health care advice.While on the other hand nurses orderedmore tests and used more other servicesthan doctors, thus reducing cost saving. Inanother review of 85 randomised controlledtrials, 10 of which were considered to be ofhigh methodological quality), while it wasconcluded that audit and feedback canimprove professional practice. the effectswere variable, “small to moderate”. It con-cludes “results of the trials do not providesupport for mandatory use of audit and orunevaluated feedback”.
Commenting on self-regulation, whileacknowledging that this can be effectiveand that medical associations etc. can regu-late the behaviour of the profession andmaintain technical competence, the reportstates “Self-regulation by professional asso-ciations is not always effective“ and com-ments on the difference between the eastand west. In the latter, notably Europe andAmerica, “the majority of organisations areat least more than 110 years old, whereas inlow income countries 4 out of 10 are lessthan 25 years old.” Even more importantly,it comments on the strain on self regulationresulting substantially from employersincreasingly overriding it, Whilst acknowl-edging this to be the case where the state isthe traditional employer of health workers,it points out that increasingly the previous-ly self-employed autonomous health work-ers are now working in an employer-employee situation. “The employer,whether the state, a non-governmental non-profit making organisation, financial corpo-ration or international organisation tends tohave the most influence on professionalbehaviour, concluding that associations bythemselves can no longer claim to providecoherent governance, in the public interest,of the health workforce as a whole.” Thisacknowledges important concerns which
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have already been increasingly occupyingthe profession for some time past.However, while the report does not specif-ically recommend the abolition of self- reg-ulation, it urges the creation (where neces-sary) of the technical bodies for licensing,accreditation etc. and also suggests theinclusion of all stake holders in forumswhich would permit interaction between allorganisations affecting the behaviour ofhealth workers and the health institutions,well illustrated in a diagram showing inter-action between professional organisations,institutional regulators and civil societyorganisations. (3)
Nevertheless, the report quotations abovereinforce the urgent need for reflection, andif need be action by the medical professionand its medical associations, in particularthose with regulating powers. The reflec-tion must take into account not only theneed to adapt the functions for which thespecial training of physicians is requiredbut also the needs of the globalised societyin which we live.
The World Health Assembly this year, in itsdecision addressing the problems of short-age of human health resources and also thechallenges of international migration ofhealth personnel in six recommendations inits resolution (4), urged Member States toaffirm their commitment by:
„Giving consideration to establishingmechanisms to mitigate the adverse impacton developing countries of loss of healthpersonnel through migration includingmeans of receiving developed countriessupporting health systems, especially inhuman resources development, in the coun-tries of origin;
promoting training in accredited institu-tions of a full spectrum of quality profes-sionals and also community health work-ers, public health workers and profession-als;
promoting training partnerships betweenschools in industrialised developing coun-tries involving faculty and studentexchange:
Guest Editorial
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encouraging financial support by globalhealth partners donors etc. of health traininginstitutions in developing countries;
promoting planning teams in each countryfacing health-worker shortages drawing onstake holders including professional bodies,public and private sectors and non-govern-mental organisations to formulate compre-hensive strategy for the health workforce,including consideration of effective mecha-nisms for utilisation of trained volunteersusing innovative approaches to teaching indeveloped and developing countries withstate-of-the-art teaching materials and con-tinuing education through the innovativeuse for information and communicationstechnology.“
It is clear from this that the crisis in HumanHealth Resources is one which NationalMedical Associations will neglect at theirperil and need to address, not only in theirown national context but also in the interna-tional global context. The WMA has
addressed the issue of physician migrationand also referred to countries’ bilateralagreement to effect meaningful co-opera-tion in health care delivery in its statementof Helsinki 2003 “Ethical Guidelines for theInternational Recruitment of Physicians.”However, the issues raised in the WHOReport, the decade of action and the globalalliance set up to address these issues (6),call for serious consideration and leadershipif the profession is to influence policy ini-tiatives proposed by governments to dealwith this serious threat to future health care.
Alan Rowe
(1) The World Health Report 2006 “Workingtogether for Health”, WHO Geneva
(2) ibid p. 138(3) Ibid p. 214(4) WHO,WHA59.23(5) WMA statement accessible on
www.wma.net(6) Global Health Workforce Alliance
Trust in Physicians
Abundance of Medical Information – Shortage of Medical Orientationby Peter Atteslander, Professor emeritus, University of Augsburg, Director, INAST Research Univ., Inst. Sociology, University of Neuchatel
Would you trust a machine? Probably you do not. You might rely on its functioning. Trusthowever has a quite clear intrinsic meaning: trust is a psychic and social process based onfirm beliefs. You definitely will not trust a medical system as such but specific personsplaying an important role in its institutions. It is above all the medical doctor on the dailyfront interacting with the patient before him that you trust, sometimes you have to trust. Inmany existential situations the patient lays his life in doctors’ hands. He is confident aboutthe physician’s professional abilities, judgements and increasingly about medical orienta-tion which only the physician is a master of. Many of us are lost before the growing amountof all kinds of public health advice, leaving us over-informed but under-oriented.
Can one measure trust in physicians? Indeed: since many decades, numerous surveys showthat medical doctors are constantly granted one of the highest prestige statuses amongst allprofessions. There is no marked decline of trust in physicians, their general acceptance inspite of the fact that medicine is increasingly experiencing all kinds of pressure, economic,bureaucratic and stressful through the increasing velocity of medical technology develop-ment, inevitably leading to more specialisation. General anxieties are felt and unspecifiedcritique finds its public. Mass media seem to be more interested in either sensationallyreporting cases of malfunctions in our health systems, creating wrong hopes or propagating
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new therapies not yet applicable. They failto adequate orientate the citizen.
Nevertheless, a traditional image of doctor’srole still seems to persist today. This in spiteof magnificent medical technologies, neworganization and miracles of medical prac-tice. It is human empathy with the patientthat the lone horse- and buggy doctor livedwith centuries ago. Compared to our days,he had rather little to offer but himself anda handful of medicaments and instrumentsto use.What has changed since then? Do wenot still talk of the physician himself as ‘themost efficient medicament’, and of his prac-tice as being an art? Until today, the interac-tion between patient and doctor remains themost important source of trust.The morecomplex health structures become, the moreimportant it is to safeguard the physician’srole to offer medical and mental orientationto patients. Even those expert in using theinternet are essentially in danger of gettinglost in a labyrinth of information they areunable to interpret. Since trust is a socialand mental process, it can neither beordered, regulated or even administrated.Without orientation, patients will complyless with medical prescriptions. Comp-liance is amongst many other aspects pre-dominantly the result of trust in the pre-scriptions and advice of the physician.
There are however many factors that endan-ger this (fortunately still persisting) com-mon trust. The World Health Organisation(WHO) stated long ago that governmentsare responsible for the health of their citi-zens and can only discharge that responsi-bility by taking adequate measures in thehealth care and social spheres. To ensurefair distribution of medical services most socalled OECD-states, representing modernrather wealthy societies, have introducedso-called cost-moderating laws. This resultsin wide spread fears that increased stateintervention will further undermine the nec-essary state-free area of doctor- patient rela-tions. Experience shows that more adminis-tration does not in itself lead to greater con-trol over rising costs. States cannot be maderesponsible for individual health conditions.On the other hand it can be expected thatthey safeguard general policies which per-mit the best possible individual medicalactions by all concerned. Adequate health
care and social measures, however, alwaysimply greater control and planning. It is notadvisable to implement too strict bureau-cratic norms at the cost of impeding doctor-patient relations. Individual behaviour is alltoo often influenced by state action, but itcannot be planned in detail, certainly notwhere health is involved.
The health care systems are highly com-plex. Today we do not know exactly howthey function. At best we still find areaswhere it does not function. In future it willbe impossible to satisfy every conceivableneed. The total sum of individual needs asexpressed, does not necessarily representthe need of a society at large on which stateinterventions (based on data from socialepidemiological surveys, that rarely meetmethodological expertise), are decided.General expectations of the kind aroused bytoo comprehensive WHO-postulates whichinterpret health as a state of “completephysical, mental and social well-being andnot merely the absence of illness”, cannotbe transposed into legally effective entitle-ments for the individual. The inadequacy ofa health care system which is widely per-ceived today, does not in itself point to thegoals which should be set.
There is an increasing pressure not only toeconomise in healthcare systems, and alsoto harmonize procedures independent ofcultural differences, leading to differentsocial behaviour. This provokes ever morenew regulation of health reporting.Warnings by many scientists have evidentlynot reached politicians and bureaucrats.Large sums have been wrongly investedtrying to measure qualitative health matterswith quantitative instruments. Of coursehealth care has material and economicaspects, but all other predominantly qualita-tive processes cannot be measured by pure-ly quantitative methods. Healing.requiresmore than a functioning human body,andthe physician more than a technician. It wasan illusion that the highly dynamic struc-tures of the health care systems could beregulated, finally controlled by simplematerial indices. It is an essential error tobelieve that the role of physicians can bestandardized. There is no such thing as astandard patient, just as there is no statisti-cally determined average health situation.
Beware of statistical artefacts when dealingwith sick human beings.
Complex systems tend to be self relevantand hard to grasp. They are even harder togovern. In health systems responsibilitiesare often nebulous and poorly defined.Combined with economic restrictions andbureaucratic standardisation, more and morenon medically trained agents tend to restrictphysicians’ traditional as well as prospectiverole. Their indispensable moral and ethicalidentity is thereby severely menaced.
The progress of modern medicine high-lights in addition another problem, whichmay be described as the concept of pressurefor ‘positivisation’:, especially in medicaltechnology, surgery and pharmacology,where the quick and obvious successes andimmediate effects are so apparent, experi-enced as “relief” and verifiable. Such pres-sure for their broad and instant applicationarises that it, in turn, increases demandleading to new problems of distribution,both of human resources and costs. Thishappens irrespective of the dangers of inter-actions with other medicaments, often onlyrecognised only later.
There is growing hedonisme regardinghealth: Eat the pills today, pay tomorrow,often with illness !
The progress in modern medicine is inmany senses of the word, fantastic. One istempted to say that as in other fields of tech-nology we are offered more answers thanwe have questions for. In medicine thismeans that there are more investigationalleys and more therapies at hand than wecan pay for. Ethical problems are not antic-ipated ; adequate and fair distribution ofmedical services remains largely unsolved,rationing wide spread. Even rationalization,as the step before restricted distribution ofmedical services is declared, should rely onsystematic, optimized action. In practice,rationing often fails to meet these criteria.The discussion, as to when it is necessary toomit certain therapy which has questionableperspectives, has only just begun. We areonly starting to comprehend that the effectsof modern medicine may also have impor-tant societal implications.
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Editorial
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Illness must no longer be understood solelyas the dysfunction of a biological organism.We have to learn and to understand it as atypical social attitude. This changes also theinteraction between physician and patient.This aspect has been largely disregarded bymedicine up to now since the manifest suc-cesses of modern medicine conceals thisweak point.
Illnesses which can be precisely defined inscientific terms and the disorders, for whichclear forms of therapy exist, are increasing.Nobody would deny this success. Their rel-ative importance measured against the gen-eral requirements placed on the medicalsystem, is however rapidly declining. Newand hard to define syndromes of illness arespreading. We see modern medicine asbeing caught in a dangerous trap betweenthe growing availability of technical andmedical expertise and the increasingly man-ifest and perceived lack of social health ori-entation.
Trust in physicians is in principal a qualita-tive property of highest importance. Thisholds true especially when we speak ofhealing processes. The question is pertinent,as to whether in future the precious asset ofa free and humane doctor-patient interac-tion can be safeguarded against the stronginfluence of growing economization,bureaucratization (above all) , in view of agrowing non steered quantitative regulationin the health system.
One of the leading medical social scientistswrote decades ago “Medicine as a socialinstitution has extremely broad functions.Not only does medicine deal with the pre-vention and treatment of pain, disease, dis-ability, and impairment, but it also providesan acceptable excuse for relief from ordinaryobligations and responsibilities, and may beused to justify behaviours and interventionsnot ordinarily tolerated by the social systemwithout significant sanctions. The definitionof illness may also be used as a mechanismof social control to contain deviance, toremove misfits from particular social roles,or to encourage continued social functioningand productive activity. Thus, the locus ofcontrol for medical decision making is a keyvariable in examining the implications ofmedical care for social life more generally”.
Physicians have rapidly to overcome themanifold effects of the further growing spe-cialization. More time will be demanded forinterdisciplinary actions. Managing rele-vant information from different sourcesapplicable in specific cases has yet to belearned. Most important, the uniquenessand intimacy in which human trust in thepatient-doctor relationship can only grow,has to be defended with all appropriatemeans. We follow Mechanic(I) in as far aswe now witness the increasing velocity ofbureaucratisation of medicine as having theeffect of diluting the personal responsibilityof physicians, making it more likely thatinterests other than those of the patient willprevail in the future.” By segmentingresponsibility for patient care, medicalbureaucracy relieves the physician of directcontinuing responsibility. If the patient can-not reach a physician at night or on week-ends, obtain responsive care, have inquiriesanswered or whatever, the problem is nolonger focused on the failure of an individ-ual physician, but on the failures of theorganization. It is far easier for patients tolocate and deal with individual failureswhere responsibility is clear, than to con-front a diffuse organizational structurewhere responsibility is often hazy and thebuck is easily passed. To the extent that thephysician knows that a patient is his or hercharge, the physician feels a certain respon-sibility to protect the patient’s interestsagainst organizational roadblocks andrequests that may not be fully appropriate.But when responsibility is less clear it is
easier to make decisions in the name ofother interests such as research, teaching,demonstration, or the “public welfare,”whatever that might be” (p. 415).
Trust, as we said before, is based on firmbelief. Belief in the the doctor-patient rela-tionship is often nurtured by hope, even if itis unrealistic and not to be granted. Themore pressures of all kinds exist in thishybris of health systems,. the more pressingis the question of what to do. My proposi-tion is that the physician has always to be inthe centre of information. We forsee thatdoctors will depend to a greater extent onother specialised experts and technical sys-tems, will have to be the centre of informa-tion , and will not be able to carry the per-sonal full responsibility for their patients.The physician may need assistance for theinterpretation of relevant data, but he aloneis in charge of the ultimate decisions. Thisentitles him to ask for all means and mea-sures to live up to his responsibility for thegood of his patient who trusts him. It is hightime that the physician’s role has to bewidely understood, honoured and enforced.
Address for correspondenceProfessor Peter AtteslanderBellevueweg 29CH 2562 PortSwitzerlandE-Mail: [email protected](I) David Mechanic, The Growth of Medical
Technology and Bureaucracy: Implications forMedical Care, in: Patients, Physicians, and Illness,E.Gartly Jaco, London, New York, 1979, p. 415)
Dr. LEE Jong-wookWe very much regret the sudden death of the Dr. LEE Jong-wook, Director General of the World Health Organisation, onthe eve of the World Health Assembly. His ambitious project3 by 5 to tackle HIV/AIDS thought by many to be unrealis-tic, nevertheless was a real attempt to unite agencies in acommon goal. His promotion of partnerships in dealing withAIDS, Tuberculosis and Malaria, the agreement on stockpil-ing Tamiflu and his efforts to stimulate countries to recognisethe real threat of pandemic influenza, were indications of hisdetermination to engage governments in the fight against thethreats posed by these diseases. Dr. LEE died on 22 May 2006. He was 61.
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Medical Ethics and Human Rights
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Preamble
It is the privilege of the physician to prac-tise medicine in the service of humanity, topreserve and restore bodily and mentalhealth without distinction as to persons, tocomfort and to ease the suffering of his orher patients. The utmost respect for humanlife is to be maintained even under threat,and no use made of any medical knowl-edge contrary to the laws of humanity.For the purpose of this Declaration, tortureis defined as the deliberate, systematic orwanton infliction of physical or mental suf-fering by one or more persons acting aloneor on the orders of any authority, to forceanother person to yield information, tomake a confession, or for any other reason.
Declaration
1. The physician shall not countenance,condone or participate in the practice oftorture or other forms of cruel, inhumanor degrading procedures, whatever theoffence of which the victim of suchprocedures is suspected, accused orguilty, and whatever the victim’s beliefs
or motives, and in all situations, includ-ing armed conflict and civil strife.
2. The physician shall not provide anypremises, instruments, substances orknowledge to facilitate the practice oftorture or other forms of cruel, inhumanor degrading treatment or to diminishthe ability of the victim to resist suchtreatment.
3. When providing medical assistance todetainees or prisoners who are, or whocould later be, under interrogation,physicians should be particularly carefulto ensure the confidentiality of all per-sonal medical information. A breach ofthe Geneva Conventions shall in anycase be reported by the physician to rel-evant authorities.The physician shall not use nor allow tobe used, as far as he or she can, medicalknowledge or skills, or health informa-tion specific to individuals, to facilitateor otherwise aid any interrogation, legalor illegal, of those individuals.
4. The physician shall not be present duringany procedure during which torture orany other forms of cruel, inhuman or de-grading treatment is used or threatened.
5. A physician must have complete clini-cal independence in deciding upon the
care of a person for whom he or she ismedically responsible. The physician’sfundamental role is to alleviate the dis-tress of his or her fellow human beings,and no motive, whether personal, col-lective or political, shall prevail againstthis higher purpose.
6. Where a prisoner refuses nourishmentand is considered by the physician ascapable of forming an unimpaired andrational judgment concerning the con-sequences of such a voluntary refusal ofnourishment, he or she shall not be fedartificially. The decision as to the ca-pacity of the prisoner to form such ajudgment should be confirmed by atleast one other independent physician.The consequences of the refusal ofnourishment shall be explained by thephysician to the prisoner.
7. The World Medical Association willsupport, and should encourage the in-ternational community, the NationalMedical Associations and fellow physi-cians to support, the physician and hisor her family in the face of threats orreprisals resulting from a refusal to con-done the use of torture or other forms ofcruel, inhuman or degrading treatment.
The World Medical Association Declaration of Tokyo. Guidelines for Physicians Concerning Torture and other Cruel,Inhuman or Degrading Treatment or Punishment in Relation to Detention and ImprisonmentAdopted by the 29th World Medical Assembly, Tokyo, Japan, October 1975, editorially revised at the 170th Council Session, Divonne-les-Bains, France, May 2005 and the 173rd Council Session, Divonne-les-Bains, France, May 2006
* the latest revisions are shown underline. See also WMA Council report page 46
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Medical Ethics and Human Rights
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1. Medical ethics in times of armed con-flict is identical to medical ethics intimes of peace, as stated in the Interna-tional Code of Medical Ethics of theWMA. If, in performing their profes-sional duty, physicians have conflictingloyalties, their primary obligation is totheir patients; in all their professionalactivities, physicians should adhere tointernational conventions on humanrights, international humanitarian lawand WMA declarations on medicalethics.
2. The primary task of the medical profes-sion is to preserve health and save life.Hence it is deemed unethical for physi-cians to:a. Give advice or perform prophylac-
tic, diagnostic or therapeutic proce-dures that are not justifiable for thepatient’s health care.
b. Weaken the physical or mentalstrength of a human being withouttherapeutic justification.
c. Employ scientific knowledge to im-peril health or destroy life.
d. Employ personal health informationto facilitate interrogation.
e. Condone, facilitate or participate inthe practice of torture or any form ofcruel, inhuman or degrading treat-ment.
3. During times of armed conflict, stan-dard ethical norms apply, not only in re-gard to treatment but also to all other in-terventions, such as research. Researchinvolving experimentation on humansubjects is strictly forbidden on all per-sons deprived of their liberty, especially
civilian and military prisoners and thepopulation of occupied countries.
4. The medical duty to treat people withhumanity and respect applies to all pa-tients. The physician must always givethe required care impartially and with-out discrimination on the basis of age,disease or disability, creed, ethnic ori-gin, gender, nationality, political affilia-tion, race, sexual orientation, or socialstanding or any other similar criterion.
5. Governments, armed forces and othersin positions of power should complywith the Geneva Conventions to ensurethat physicians and other health careprofessionals can provide care to every-one in need in situations of armed con-flict. This obligation includes a require-ment to protect health care personnel.
6. As in peacetime, medical confidentiali-ty must be preserved by the physician.Also as in peacetime, however, theremay be circumstances in which a pa-tient poses a significant risk to otherpeople and physicians will need toweigh their obligation to the patientagainst their obligation to other individ-uals threatened.
7. Privileges and facilities afforded tophysicians and other health care profes-sionals in times of armed conflict mustnever be used for other than health carepurposes.
8. Physicians have a clear duty to care forthe sick and injured. Provision of suchcare should not be impeded or regardedas any kind of offence. Physicians mustnever be prosecuted or punished forcomplying with any of their ethicalobligations.
9. Physicians have a duty to press govern-ments and other authorities for the pro-vision of the infrastructure that is a pre-requisite to health, including potablewater, adequate food and shelter.
10.Where conflict appears to be imminentand inevitable, physicians should, as faras they are able, ensure that authoritiesare planning for the repair of the publichealth infrastructure in the immediatepost-conflict period.
11. In emergencies, physicians are requiredto render immediate attention to thebest of their ability. Whether civilian orcombatant, the sick and wounded mustreceive promptly the care they need. Nodistinction shall be made between pa-tients except those based upon clinicalneed.
12.Physicians must be granted access topatients, medical facilities and equip-ment and the protection needed to carryout their professional activities freely.Necessary assistance, including unim-peded passage and complete profes-sional independence, must be granted.
13.In fulfilling their duties, physicians andother health care professionals shallusually be identified by internationallyrecognized symbols such as the RedCross and Red Crescent.
14.Hospitals and health care facilities situ-ated in war regions must be respectedby combatants and media personnel.Health care given to the sick andwounded, civilians or combatants, can-not be used for morbid publicity or pro-paganda. The privacy of the sick,wounded and dead must always be re-spected.
The World Medical Association regulations in times of armed conflictAdopted by the 10th World Medical Assembly, Havana, Cuba, October 1956, edited by the 11th WorldMedical Assembly, Istanbul, Turkey, October 1957, amended by the 35th World Medical Assembly, Venice, Italy, October 1983 and the WMA General Assembly, Tokyo 2004, and editorially revised at the 173rd Council Session, Divonne-les-Bains, France, May 2006
* The latest changes in text are shown underline. See also WMA Council report page 46
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WMA Declaration of MaltaA background paper on the ethical management of hunger strikes
The following background paper and glos-sary of terms were prepared by the BritishMedical Association in association with therevision of the Malta Declaration currentlybeing considered by WMA Council andNational Medical Associations. See also „glossary of themes“, p. 41-42.
Introduction
Physicians need to understand the back-ground to the guidance given in the WorldMedical Association’s Declaration ofMalta. This paper aims to set out that back-ground and some authentic case examplesare included to illustrate how complex thisarea of practice can be. These cases aretaken from field experience in widely dif-fering contexts and countries. They havebeen simplified and anonymised to protectindividuals’ confidentiality and they reflecthow very different strategies may have tobe adopted by physicians according to thecircumstances of the case.
Although the Malta Declaration sets broadinternational standards for managing hungerstrikes in custodial settings, physicians stillneed to use their own moral judgement inparticularly complex situations. To do this,they should be aware of the various differentforms of fasting which stem from differingintentions on the protesters’ part and whichrequire different handling. Hunger strikers’motivations and their perseverance in a par-ticular kind of hunger strike can differ great-ly. Gaining their trust can be difficult but iscrucial for doctors, who must be able to actindependently from the detaining authori-ties. Physicians also need to be alert to thepressures which can be exerted on hungerstrikers in custodial settings - not only by theauthorities but also by peer group hierar-chies and sometimes even by physiciansthemselves. For example, if doctors askhunger strikers to give advance instructionsat the start of a fast saying whether or notthey would refuse resuscitation at a later
stage, it may be difficult for the hunger strik-ers to do anything other than refuse artificialfeeding, without losing face with their peergroup. This may not be a truly valid andinformed choice unless physicians can dis-cuss it in private with the hunger striker.Physicians need to understand the clinicaland moral criteria concerning when to resus-citate a protester and when to abide by sucha refusal of treatment. The crucial differ-ences between “artificial” and “force” feed-ing need to be understood. Physicians alsoneed to be aware of the symptoms and theclinical physiology of the different stages offasting in order to give accurate medicalcounselling to patients about what to expect.(Such advice can be found in the ‘Course forprison doctors’, chapter 5, by the WorldMedical Association, Norwegian MedicalAssociation and International Committee ofthe Red Cross at http://lupin-nma.net).Health professionals often act as mediatorsbetween patients, authorities and other peo-ple such as patients’ families. They can be ina position to facilitate face-saving opportu-nities which could bring the hunger strike toan end for the benefit of all involved. Thispaper seeks to help them do that.
Definition of “hunger strike”
As explained in the glossary, a “hungerstrike” involves food refusal as a form ofprotest or demand. Such fasting is particu-larly undertaken by people in custodial set-tings who lack alternative means to gainattention and bring pressure to bear toobtain some goal. Short-term rejection offood rarely gives rise to ethical dilemmas ashealth is generally not permanently dam-aged as long as fluids are accepted. It isimportant, however, for physicians to havea clear frame of reference on how to definea serious “hunger strike”.
Excluded here are short-lived fasts whichpeter out within 72 hours. If hunger strikers
continue to refuse both nutrition and hydra-tion for more than 48 hours, however, theyrisk significant harm. Dry fasting withoutany fluid intake which persists for morethan a few days would fall within the defin-ition of “hunger strike” used here but, fortu-nately, this is rare. As the body cannot sur-vive more than a few days without fluid,death would occur within the first weekwhich, from the protesters’ perspective, istoo short a period for negotiation to beeffective. In short, the term “hunger strike”as discussed here refers to protest fastingwithout any intake of food but with inges-tion of adequate quantities of water.
In the first days of fasting, the body uses itsstores of glycogen in the liver and muscles.Ketosis occurs and is discernible clinicallyon the breath or by laboratory test in theurine. It subdues the voracious sensation ofhunger experienced during the first days offasting. It can be argued that total fasting(taking water only) for longer than 48 - 72hours is the clearest definition on metabolicgrounds for the term “hunger strike”.Glycogen stores are exhausted by about day10-14 and certain amino acids take over asthe substrate for gluconeogenesis. Muscle,including heart muscle is gradually lost.Close medical monitoring is recommendedafter a weight loss of 10% in lean healthyindividuals and major problems arise at aweight loss of about 18%. Hunger strikersneed to be aware that dehydration is a riskas they lose their sensations of hunger andthirst.
1. The medical duty to establishcompetence and motivation
Assessing patient competence and gainingan understanding of the purpose of the fastis crucial for physicians. Good communica-tion and trust are essential here. Fasting as asymptom or manifestation of a psychiatricdisorder such as anorexia or depressionrequires a totally different approach, soassessing patients’ mental health must be afirst step for physicians. People sufferingfrom any serious psychiatric or mental dis-order likely to undermine their judgementneed medical attention for their disorderand cannot be permitted to fast in a way thatdamages their health. Fasting for religiousreasons should also not be confused with
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protest fasting but should be respected. It isgenerally not health threatening and doesnot raise dilemmas when undertaken by anotherwise healthy person.
Two main categories of individuals embarkon hunger strikes with quite different inten-tions and motivation. In potentially coercivecontexts, (which include any situation ofdetention) it is important for physiciansalways to determine for themselves what arethe exact motives for refusing nourishment.
Some food refusers fast to gain publicity toachieve their goal, but have no intention ofpermanently damaging their health. Theirgoal may seem relatively petty or it mayinvolve reasons of principle. As they do notwish to die, these protesters often agree toartificial feeding being provided at somestage and may actually request medicalassistance in monitoring their fast. Thosewho repeatedly make this type of protestcan come to be seen as exercising a form ofblackmail by the authorities, who then letstrikes continue to test protesters’ resolve.Physicians need to clarify privately withprotesters, at regular intervals, how far theyare willing to go and when they expect anddesire medical interventions to be made toprevent lasting harm to their health.
The other very different category consistsof what might be seen as very determinedhunger strikers who are not prepared toback down unless their goal is actuallyattained. Individually or in groups, theymay differ in their mode of fasting but theyshare a determination to risk their health ortheir lives for a cause. Political hungerstrikers often fall into this category. Unlikethe food refusers who rely on medical helpto prevent serious harm, this category ofprotesters often mistrust physicians, whomthey see as belonging to the detaining sys-tem. Such protesters pose a serious chal-lenge to medical ethics, as their willingnessto take fasting to the extreme inevitablyraises difficult questions about whether andwhen to intervene and the thorny ethicalquestion of whether feeding contrary topatients’ expressed wish can ever be justi-fied. In this paper, we have rejected the term“death fast” which is sometimes used todescribe a determined hunger strike. Theterm is unfortunate in that it appears to
assume death is the inevitable outcome. Byperceiving death as the objective of the fast,opportunities for constructive dialogue maybe lost from the outset. It is seen by theauthorities as establishing an unacceptableultimatum with no leeway for discussion.This can deter doctors from even attemptingto mediate.
2. The medical duty to attempt toestablish “voluntariness”
“Voluntary total fasting” is a term oftenused, but fasts in detention are seldom total.Most protesters accept fluids and some-times the rejection of food too is less thantotal. Participation can also be morecoerced than voluntary, particularly in longcollective hunger strikes. The authoritiesmay want to stop protests by finding accept-able compromises but pressures may comeinadvertently from staff, such as guards,whose taunts and derision of protesters canlead to a hardening of positions. Detaineesmay also suffer coercion from peer groupsin subtle as well as obvious ways. Theseoften complex situations can lead to thepoint where it becomes virtually impossiblefor a protester to cease fasting voluntarily.The informed and voluntary nature of indi-viduals’ food refusal are key aspects thatphysicians need to ascertain once mentalcompetence has been established.Physicians must do their utmost to speak toeach patient privately, out of earshot of allother people but with an interpreter if nec-essary. It is important that interpreters arenot connected with the detaining authoritiesor the patient’s peer group and that they areaware of the confidentiality expected ofthem. Those orchestrating collective hungerstrikes are often reluctant to allow suchtalks, as this undermines their authority.This is possibly the most complex situationto deal with in determining whether hungerstrikers are indeed genuine volunteers. Thesubsequent extent to which medical confi-dentiality can be guaranteed in custodialsettings needs to be discussed with thepatient. Physicians should do everything intheir power to engage in frank discussionwith patients and gain their trust. Whereprotesters appear to be fasting under duress,a solution may be to separate those individ-uals in hospital on a medical pretext, there-by extracting them from the influence of
others and allowing them, if they agree, toresume nourishment on medical grounds.Pressure may still come from relatives orthe media. Families often alert the media,hoping this will heighten the pressure on theauthorities to make concessions but it canalso increase pressure on the protester not togive way.
Physicians sometimes cannot gain the trustof patients. In such situations, it may bepossible to bring in an external physicianunconnected with the detaining authority orone nominated by the patient to ascertainwhether the fast is truly voluntary. If the“voluntariness” of the decision appears tobe established, protestors’ decisions shouldbe respected. It is likely that some cases ofcoercion go undetected, even if all reason-able precautions are taken, but in theabsence of evidence to that effect, physi-cians must listen to and abide by whatpatients say.
Physicians can discuss with patients theflaws or lack of logic in their expressedwishes without exercising undue pressure.Experience shows that particularly in high-ly political hunger strikes, decision-makingis far from simple. There may be situationswhere physicians need to challenge thepatient rather than accept that person’sviews at face value. It is here that the impor-tance of trust and the confidentiality of theindividual interview become of paramountimportance. There are cases in which physi-cians, confronted with an apparently fanati-cal hunger striker, can use their position oftrust and medical authority to try to bringthe protestor to reason.
Case example 1 – Difficulties of establish-ing a hunger striker’s real wishes
A physician, visiting a collective hungerstrike involving many politically motivatedprisoners, listened carefully to the story of afemale protestor. She had suffered manyhardships, including rape and the loss offamily members. She was barely 20 yearsold and appeared politically motivatedalmost to the point of fanaticism. Her inten-tion, she said, was to fast unto death toprotest against oppression. The physiciandecided to test her determination as he was
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not convinced her words reflected her realwishes. He took a firm stance, arguing thather apparent choice to die seemed wrongafter all she had already endured and sur-vived. In his view, her decision was illthought out and he said that, as a doctor, hewas unwilling to let her waste her life butwanted her to reconsider. The young womanwas shocked as nobody – not even she her-self - had questioned her intention previous-ly. She burst into tears but, on reflection,agreed that she did not want to die. As theytalked, the doctor’s careful reasoning andanalysis of her situation helped her to iden-tify her real wishes. The conversationbetween them was kept confidential but thewoman agreed to accept nourishment whichwas given on a medical pretext to avoidpressure being brought to bear upon her byher peer group. The doctor’s willingness toprobe deeper than the woman’s superficialstatements allowed him to test whether herstatements really were an autonomousexpression of her views. Her readiness tohear his arguments made the hunger strikerre-evaluate her intentions and realize thatshe had suppressed her true feelings. Theexample shows how complex such issuescan be and the risks of accepting an individ-ual’s views without any question.
3. The duty to provide accurate information to patients
Physicians need to explain to each protesterthe implications of fasting for that person.This entails first taking a detailed medicalhistory and conducting an examination sothat existing medical conditions are identi-fied and discussed. They should objectivelywarn patients who suffer from ailments thatare incompatible with prolonged fasting,not to embark on a hunger strike or torestrict themselves to a limited form of fast-ing. Conditions such as diabetes, gastritis,gastric or duodenal ulcer and many meta-bolic diseases are contra-indications to totalfasting. Only if fully informed, can protest-ers make a truly voluntary and informeddecision on whether to embark on a hungerstrike. They only have a chance of obtainingtheir goals if there is enough time for theauthorities under pressure to react. The like-
ly duration of their fast is therefore of para-mount importance to hunger strikers, espe-cially if they have difficulties in makingtheir plight known to those outside who cantry to exercise influence. It will be essentialfor hunger strikers to know as accurately aspossible how long they personally couldfast. The fatal outcomes of total fastingwere first documented during the 1980 and1981 hunger strikes in Northern Irelandwhere death generally occurred between 55and 75 days. Similar experiences have con-firmed this wide time bracket. The three-week interval is due to differences in initialphysical constitution and individual adapta-tion. It is not possible to predict any timespan more precisely. Protesters need to beadvised that death occurs some time aftersix full weeks of fasting and survival afterten weeks of total fasting is practicallyimpossible. They also need to know that inthe final clinical stages of fasting, they willno longer be capable of discernment andneed to make clear in advance what theyexpect physicians to do for them then.
4. The duty to give counselling
Medical counselling may often be a key ele-ment in determining the duration of ahunger strike. Physicians often find thatsome patients do not believe them, evenwhen they try to give objective counselling.Some people who are detained understand-ably mistrust physicians, whom they see asworking for the authorities. Doctors canhave a difficult task convincing hunger-strikers that they are acting on their behalf,partly because in many cases doctors areunable to show that they are neutral. In suchsituations, there is a role for outside physi-cians, not only to give medical advice, butalso to act as neutral intermediaries in nego-tiations with the authorities. Doctors areoften able to play a crucial role, but only ifthey obtain the trust of the patient. In somecases, transferring a hunger striker to hospi-tal on the pretext of performing further testsmay serve a humanitarian purpose, allow-ing the protester to resume nourishment onthe doctor’s orders. Detainees, however,confide in the physician only if they areconvinced that medical confidentiality willbe respected. The element of trust is hereall-important.
To give accurate advice and counselling,physicians need to clarify the type ofhunger strike that will occur. Most so-called“total fasts” involve protesters acceptingwater but abstaining from all foodstuffs.Different cultures, however, have differentnotions of how fasting should be defined.Salt (either NaCl alone or a combination ofminerals) is often added to the water andpossibly sugar or other sweet substancessuch as honey. Some cultures define fastingin terms of abstaining from solid food (sub-stances that need to be chewed) or fromfood that is cooked or heated. They maydiscount the ingestion of milk, honey oreven nutrients such as eggs but the durationof the fast remains the crucial element.Physicians need to make clear to hungerstrikers that non-total or partial strikes, ifprolonged, lead to death but at a much laterstage than a total fast.
Some forms of partial fasting are consid-ered as “cheating” by the authorities. Thiscan lead to controversy about the serious-ness of the protest. Prolongation of the peri-od for potential negotiation, however, isoften beneficial to the final outcome andhelps avoid deaths. Therefore physicianscan find themselves in an apparentlycounter-intuitive situation. They may seemore advantages in terms of life-savingopportunities in a longer hunger strikewhich allows more time for negotiationrather than a short fast which is morerestrictive in terms of what can be ingestedand therefore more lethal. Physicians needto avoid implying to protesters or theauthorities that non-total fasting is not seri-ous or lacks credibility. They should notchallenge partial hunger strikers on the non-total quality of their protest fast. Physiciansneed to understand that partial fasting for alengthy period of time can be a legitimateform of protest which could provide moretime to find a face-saving solution for allinvolved and thus be instrumental in avoid-ing fatal outcomes. They must not, howev-er, let themselves be manipulated by eitherthe authorities or the hunger strikers.Physicians must not give erroneous clinicaltestimony or advice. Prison doctors, forexample, have been known to threatenhunger strikers with grave medical sequelaethat are fictitious. In one example, doctors
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told hunger strikers that fasting causedimpotence, with the sole purpose of fright-ening them into giving up their fasting. Thissort of action is completely unethical andundermines any trust that hunger strikersmay have in the medical profession.
5. The duty to maintain confidentiality
The duty of confidentiality is as strong incustodial situations as in the community. Itis never an absolute requirement in eithercontext if serious harm would result fromnon-disclosure and physicians need to makean evaluation about where the best balancelies. In situations where physicians areunable to maintain some aspects of apatient’s confidentiality, this should ideallybe made clear at the start of the consulta-tion. Wherever possible, however, physi-cians should respect patient confidentialityas the maintenance of trust depends upon it.This applies to non-medical informationgiven to physicians by patients. For exam-ple, physicians interviewing hunger strikersmight learn the names of the ringleaders ofthe protest, but they would lose patients’trust and may put them at risk of reprisals ifthey disclosed that information to theauthorities.
Case example 2 – Challenges in maintain-ing confidentiality
In a collective hunger strike, the physicianrealised that the hunger strikers needed toprolong their protest to allow time for thenegotiation of their goals but none wishedactually to risk their lives. As the protestwas the focus of media attention, however,they could not be seen to be lacking in com-mitment and so while ostensibly refusingnormal food, they privately agreed with thedoctor to accept some nutrition and hydra-tion intravenously. The physician main-tained the trust and confidentiality of theprisoners by not disclosing the full situationto the prison authorities who, recognisingthat normal food was still being rejected,eventually threatened to end the strike byforce feeding. The physician intervened andexplained that he had the situation undercontrol without force. Both sides in theprotest were engaged in a drama where nei-ther was willing to be seen to concede. The
doctor’s ability to agree privately with theprisoners to provide artificial feedingallowed time for both sides to reach anacceptable compromise without publiclylosing face.
Hunger strikers also need to be aware thatrequiring a doctor to maintain their confi-dentiality can in some cases have potentialdisadvantages for them. Such aspects needto be discussed at an early stage.
Case example 3 - Challenges in maintainingconfidentiality
A political prisoner on hunger strike com-plained to a visiting physician that he hadbeen forcibly fed while semi-conscious con-trary to his verbal advance instructions. Theprisoner wished to register a formal com-plaint. Having listened carefully to the pris-oner’s story, however, the doctor had doubtsas to whether the prisoner had indeed beenfed against his will since although semi-comatose, he was a strong man who couldhave exhibited some signs of resistance. Infact the prisoner had made no effort to resistand later, in private, he confided in thephysician that he was relieved to have beenresuscitated but that these facts had to bekept confidential both from other prisonersand from the prison authorities. The doctor,therefore, was obliged to continue the pre-tence of taking the complaint seriously butin cases such as this, physicians also need toexplain to hunger strikers the risks of such adeception since in future situations, it wouldbe assumed that the hunger strikers did notwant to be resuscitated unless they hadmade their real views plain. A hunger strik-er in this situation would have a particular-ly difficult dilemma if asked to sign a formaladvance directive refusing future resuscita-tion since this would either force him toexpose his real views or it would mean thathe risked being allowed to die in future ifevidence were lacking of his real feelings. Inthis case, as a last resort, the confidentialityof the prisoner’s discussion with the visitingphysician could arguably be breached toavoid that harm but this would really need tobe discussed in advance with him.
6. The advantages and disadvantages ofcommunicating with families
Families may support detainees’ fasting ortry to get the authorities to intervene to savethe prisoner’s life regardless of that individ-ual’s views. Given, however, that people incustodial settings often have only limitedways of making their own genuine viewsknown, physicians attending them can findit useful to communicate with their rela-tives. Direct contact with them may providecrucial background information allowingthem to make the best decision. Cases alsoarise where physicians find themselves atodds with a family demanding interventionwhich the patient refuses. In many coun-tries, the family of a prisoner on hungerstrike has the legal right to require medicalintervention. While keeping this in mind,physicians should never forget that theirprimary professional commitment is to thepatient. Where families support the hungerstriker or openly lobby for media attention,the authorities may be reluctant to allowfamily visits and physicians may have animportant role as intermediary. Althoughpressures on hunger strikers should obvi-ously be kept to a minimum, this should notbe an excuse to suppress family visits.
7. Is there a duty to act as mediator?
The role of mediator is outside physicians’obligations in most circumstances but in thecontext of hunger strikes, they can be par-ticularly influential in saving life if they arewilling to do so and have the trust of bothsides. They also need an objective view ofthe true situation. They may then be in aposition to negotiate and possibly obtainconcessions from both sides. They have todecide from the start, however, whetherthey can act as a medical intermediarybetween hunger strikers and the authoritiesand if they cannot, they need to make thatclear to patients and not pretend to play therole. Prison doctors are likely to be in aprivileged position if they have the trust ofthe prisoners and the confidence of theprison authorities. If hunger strikers trustand confide in them, physicians are able toevaluate how urgent is the need for media-tion. Most hunger strikers desperately wantto find a way out of the confrontation and
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often stop fasting if they obtain some minorform of concession from the authorities. Insuch cases physicians may be in the best posi-tion to negotiate some compromise betweenthe two parties. When the demands of hungerstrikers are very obviously out of reach,prison doctors must not fall into the trap ofpretending otherwise or insinuating that asolution is achievable through mediation.They should make clear that they are outsidethe negotiations but the crucial role of provid-ing accurate information to patients abouttheir medical condition should continue.
8. The duty to remain objective and inde-pendent
Medicalisation of hunger strikes oftenoccurs and can threaten physicians’ abilityto act independently. Local law may requiremedical monitoring of the hunger strike andthe status of a particular hunger striker canalso influence the attention given to thatperson. Physicians may have to balanceobjective medical observations with prag-matic face-saving situations, in order to buytime for essential negotiations to produceresults. They must avoid pandering to anyparticular interest group by giving medicalinformation or advice that is scientificallyquestionable or inaccurate.
Physicians working for prison administra-tions or other detaining authorities some-times cannot be really independent. Even ifthey are fully aware of the ethical implica-tions of a terminal hunger strike, withoutexternal support they are often powerless tooppose administrative decisions imposedon them by the authorities. Medical associ-ations have a duty to inform physicians ofinternational ethical guidelines that shouldbe respected at all times and to provide sup-port for them. Independent physicians ide-ally should be permitted to counsel hungerstrikers in the interest of all involved and inorder to try to avoid any fatal outcome.Some countries do allow this, and thesephysicians’ independent status ensures theircredibility as acceptable intermediaries forall parties concerned.
9. Management of medical conditionsduring a hunger strike
The WMA’s training module on prisonhealth care contains a detailed account of
the clinical stages undergone by hungerstrikers between the first days of fasting andthe final stage between 45 to 75 days laterwhen death occurs from cardiovascular col-lapse or severe arrhythmias. As well as thephysical aspects, physicians need to beaware of patients’ mental and psychologicaldisruptions. Refusal to take sustenanceleads to a clinical syndrome that resembles,but is not equivalent to starvation. In the lat-ter case, body depletion is a dragged-outprocess, with little caloric intake, but stillminimum absorption of vital elements suchas vitamins or proteins. It is this intake thatdifferentiates total fasting in a hunger strikesituation (taking just water) with starvationin concentration camps. Among the symp-toms experienced by long term hungerstrikers are significant gaps in memory andinability to concentrate. They live for themoment. Total fasting forces the body tofind substitute sources of glucose, essentialfor providing energy, to the brain in partic-ular. Lack of calorie intake disrupts theusual pathways, and complex mechanismskick in to replace the external energysource. The body begins to digest itself,breaking down the various tissues so as tohave a constant supply of glucose. If thefasting leads to medical complications, it isthe duty of physicians to do more thanmerely take notes and monitor vital signs.There is need for them to enter into a seri-ous discussion with each hunger striker. Itcannot be stressed enough that the privacyof the medical consultation is of paramountimportance, so as to avoid any meddling orcoercion, from any side, and for physiciansto be able to play their role.
It is important that physicians understandthe moral and practical distinctions betweenforcible feeding, artificial feeding andresuscitation. The WMA Malta Declarationgives some leeway to the treating physician,who should have the final word in decidingwhat is best for the patient, all factors beingtaken into consideration. Force-feeding,however, is out of the question. If the pro-tester’s intent is to extend the fasting aslong as possible, there should be advancediscussion between the physician andhunger striker to clarify the expectations on
either side. In particular, physicians need tobe clear what actions they have patient con-sent for once the fasting has clouded thepatient’s mind and coherent communicationbecomes impossible. Physicians must dis-cuss the crucial issue of artificial feedingand resuscitation before that stage. In somecountries, patients’ known wishes dictatewhat the physician does after consciousnessis lost. In others, this is not an option andphysicians may be prosecuted if they fail tointervene to save the hunger striker’s life.Physicians need to know clearly what atti-tude to adopt and also make this clear to thehunger striker, so that they can reach a deci-sion in common. If, for personal reasons,physicians cannot accept the patient’s deci-sion, they should say so and step aside sothat another physician can act according tothe informed decision of the hunger striker.
Artificial feeding should not involve coer-cion. It may be prescribed by a physician orbe imposed by a judicial authority. Thisoccurs usually at a stage when the hungerstriker is no longer fully conscious and tooweak to express a view. Artificial feedinginvolves administering nutriments and liq-uids parenterally or through a naso-gastrictube. Even when physicians agree to respectpatients’ advance refusals, some circum-stances may justify a decision to resuscitateor artificially feed a hunger striker who haslost competence. A justification would befor example, that the situation has changedafter the patient lost awareness so that theadvance refusal may be considered inap-plicable to the new scenario. If, however,when competence is regained, the hungerstriker persists in the refusal of feeding ortreatment, the physician should allow theperson to die in dignity, without repeatedresuscitations.
Physicians should never condone or partic-ipate in forcible feeding or any otherenforced measures which may amount tocruel, inhuman and degrading treatment.When hunger strikes have a political com-ponent, the authority in charge may decideto end them by force and order the forcibleartificial feeding of protesters. This may bedecided very early on in the fasting, whenthere is no actual medical need to adminis-ter nutrition. It should be realized in this
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Declaration of MaltaGlossary
To be read in conjunction with the background discussion paper on management of hunger strikes.
Advance instructions/advance directive
Mentally competent patients can give consent or refusal in advance for future medicalinterventions, in order for their wishes to be known if later mental impairment leaves themunable to express a view. Advance instructions are a useful indicator of an individual’sviews but only if the person making them is aware of the implications and not pressuredto make a certain choice. These criteria can be hard to meet in custodial settings but arenot invariably absent. Physicians need to be aware that at the start of hunger strikes, therecan be pressure for hunger strikers to prove that their intentions are serious which maypush them into making an ill-considered advance refusal of resuscitation. Where possible,physicians need to discuss this privately with hunger strikers and ascertain their real inten-tion. Some advance instructions truly reflect the individual’s wishes but others do not.Physicians need to assess the evidence. Advance instructions can be written or verbal buthave no value if made under duress. They may also be invalid if the situation has under-gone significant change since the individual lost competence and it is no longer what heor she expected it to be. (See WMA statement on advance directives, Helsinki 2003).
Artificial feeding
Although often seen as synonymous, artificial feeding is not the same as forcible feeding.All force-feeding is artificial but not all artificial feeding is forced. Artificial feeding inhunger strikes can be a solution for hunger strikers who do not want to endanger theirhealth but who refuse to take nourishment normally for reasons of their own. Artificialfeeding is acceptable if hunger strikers make known their agreement to it by any means or,if incompetent, they have not refused it in advance.
Force feedingForce feeding not acceptable. It involves use of force and physical restraints to immobilisethe hunger striker. Although described as life saving, it is sometimes implemented as acoercive measure to break a hunger strike
Autonomy
Physicians should respect patients’ autonomy by not overriding their voluntary, informedand competent decisions. In the case of hunger strikes, this means physicians shouldrespect patients’ refusal of feeding. It is important for physicians to explain accurately tohunger strikers the potential health impact of prolonged fasting and to advise them on howto minimise the harmful consequences by for example, increasing fluid and vitaminintake. Consent and refusal are invalid if the result of coercion. Autonomy is one of fourkey principles that are frequently portrayed as core to modern medical ethics.
Beneficence & Non-maleficence
The duty to benefit (beneficence) and not harm (non-maleficence) are also part of the fourkey principles but need to be interpreted holistically. Imposing treatment in the face ofvalid patient refusal is seen as a harm not a benefit. In custodial settings, this raises ques-tions about whether prisoners or detainees can make such free choices.
Best interests
Physicians are morally obliged to act in patients’ best interests but this does not mean pro-longing life at all costs. An assessment of best interests must be a balance between seek-ing the best medical outcome and a consideration of the patient’s own views, values andpreferences. Physicians do not act in patients’ best interests by overriding patients’ strong-ly held wishes.
Confidentiality
All patients, including detainees, have rights of confidentiality but these are not absoluterights. Consent to disclosure should generally be sought from competent individuals.Information about incapacitated individuals can be disclosed if it is in their best interests.For all patients, disclosure is also permitted if it prevents serious harm to others. In hungerstrikes, information about the patients’ views and medical condition should be sharedamong health professionals providing care. Information can be given to other people suchas relatives and lawyers with hunger strikers’ consent.
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respect that the authorities often have spe-cific agendas when ordering doctors to arti-ficially feed (or force-feed) hunger strikers.While claiming to want to save lives, somecoercive authorities clearly intend to repressthe principle of protest. For example, theauthority may decide to force-feed hungerstrikers after two weeks of fasting, whenthere is no immediate medical need to inter-vene. It may also be decided to feed prison-ers who resist by brute force, tying downtheir limbs and forcibly inserting a naso-gastric tube. This coercion is what definesforce-feeding. It is not necessarily carried
out by medical staff but may involve med-ical orderlies if doctors refuse.
Case example 4
In a collective hunger strike, the degree ofcommitment to the fast varied considerablyamong the hunger strikers. It was clear tothe visiting physician that some prisonerswere absolutely determined to fast untilthey died. These prisoners not only refusedall nourishment and drank only water butthey resisted all attempts to provide nutri-
tion by naso-gastric tube. If tubes wereinserted against their will, they used themto suck out any nourishment that had goneinto their stomach. Other prisoners in thesame strike however, told the doctor pri-vately that they were willing to accept anintravenous line or naso-gastric tube aslong as they could maintain the pretencepublicly that these interventions were doneagainst their will. Since all the prisonerswere saying publicly that they were unwill-ing to be artificially fed (even though pri-vately some were saying the opposite), thefirst task for the doctor was to separate the
Confidentiality
All patients, including detainees, have rights of confidentiality but these are not absoluterights. Consent to disclosure should generally be sought from competent individuals.Information about incapacitated individuals can be disclosed if it is in their best interests.For all patients, disclosure is also permitted if it prevents serious harm to others. In hungerstrikes, information about the patients’ views and medical condition should be shared amonghealth professionals providing care. Information can be given to other people such as rela-tives and lawyers with hunger strikers’ consent.
Dual loyalties
Physicians supervising the management of hunger strikers often have contractual duties andobligations to other agencies, such as prison authorities. The WMA strongly emphasises thatmedicine is a privilege that invariably carries certain responsibilities. All medically quali-fied individuals must demonstrate the professional duties of beneficence and non-malefi-cence even when they have dual loyalties and even if their work does not involve the actu-al provision of care. This means that all people who have been trained as care givers havethe same ethical duties of care givers even when not employed to provide care.
Eating/fasting
Good communication depends on all parties understanding common terms in the same way.Different cultures have very differing views on what constitutes fasting or accepting nutri-tion. This is addressed in the WMA background paper and also in chapter 5 of the WMA’sInternet course for prison doctors on www.lupin.nma.net.
Hunger strike and „Voluntary TotalFasting“
Refusing nutrition takes different forms. The terms “hunger strike” and “voluntary total fast-ing“ are sometimes used inter-changeably even though fasting may be neither voluntary nortotal. The” voluntariness” of the individual’s decision is a key issue for physicians in assess-ing whether to abide by it.
Partial or short-term food refusal rarely raises ethical dilemmas. The most accepted defini-tion of a hunger strike is total fasting (taking only water) for over 48-72 hours. Salt, miner-als or sugar may be added to water. Dry fasting where all nutrition and hydration are refusedis uncommon and leads to death within a week. A hunger strike is not equivalent to suicide.Individuals who embark on hunger strikes aim to achieve goals important to them but gen-erally hope and intend to survive.
JusticeJustice is another of the commonly cited four key principles of medical ethics. In this con-text, it is the requirement for physicians to treat hunger strikers fairly, by listening to theirviews and trying to minimise undue coercion from any source.
Physician/physician assistant
The WMA primarily addresses its guidance to physicians but in the context of hunger strikemanagement, other health professionals are likely to be involved and should be encouragedto abide by the Malta Declaration. Professional guidance for other groups such as nurses andparamedics, for example, generally reflects the same principles.
Undue pressure/coersionInforming hunger strikers of the implications of their decisions and encouraging them toreflect are essential and do not constitute undue pressure. Attempting to dissuade them fromfasting by threats, including the threat of forcible feeding, is not acceptable.
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prisoners from each other without in anyway indicating that some were willinglyaccepting nutrition. Eventually, however, itwas bound to become clear which prisonerswere determined to fast to death since thephysician recognised that it would beunethical to force feed those who were gen-uinely resistant. He hoped that by separat-ing them, each of the prisoners would havesome opportunity to reconsider their deci-sion away from the influence of the peergroup in a situation of privacy. For thosewho maintained their fast, their decisionswere respected.
11. Gaining support from professionalassociations
Physicians can themselves in difficult situa-tions if they want to comply with the inter-national guidelines which are in conflictwith local legislation. They may face thedilemma of whether to do everything tosave a person’s life or respect the right ofindividuals to dispose of their bodies asthey please. This question is often furthercomplicated by religious or legal issues.Local law may require physicians to inter-vene, even against their will, if a hungerstriker’s life is at stake. On the other hand,international ethics guidelines focus on the
rights of individuals to determine what isdone to them. Where individual rights arerespected, hunger strikers have a chance tohave their decisions respected. Physiciansencountering difficult dilemmas shouldappeal to their national associations ordirectly to the World Medical Associationfor guidance and support. It may also some-times be necessary to have help from a per-ceived neutral organization, such as doctorsfrom the ICRC (International Committee ofthe Red Cross), Council of Europe CPT(Committee for Prevention of Torture andInhuman Degrading Treatment andPunishment) or similar organizations.
From the Secretary General’s Desk
“What do we expect from the next WHO Director General?”On the day he was supposed to open the 59th
World Health Assembly on May 22nd thisyear, the Director General of the WorldHealth Organization (WHO) tragically diedfollowing a sudden illness. The WorldHealth Assembly decided to hold an extra-ordinary session later this year to determinethe next Director General (DG).
Dr. Lee was committed to give more powerto the regional organizations of WHO.Certainly all health care is local and comingcloser to place of need was logical and nec-essary. He headed a difficult institution,because a political organisation is strugglingbetween opposing political interests, increas-ing challenges for health and an always inad-equa te budget. This task is like squaring athe circle – there is no final solution.
Geneva is the home of the Red Cross, theUnited Nations Commission on HumanRights, the first assembly place of a supra-national organization preceding the UnitedNations. The Conventions regulating mini-mal human behavior in wars have the nameof this city and what ever is connected withit has the bonus of being of high moralstanding. But that is an illusion. The WHOis a good example of an institution which
many people believe it to be a moral author-ity for health care. Something it never was,and most likely never will be.
The organization was build right in the mid-dle of a political minefield between the eastand the west. In times of cold war it was oneof the green tables where leaders of thepolitical blocks could meet and discuss,without pretending to like each other. Theold demarcation lines have gone. In time ofglobalisation, trade determines the rules.But the borders and frontiers are not gone.They are now more complex, sometimesinvisible and often blurry. Players in theglobalisation game often don’t knowwhether they are friends or foes. And allmay be different tomorrow. The problem is:“the old mines are still hot”.
The WHO is a governmental organizationand it is only as good as the governments itrepresents. No government of this world ismade of Saints, no government is withoutmistakes, yet many deserve our respect. Butmany others have no democratic back-ground – they are not elected leaders oftheir people. Many governments of thisworld deny their people basic rights, thefreedom of speech, the right to work, the
right to move, the right to build coalitions.Many governments deny their people eventhe right to live, they torture and abuse theirown people. Yet they sit in the World HealthAssembly, the highest deliberative body ofthe WHO.
WHO has driven many health campaigns:The fight against small pox and polio arewonderful success stories, much of it Dr.Lee’s achievement. The WHO works suc-cessfully on tobacco control and fightstuberculosis world wide, it has programmeson injury prevention and disaster relief, itsupports medical reference centres and pro-vides administrative guidance for the recog-nition of education and training. In otherwords there are many, many things theWHO has to be praised for. If it wasn’tthere, we would have to build it.
But then it is a political organisation withthe parameters described above, excludingmany people from cooperation just forpolitical reasons: Taiwan is a good exampleof this. Its basis of work are the decisions ofthe World Health Assembly and reports,facts and figures provided by the countries– or better their governments. How muchdo we trust reports from countries without
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free press, without the freedom of expres-sion? Large parts of the WHO work are ide-ologically biased, they are neither thereflection of high morals nor of good sci-ence but just of political powers.
Whoever goes there to be the new DG hasan uphill battle before him. Organisationalreform like with the rest of the UN-Institutions is urgently needed. So what canwe realistically expect? The political prob-lems will remain. However, a re-focusingon true health issues and a closer coopera-tion with the health care community would
be a good start. There is a strong allianceout there for health care, but WHO is goingin another direction. The revitalization ofbare-foot-doctor concepts in the recent dis-cussion on “human resources for health” isjust one example of the misled attempts totackle one of the worst current problems inglobal health care: the global shortage ofhealth professionals.
To take out politics will be the biggest politi-cal challenge for the new DG. To orient WHOtowards health and not political problems willhelp to shift resources in the right direction.
More transparency to and cooperation withthe health community is high on our wish list.
At WHO many people work as staff and asvolunteers who care for health. Theydeserve our cooperation and support. Theyalso deserve a powerful DG who is able tofree their way. WHO doesn’t need a com-promise candidate, it needs a strong andcourageous leader. WHO needs a leaderwho knows that the Organization is there toserve the people of the world – and govern-ments only if they do exactly the same.
WMA
173rd WMA Council Meeting held in DivonneThe 173rd Council met in Divonne les Bain,France 18-20th May 2006 under the chair-manship of Dr. Yoram Blachar.
After welcoming new members the firstitem of business was to elect a new ViceChairman to replace Dr. Hashimoto, whohad resigned. Following nomination Dr. K. Iwasa (Japan) was elected as Vice-Chairman of Council.
Following the approval of theminutes of the 171st and 172nd
meetings, the President, Dr.Kgnosi Letlape reported on hisactivities since the last meeting.He had just visited Finlandwhere he participated in a veryproductive WHO meeting on“Health as a bridge for Peace”.Turning to Africa he reportedthat the establishment of anAfrican Regional meeting wasprogressing very well. Thisshould be formalised at a meeting in Julyand it was anticipated that it would meetlater in the year. HIV/AIDS remained amajor problem and he felt that actions ofWMA needed to become more open in thisarea. Priorities were preventing the exten-sion of HIV/AIDS and increasing access totreatment. In this connection he stressedthat the unavailability of medicines was
aggravated by problems with patent sys-tems.
He was also concerned about those infec-tious diseases which were not adequatelycovered and welcomed the role of theHealth Protection Agency He was very dis-turbed by the lack of disaster plans andpreparations still in many countries. NMAscould assist with these, but there was a lackof appropriate mechanisms for mobilisation
of the profession.
On a different note he stressedthe need for coordination ofthose health professionals whorapidly respond to the need forassistance in major disasters.
He paid a special tribute to Dr.Yank Coble for his work ininspiring the “Caring Physiciansof the World” project, especiallyin promoting and supportingregional meetings. These had
permitted real dialogues on major issuesrelating to medicine.
He felt that WMA needed to become moreengaged in policy decisions in the health-field, particularly with WHO. It also neededto promote leadership within the profession.
Concluding by referring again to the prob-lems of Africa he said that while the “3 in
5” initiative was a most welcome one,unfortuntely the target was not beingachieved. Only 1.3 of the three million tar-get had been achieved by the programme.At the same time he paid tribute to the workof the catholic missions who quietly got onwith work providing care, particularly inthe most remote areas.They were one of thebiggest providers of help globally and inAfrica provided 10% of the aid forHIV/AIDS care.
The Secretary General invited to speak tohis written report, (see 49 for the fullreport), said that the first part concernedthe Caring Physicians of the WorldInitiatative and it was appropriate there-fore that Dr. Yank Coble should presentthis.
Dr. Coble, referring to the World MedicalJournal (WMJ 2006, 52, (1), 11) said thatthe start of this project was in Helsinki. Thebook had been launched in Santiago, hadbeen sent to NMAs and will go to allMinistries of Health. It had been distrib-uted to Ministers in Bangkok, Taiwan,India, to the President of the United Statesof America and also to many internationalbodies. The programme had been expandedthrough regional meetings in Johannisburg,Bangkok, Prague, North and SouthAmerica. He was delighted that these meet-ing provided firm evidence that peoplewould agree on the enduring traditions ofCaring, Ethics and Science in medicine.
Dr. K. Iwasa
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The Secretary General, Dr. Otmar Kloiber,expressed his pleasure at being part of theseactivities which also increased the visibilityof the WMA, especially for those memberswho cannot get to global meetings such asthose of the Council and the GeneralAssembly. Returning to his report he said thatmuch of the work had concentrated on gover-nance, statutory reform, finance and balanc-ing the budget. Referring to problems of get-ting NMA subscriptions, he reminded NMAsof the need to pay both in time, and in full.
There had been continuing discussion onfinance and partnerships and he pointed outthat engagement in new activites could notbe done without forming partnerships.
Turning to the World Health Professions’Alliance (WHPA), he reported that cooper-ation had been very positive, although pos-sible points of critical discussion had still tobe faced by the Alliance, such as sharedcompetences and the limits of each profes-sion. The Alliance was in agreement that theWorld Health Report (WHR) on the workforce was distorted. There was an emphasisin this WHO report on training lay people,but while some of this emphasis had beenmodified during the preparation of thereport, there were still statements about selfregulation and a preference for a “commandand control” style. The so called “GlobalAlliance for the Workforce for Health” hadprepared its work without the HealthProfessions. The WHPA had asked for a dis-cussion on the World Health Report withthe Director General. As it was not possibleto see him about their concerns beforeWorld Health Day, the Health ProfessionsOrganizations did not participate in this.
There was a need to cope with the problemof representation at WHO. This would be acore part of the strategic development of theWMA.
Both Dr. Blachar and Dr. Letlape concurredin their concern that the WHR possiblydowngrades the profession.
Dr. Blachar thanked Dr. Kloiber, in particu-lar for his work in taking over WMA at adifficult time and in fulfilling the Council’sexpectations.
In response to a question about the obliga-tion of the Chinese Medical Association to
include a member of the governmentamongst the senior officers of theAssociation, Dr Coble observed that at thetime of the SARS epidemic, the VicePresident of the Chinese MedicalAssociation was a Minister, the executiveVice President and executive staff werepolitically determined.
Council then adjourned for the Meeting ofthe
Finance and PlanningCommittee
This meeting was opened by the Chairman,Dr. John Nelson and the minutes of the lastmeeting in Santiago were approved.
Dues
The committee considered various reportsconcerning NMAs’ dues and actual duespayment; also the status of council mem-bers and officers during their term of officein the event of irregularities in payment ofdues by their NMA. Legal counsel con-firmed that NMAs who are represented onCouncil are required to pay their dues onschedule, or have a written agreement withthe Secretary General that they will be reg-ularised before the General Assembly. TheSecretary General outlined the process ofdealing with non dues payment, a processwhich now leads to the termination of sin-gle membership.
Financial statement 2005
After further discussion on the issue of nondues payment, the committee consideredthe financial statement for 2005, presentedby Mr. Adi Häallmayr who gave a particu-larly clear transparent presentation of thesituation. The Council noted the remarkableachievement of “turn round” in the financialposition which had taken place, achieving abalanced budget for the first time in years.This was thought to be impossible in thespace of a year and the Secretary Generalwas congratulated on this achievement.This, Dr. Kloiber reported had been largelydue to strict budgetary constraints on activ-ities and a number of other factors whichwere included in Mr Häallmayr’s report.
In response to a question as to whether thisimprovement was sustainable, the SecretaryGeneral responded positively, but only ifthe WMA confined itself to its Core busi-ness. Any extra activity would call for extrafinancing. Concerning any advantage to begained by moving from Ferney Voltaire toGeneva, he referred to a relevant study cur-rently being undertaken by the WorldDental Federation.
The committee recommended that the pre-liminary financial statement for 2005 beapproved, also by council later.
Governance changes
The Finance and Planning Committee dealtwith the Governance changes that had beendeveloped over the last year. These recom-mended changes in the Bye laws includinga limitation of the terms of officers to amaximum time of six years, during which acouncil member could hold a specific func-tion. Furthermore the Executive Committeeconsisting of the chairpersons of Council,the Committees and the Treasurer, wasenlarged to include the President as a non-voting member. The executive committeewill serve at the request of the CouncilChair and will advise the Chair of Council,Council and the Secretary General. Theamendments to the Bye-Laws were recom-mended for approval and submission to theGeneral Assembly. This was subsequentlyapproved by Council.
Business development Group
An oral report from the Business develop-ment Group was considered. Eight optionswere identified and the group sought toidentify two for initial consideration. A sur-vey of the views of participants present atthe council meeting on the options was dis-tributed.
Strategic Plan
The Secretary General presented theStrategic Plan for 2006-2010. He comment-ed that during the Caring Physicians of theWorld Initiative and the Strategic surveythey had learnt that there was a need forclear advocacy work called for by mostNMAs, an issue which was also discussedin parallel by the Business Group. Referringto the document he indicated that before the
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committee there were three areas reflectingNMAs needs, namely, Ethics Guidanceincluding Social- Medical Questions,Advocacy Representation and Service andOutreach.
Dr. Kloiber said that outreach servicesneeded to be developed, as did Advocacy.The Ethics Unit needed to be strengthenedand this was the way forward to maintainthe high reputation of WMA, as exempli-fied by Helsinki, Geneva and Tokyo. Hepaid tribute to the outstanding work of Dr.John Williams both in the unit and his othercontributions in the representational work.Speaking generally about ethics, he felt thatmore attention needed to be given to begin-ning and end of life issues, many of whichmay not lead easily to consensus agree-ments. Issues of cloning, of stem cells andof the use of modern technology and itsproblems need equal attention. We alsohave our own problems. NMAs should bechallenged to report back if WMA guidancewas not acceptable. Prison Medicine andmulti-drug resistant tuberculosis need to betackled. Awareness of the problems ofyoung physicians and young students mustbe strengthened and WMA needs to advo-cate for them. Referring to the importanceof the location of the Office near to Geneva,he outlined the opportunities this providedfor discussions with the UN, WHO, ILO,the Commission on Human Rights etc..There was however some limit on howmuch the Secretary General and Dr.Williams could do. Asking NMAs to sit inon some meetings was difficult as meetingswere often at short notice and air fares cost-ly. Nevertheless in order to avoid lostopportunities, there is a need for moreinvolvement of NMAs.
Services and support to NMAs also need tobe strengthened. In this connection he wasglad to respond to NMAs who ask for help,but this had to be within the limits imposedby shortage of staff.
The services to individual associate mem-bers need to be broadened. The web portaland other projects should to be part of theoutreach to associates. The benefits of asso-ciate membership need to be strengthenedbeyond receipt of the WMJ and insurance.The Journal now has a new image, is now
more orientated to WMA work and offers aplatform for discussion.
Dr. Haddad welcomed the SecretaryGeneral’s plan. The three areas highlightedwere absolutely right and should be used tobuild upon. He agreed with the emphasis onAdvocacy, but more resources were needed.
The committee recommended that the Chairof the committee and the Secretary Generalconvene a working party to develop animplementation plan proposing specificobjectives, deliverables and time tables,with cost estimates for the actions proposedin the Strategic Plan.
In further discussion the committee consid-ered the financial implications of expandingthe advocacy role, the manpower needs todevelop the Ethics Unit, to deal withDocumentation and the development of thewww portal etc.
Future General Assemblies
The arrangements for the 2006 WMAGeneral Assembly in South Africa werereported. The Danish Medical Associationproposed “Health Care InformationTechnology” as the theme of the ScientificSession in Copenhagen in 2007, but thefinal decision on the theme would be for the2006 General Assembly to decide.
Associate members
The report on Associate membership wasreceived.
Public relations
The Committee received the report of thePublic Relations consultant and thankedMr. Nigel Duncan for his work.
World Medical Journal
The committee received the report of theEditor of the World Medical Journal and theHon Editor stressed that a successor had notyet been identified. The Chair recognisedthe need to identify a successor to Dr. AlanRowe soon and thanked him for his consid-erable efforts.
The Ethics Committee
Dr. Eva Bagenholm, opening the meetingwelcomed new members, following which
the minutes of the last meeting in Santiago2006 were approved.
Ethics Unit
Dr. Williams, who will be leaving theWMA Ethics Unit at the end of the year,presenting the report of the Ethics Unit,informed the committee that the EthicsManual had now been translated intoMacedonian, Albanian, Taiwanese, Indo-nesian and Chinese, French and Spanish. Itwas hoped to produce the manual as a CDROM in three languages. The Bulgarianshad also offered to translate it, bringing thetotal translations to 19 languages. An on-line version in Norwegian will soon beavailable as well as Arabic, if funds areavailable.
Policy review
The committee then considered proposedchanges to policy and NMAs comments onthem.
The Declarations of Geneva, of Tokyo andthe Regulations in Times of Armed Conflictwhich had undergone minor revision (seepages 29, 34, 35 for the revised texts), wererecommended for approval and were laterapproved by council.
The committee then considered policiesclassified as requiring major amendment.
In the list of amended documents recom-mended for approval (see list below),notable points raised included the removalof Human Tissue from the proposed revisedStatement on Human Organ Donation andTransplantation. This was requested inorder to distinguish between organs and tis-sues, which were subject to different legaltreatment in European Community legisla-tion. The German Medical associationagreed to develop a new proposal for astatement on Human Tissue Donation.Other amendments to the original text wereadopted.
The proposed revision of the InternationalCode of Medical Ethics led to considerablediscussion which substantially focused asmuch on the concepts underlying proposedphrasing, as on individual words. Afteragreement on some word changes, it wasagreed that a new working group would fur-
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ther consider the revision, the group to beled by the Icelandic Medical Associationand includes members from the MedicalAssociations of Canada, Israel, Slovakiaand the United Kingdom.
After some discussion of the 1996 PolicyStatement on Weapons and their relation toLife and Health Issues which had been rec-ommended for minor revision, followingNMAs’ expression of views, it was agreedthat the BMA would do a revision for con-sideration at the next meeting.
Concerning those WMA policies undergo-ing major revision the committee recom-mended and, with some changes in theDeclaration of Oslo, the Council laterapproved the following:
• That the Proposed Revision of theInternational Code of Medical Ethics beassigned to a new working group led bythe Icelandic Medical Association andincluding the NMAs from Canada,Israel, Slovakia and the UnitedKingdom;the Proposed WMA Statement onHIV/AIDS and the Medical Professionbe approved and forwarded to the 2006General Assembly for adoption and thatthe Interim Statement on AIDS, Statement onthe Professional Responsibility ofPhysicians in Treating AIDS Patients,and the Statement on Issues Raised bythe HIV Epidemic be rescinded andarchived.
• That the Proposed Revision of theDeclaration of Venice on TerminalIllness be approved and forwarded to the2006 General Assembly for adoption andthat the Statement on the Care ofPatients with Severe Chronic Pain inTerminal Illness be rescinded andarchived;the Proposed Revision of the Statementon Human Organ Donation andTransplantation, as revised, be approvedand forwarded to the 2006 GeneralAssembly for adoption; the Proposed Revision of the Statementon Ethical Issues Concerning Patientswith Mental Illness, as revised beapproved and forwarded to the 2006General Assembly for adoption;
the Proposed Revision of theDeclaration of Sydney on theDetermination of Death and theRecovery of Organs as re-titled, beapproved and forwarded to the 2006General Assembly for adoption;the Proposed Revision of the Declarationof Oslo on Therapeutic Abortion, asrevised and amended by Council, beapproved and forwarded to the 2006General Assembly for adoption;the Proposed Statement on AssistedReproductive Technologies be approvedand forwarded to the 2006 GeneralAssembly for adoption; and that theStatement on In-vitro Fertilisation andEmbryo Transplantation and theStatement on Ethical Aspects ofEmbryonic Reduction be rescinded andarchived.
• That the Proposed Revision of theStatement on Animal Use in BiomedicalResearch be approved and forwarded tothe 2006 General Assembly for adop-tion; the Proposed Revision of the Statementon Medical Ethics in the Event ofDisasters, as revised be approved andforwarded to the 2006 General Assemblyfor adoption;the Proposed Revision of the Statementon Child Abuse and Neglect, as revised,be approved and forwarded to the 2006General Assembly for adoption;the Proposed Revision of the Statementon Patient Advocacy and Confiden-tiality, be approved and forwarded to the2006 General Assembly for adoption;andthe Statement on Foetal Tissue Trans-plantation be rescinded and archived.
• That the Proposed Revision of theDeclaration of Malta on Hunger Strikersbe referred to NMAs for comment, alongwith a background paper and glossary ofterms prepared by the BMA.(see pxxx)
The recommendations were later app-roved by council.
Human Rights
The Secretary General reporting on HumanRights matters, said that the CD ROMCourse for Prison Doctors was completed in
English and Spanish, Mr. Hernan Reyes(ICRC) added that the French version wasvirtually complete and the CD ROM wouldthen be in English, French and Spanish. Dr.Terje Vigen (Norway) stated that a Chineseversion was under discussion. Dr. Kloiberresuming his report reminded the commit-tee of WMA’s participation in the teachingproject in relation to the Istanbul Protocol.The number of countries who would permitthis to take place was unfortunately limited.
Speaking of problems which had come tothe WMA, he spoke first about GuantanamoBay. The American Medical Associations intheir discussions with the USA governmenthad made WMA policy on this issue veryclear and the AMA continued to be veryhelpful.
Referring to Cuba he reminded the commit-tee that two years ago doctors were impris-oned for speaking among other issues aboutproblems of health care and of preferentialtreatment for some parts of the population.The WMA had appealed for better condi-tions and for the release of those doctorsimprisoned. Dr. Parsa-Parsi had attended ameeting on Medical Apartheid in Cubawhich was held in Germany. Dr. Parsa-Parsisaid that medical care was available forTourists and High Officials in reasonableconditions but there were few facilities forthe rest of the population. There was a highabortion rate in the absence of birth control,especially amongst the younger population.He also spoke of the suffering of doctorsimprisoned in inhuman conditions whosefamilies had evidence of their bad physicalstate. Dr. Kloiber urged NMAs to pick upthis issue and support these doctors.
China
The Secretary General then addressed thesubject of China. He reminded the commit-tee that they had asked him to write to theChinese Medical Association about the har-vesting of organs from executed Chineseprisoners. This matter had already been dis-cussed at a time when China applied to be amember of WMA in 1997. Last year theTimes newspaper had reported that theDeputy Minister of Health admitted thatthis activity had taken place but stated thatregulations would deal with this.Nevertheless advertisements still appeared
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from hospitals offering kidney transplantsobtained from this source. Since then therehave been reports that Chinese doctors haveparticipated in removing organs from exe-cuted prisoners, and allegations have evenbeen made that vivisection is taking place.
The Secretary General wrote to the ChineseMedical Association as instructed and hadhad no reply. Likewise there had been noreply to a second letter in December 2005,requesting that the association confirm itssupport of WMA policy on this matter asfor all other policies, in accordance with theWMA conditions of membership.
In view of the consistent failure to reply notonly to letters but also to e-mails and faxesetc, the Council now had to consider furtheraction.
In the ensuing discussion, speakers soughtclarification that the policy referred to wasthat prisoners were in no position to giveinformed consent and that physiciansshould not participate when organs wereremoved from prisoners after execution.This was confirmed and it was further indi-cated that China was a fully paid up mem-ber of WMA in 2004.
Following extensive discussions duringwhich very deep concern was widelyexpressed, it was proposed and agreed thatthe secretariat prepare a document with allthe evidence of these practices, for informa-tion and use by NMAs. The followingResolution was later adopted unanimous-ly by the Council after further discussion.
The committee also recommended andcouncil later approved:
“That the Secretary General forward theResolution on Organ donation in China to theChinese Medical Association with a letterexpressing the council’s grave concerns. Theletter will indicate that the Council had dis-cussed future possible actions with respect tothe Chinese Medical Association in the eventthat it did not respond to WMA with anexpress condemnation of this practice and itssupport of WMA policy on this issue.”
Taiwan
The committee also reviewed its concernsabout WHO denial of participation of
Taiwan in the World Health Assembly andother technical meetings and adopted thefollowing recommendation which Councillater endorsed:
“That the WMA issue a press release reaf-firming its position on the status of Taiwanas an observer at the World HealthAssembly, the importance of the meaning-ful participation of Taiwan in technicalmeetings of the World Health Organisationand urging that Taiwan’s status and partici-pation not be hindered by excessive bureau-cratic or administrative requirements.“
Socio-Medical CommitteeThe Socio-Medical Affairs committee metunder the Chairmanship of Dr. HenryHaddad and approved the minutes of themeeting in Santiago 2006.
Policy Revision
The committee proceeded to consider com-ments from NMAs on policies requiring
major revision, using the consent agendaprocedure (the final recommendations ofthe committee are set out below). Under thisprocedure, which agrees all items other thanthose identified by committee members asindicating a need for discussion, followingshort discussion, the Statement on MedicalEducation was approved, as was that onAdolescent Suicide and Traffic Injury.
There was some discussion on the Role ofPhysicians in Environmental Issues inwhich the importance of the environment indisease was stressed It was pointed out thatthe European Union had addressed thistopic, but that this was ,of course, a world-wide issue. The document was drawn up in1997 and it was suggested that the docu-ment needed to be expanded. It was recom-mended that a working group be established(see below)
The committee’s recommendations, lateragreed by Council, were
• That the Proposed Statement on MedicalEducation be approved and forwarded tothe 2006 General Assembly for adop-tion; the Fifth World Conference on MedicalEducation and the Declaration ofRancho Mirage on Medical Educationbe rescinded and archived;the Proposed Revision of the Statementon Adolescent Suicide, (as revised), beapproved and forwarded to the 2006General Assembly for adoption;the Proposed Revision of the Statementon Traffic Injury, as revised be approvedand forwarded to the 2006 GeneralAssembly for adoption.
• That a Working Group be established toaddress the topic of the Role ofPhysicians in Environmental Issues.
• The Working Group, composed of theNMAs from France, Brazil, South Africaand the United States, will review all ofthe proposed documents developed todate on this subject.
• That the Proposed Revision of theStatement on Health Promotion bereferred to NMAs for comment;the Proposed Revision of the Statementon Injury Control be referred to NMAsfor comment;
Council Resolution on OrganDonation in China Whereas, the WMA Statement on HumanOrgan and Tissue Donation and Transplanta-tion stresses the importance of free andinformed choice in organ donation, andWhereas, the statement explicitly states thatprisoners and other individuals in custody arenot in a position to give consent freely, andtherefore their organs must not be used fortransplantation, and Whereas, there have been reports of Chineseprisoners being executed and their organs har-vested for donation,Therefore, the WMA reiterates its position thatorgan donation be achieved through the freeand informed consent of the potential donor.
The WMA demands that the Chinese MedicalAssociation condemn any practice in violationof these ethical principles and basic humanrights and ensure that Chinese doctors are notinvolved in the removal or transplantation oforgans from executed Chinese prisoners.
The WMA demands that China immediatelycease the practice of using prisoners as organdonors. 20.05.06
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the Proposed Revision of the Statementon Access to Health Care be referred toNMAs for comment;the Proposed Revision of the Statementon the Twelve Principles of Provision ofHealth Care in Any National HealthCare System be referred to NMAs forcomment;the Proposed Statement on theResponsibilities of Physicians inPreventing and Treating Opiate andPsychotropic Drug Abuse be referred toNMAs for comment andthe Proposed Revision of the Statementon Alcohol and Road Safety be referredto NMAs for comment.
After considering NMAs’ suggestions forclassifying the five Socio-Medical Affairspolicies adopted in 1996 the committee rec-ommended and Council later agreed
• that the Statement on Family Planningand the Right of a Woman toContraception undergo major revisionby the British Medical Association andthe Statement on Resistance toAntimicrobial Drugs undergo majorrevision by the American MedicalAssociation;
• That the Declaration on Family Violenceand the Statement on ProfessionalResponsibility for Standards of MedicalCare undergo minor revision.
• That the Resolution concerning Dr.Radovan Karadzic be rescinded andarchived.
Tuberculosis
During the consideration of NMAs’ com-ments on a proposed Statement onTuberculosis, the committee proposed thatthe Resolution on Tuberculosis as revised,be approved and forwarded to the 2006General Assembly for adoption and that the1997 Statement on Drug treatment ofTuberculosis be rescinded and archived.This was subsequently agreed by Council
In an oral report by the Secretariat onprogress in the development of the on-linecourse on the treatment of drug-resistantTB, reference was made to the success ofthe Geneva Press conference, that a chapteron Tuberculosis in prisons had been added
by ICRC, that the text material would betested in South Africa and then be translat-ed into other languages.
Medical Assistance in Air Travel
There was considerable discussion on aResolution, originally proposed in theAssociates’ meeting, on Medical Assistancein Air Travel. The Secretary General point-ed out that this dealt with the problems andthe risk of physicians’ liability whenresponding to calls for medical assistance inthe air. He considered that this needed to beregulated internationally. While in somelegislation there was a limit on the financialliability in these circumstances, a speakercalled for the enactment of legislation toprovide immunity from liability action tothose physicians who provide emergencyassistance in in-flight incidents. A furtherspeaker pointed out that the request forassistance came from the airline and itcould be that the Aviation Authority shouldaccept the liability. It was also suggestedthat the Airlines should regard the doctor asan employee in these circumstances.Several speakers observed that there couldbe no immunity from criminal liability anda suggestion was made that in the absenceof immunity from legal liability, airlinesmust “accept all legal and financial conse-quences of asking for assistance”.
Dr Kloiber said that there were differencesin legal responsibilities in different coun-
tries. After amendment, the committee rec-ommended “that the Resolution on Medicalassistance in Air Travel, as revised, be rec-ommended for approval and forwarding tothe 2006 General Assembly for adoption.This was subsequently approved byCouncil.
Discussion of a proposed Resolution onChild Safety in Airline Travel was deferred,pending a review of this topic by theGerman Medical Association
Avian and Pandemic Influenza
Finally, the committee recommended that inview of the importance and urgency of thisissue:
“The Proposed WMA Resolution on Avianand Pandemic Influenza, be sent withoutdelay to NMAs, and that NMAs be urged touse the recommendations in the documentin their policy and advocacy activities, inadvance of further consideration of thistopic at the 2006 General Assembly”.
Further Council discussion
In addition to the decisions of Council inthe second part of its meeting set out above,the Russian Medical Society made a state-ment about the situation of physicians inRussia clarifying that the PirogovConferences were called by the HealthMinister. They were not meetings ofNational Medical Associations. TheChairman of Council took note of this.
Secretary General’s Report to the 173rd WMA Council Session(October 2005 – April 2006)
Consolidation
The year 2005 was determined by the seri-ous financial situation of the WMA. Theyears before the operation of the WMA
ended with deficits, thus consuming signif-icant parts of its assets. It therefore was thefirst priority to maintain strict control overthe WMA finances. This has been success-fully achieved by
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• Consulting with the executive treasurer,who immediately reorganized ourinvestments and cash management andthereby stopped financial losses.
• Quarterly financial reports, allowing bet-ter control over the financial and eco-nomic situation.
• Priority setting: The World MedicalAssociation has been involved in a vari-ety of fields which certainly are relatedto medicine and the work of physicians,however we were not able to provide auseful and sustainable service. Thoseactivities were terminated or reducedand will only be revived, if an idealisticor material net value can be obtained forthe association or its members.
• Reviewing contracts and business rela-tions. We examined all contracts fornecessity and price-worthiness. In manycases we achieved better prices for thesame service or better service for thesame price. We reduced spending fortravel and representational expenses toan absolute minimum.
• Outsourcing. After the resignation of ourFrench translator the position has notbeen refilled. French translations arenow being done by an outside translatorat lower cost to the association with noloss in quality and speed.
• Application of rules. Consulting with theexecutive committee, the financial offi-cers or the Sponsorship advisory com-mittee leed to clear governance andfinancially sustainable partnerships andsponsorship arrangements, thus reducingthe risk of financially non-sustainableengagements or ethically questionableliaisons.
The strict application of these methodshelped to achieve a balanced budget for2005 much earlier than anticipated.However, this does not mean that the WMAis in a financially comfortable situation:
• The income from dues is still unstable.Again in 2006 some major dues did notcome in time or as agreed, some did notcome in full.
• Some member associations pay onlynominal dues, some because clearly their
financial situation does not allow other,some which have obviously other rea-sons.
• Even with a complete income from duesthis would not allow extra activities,which increase our visibility, presence atinternational organization or own activi-ties providing service to our members orthe general public.
• Revenue from sponsorship is problemat-ic as it may produce dependency we donot wish and as it is of course in thehands of a partner whether to engage ornot.
• With the opening of the borders betweenSwitzerland and the European Unionconsumer prices and labour costs adapt-ed to the level of the dominating Swissneighborhood,.the once very cheapFrench area “Pays de Gex” west ofGeneva has become one of the mostexpensive areas in Europe.
Caring Physicians of theWorld Initiative
Prior to our General Assembly in Santiagode Chile, October 2006 we organized aregional conference with the LatinAmerican Confederation of MedicalAssociations CONFEMEL in Santiago on10/11 October 2006 and we publiclylaunched the Caring Physicians of theWorld-Book on October 12th. Since then thedistribution of the Caring Physicians of theWorld-Book has continued and its receptionis overwhelmingly positive. We have notreceived a single negative comment on thebook, but a great deal of support and inter-est in it.
The campaign is about values, dedicationand pride and upholding our traditions ofcaring, ethics and science. At the same timein our conferences we are addressing thecurrent needs of the member associationson a very practical level. With own confer-ences in Europe and North America and theparticipation of WMA leaders in regional ornational meetings in various places, we arecontinuing the CPW campaign.
Regional LeadershipConferences
Latin America
Together with the Confederation of MedicalAssociations in Latin-America CON-FEMEL the World Medical Associationheld a regional conference prior to ourGeneral Assembly in Santiago de Chile,October 9th and 10th. The Cooperation withCONFEMEL allowed us to meet not onlywith our regional member associations, butalso other medical associations which existeither in parallel with our members in someof the countries or which are from countrieshaving no association with WMA memberstatus. The conference dealt with issues ofhealth system reform and continuing pro-fessional development.
Europe
The heads of the European MedicalAssociations in the WMA met in Prague,December 9th and 10th. The leadership sem-inar focused on:
• Health and Human Resources, analysingthe global trends of migration from southto north and in the European region fromeast to west. In general the migration fol-lows an economic gradient from poorerto richer countries, from less favorable tobetter working conditions. Concerningthe situation in Africa it was noted thatfor many countries there, the loss ofhealth professionals is catastrophic. Insome of the European countries italready leads to a significant shortage ofprofessionals endangering continuationof care especially in rural areas.Among the factors that make profession-als migrate are not only payment issuesbut also too high workloads, inadequateworking circumstances and overburden-ing democracies. In European countriesthe loss by migration into other countriesis even exceeded by loss to other occu-pations of young physicians and thechoosing of early retirement by estab-lished physicians.
• In Germany, Belgium and France, strikesand demonstrations of doctors were theapparent signs of a deep dissatisfactionwith the conditions doctors have to work
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under in many European Countries. Apresentation on the perception of the cur-rent protest actions taken by doctorsespecially in Belgium and Germanyshowed an overwhelming support by thepublic for the strikes and demonstrationsof the doctors.
• A second session dealt with pandemicpreparedness and the threat of the avianflu outbreak turning into a human pan-demic. Although in all of the countriesrepresented pandemic plans werealready prepared or under preparation,the overall preparedness was not seen tobe sufficient. Questions of management,resource allocation but also preventivestrategies remained still open. The repre-sented leadership felt it necessary thatthe National Medical Associationsshould be more strongly involved in thediscussion of and preparation for a pos-sible pandemic. Finding a fine line andappropriate risk communication that onthe one hand explains the threats andnecessity for preparation, but on theother hand does not trigger panic, seemsto be the challenge in which the organi-sations of physicians can help most.
It was mentioned by some of those presentthat regional conferences like the one inPrague would offer possibilities for partici-pation
North Americas
Leaders of the Canadian, American andMexican Medical Associations met onAmelia Island, Florida, March 24th and 25th
to discuss – for the first time in this group –emerging health topics for the region withleading experts from academic institutionsand the industry.
• The development of the profession, itsnew challenges through rapid changes intechnology, demography and patientdemands meet in North America with asharp deficit of health professionals.Currently the health care markets inCanada and the United States are thestrongest magnets for health profession-als. This stimulates a global migration asit has been described in our preceedingEuropean conference (see above). Newtechnologies but also better planning for
the health work force may counteract theproblems of human resources.
• For many years now counterfeit drugshave been observed and registered as aserious threat to the developing nations.However the notion that this is a prob-lem of developing countries is a mistake.Counterfeit drugs probably occur in allcountries, certainly in the rich countriesof the northern hemisphere. This posesmultiple dangers:
• Counterfeits are theft of intellectualproperty. They reduce the return oninvestments others have made andreduce the resources for new develop-ments.
• Counterfeits are of uncontrolled qual-ity. They may or may not contain theactive substance, they may or may notbe dosed correctly, they may or maynot carry other poisonous substances,and they may deteriorate faster thandescribed on the package
• Counterfeits destroy trust. The occur-rence of counterfeits severely endan-gers patients’ compliance.
It will be challenge for us to help todetect counterfeits (by just consideringthem), but at the same time not to dimin-ish the compliance of our patients.
• Although North America has beenspared from infection with the avianinfluenza virus H5N1, the threat of aglobal health pandemic exists for theAmericas as for any other region in theworld. Although our knowledge aboutthe pandemic development and the med-ication options, both those for prevention(vaccines), therapy (anti-virals) and thetreatment of opportunistic infections(antibiotics) have strongly improved, therisk has grown as well. A century agopandemic spread was somewhat limitedby the slowness and low density of trans-portation. At that time traveling aroundthe world took weeks, but now it takesonly hours and before a serious virusmay be diagnosed, it most likely to havealready landed on another continent. Ourawareness of this threat has to beincreased and our resources, communi-cations structures and our regulations,
have to be tested in the preparedness fora global pandemic.
The three North American MedicalAssociations agreed to work on a commonaction plan.
World Health ProfessionsAlliance (WHPA)(www.whpa.org)
In 1999 the International Council of Nurses(www.icn.ch), the International Pharma-ceutical Federation (FIP) (www.fip.org) andthe WMA founded the World HealthProfessions Alliance. The alliance aims areto foster the cooperation of the professionalorganizations and to augment our advocacywork with the international organizations,especially the WHO and the public. Lastyear the World Dental Federation (FDI)(www.fdiworldental.org) joined the alli-ance.
Since its inauguration the WHPA has takenan active role in the anti-tobacco initiative,in the fight to protect human rights, therecognition of the HIV/AIDS pandemic andagainst discrimination of the mentally ill. Itpromoted awareness on issues such asantimicrobial resistance, nutrition andhealth care for the elderly. The WHPA hasengaged in leadership issues and has oftenovercome objections of officials who preferto speak with a “single” health profession.
During the last year WHPA has cooperatedwith the International Alliance of PatientOrganisations, IAPO (www.iapo.org). Onthe occasion of its second annual meeting inFebruary 2006 the WMA President, Dr.Kgosi Letlape, represented the WorldHealth Professions Alliance and spoke ontheir behalf on patient safety.
The WHPA serves as a platform for variousdiscussions and initiatives in health care.
• it cooperates closely with the WHO andthe Industry to combat counterfeit drugsand materials,
• it develops guidelines for the compe-tence of international health care consul-tants,
• it discusses overlapping educationalissues and
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• it serves as a common platform on healthprofessional issues with WHO.
The latter point has led to a personal discus-sion with the Director General of WHO, Dr.Lee Jong-wook. Dr. Lee met with theSecretaries of the four WHPA Associationson April 3rd, 2006. In the meeting theAssociations documented their interest andneed for a closer relationship with WHOand their preparedness for a stronger coop-eration especially on human resource relat-ed issues. The secretaries’ expressed theiropinion that there is a need to further dis-cuss some aspects of the World HealthReport 2006 in common. It was agreed thatthe relative status of the health professionsassociations be revised and that commonwork on human resources issues with afocus on regulation should start as soon aspossible. We were not able to achieve a sig-nificant role in the “Alliance for the work-force for health” under preparation byWHO.
The WHPA LeadershipSymposiumIn May 2004 the WHPA staged its firstWHPA leadership symposium. The sympo-sium aimed to strengthen the bond andencourage collaboration between the threehealth professions at the country level.
The second biennial WHPA Leaders’ Forumwill be held on May 20-21, 2006 in Geneva,Switzerland. The main focus of this forumis patient safety, highlighting the criticalrole of health professionals. Daniel Ford ofthe National Patient Safety FoundationPatient and Family Advisory Council willlead a discussion on building blame-free,responsible health care environments. Theways in which health professionals cancombat counterfeit medicines will also bediscussed, along with the importance ofhealth professionals working together.
The European Forum ofMedical Associations andWHO (EFMA) Budapest 21-22 April 2006
The EFMA is a common forum of MedicalAssociations of the WHO-Region “Europe”
and the WHO EURO in Copenhagen.Although existing now for nearly a quarterof a century WHO has lost interest in theForum during the last years under the lead-ership of the current director, Dr. MarcDanzon in the year 2000. This year thedeputy director of WHO EURO, Dr. NataMenabde, joined the Forum in lieu of theRegional Director who was unable to attendbecause of illness. This was the first partic-ipation of WHO leadership since the year2000.
The current leadership made it clear that thesupport formerly given to this Forum couldnot be reestablished. However, the WHOoffered partnerships for the establishmentof common projects.
The Forum discussed among others topics
• National patients’ records databases, andstressing the importance of having theusers of these systems, patients andhealth professional included in the plan-ning of the systems.
• Collaboration between the medical pro-fession and the pharmaceutical industry,including the guidance given by theStanding Committee of EuropeanDoctors (CPME).
• Threats to health and pandemic pre-paredness
• Patient safety and “no blame” approach-es were discussed using the example ofthe legally regulated blame free report-ing system in Denmark, and
• Health policy reforms in Europe. TheForum received reports on the current sit-uation in Albania, Germany, Kazakhstan,Croatia, United Kingdom, Byelorussiaand Azerbaijan. It was apparent that inmost of the countries the governments,while on one hand talking about morecompetition, on the other they are moreand more regulating the health care sys-tems directly and by that doing just theopposite of what they are preaching.Professional autonomy and self-regula-tion are under pressure. A presentation onthe perception of the current industrialactions taken by doctors especially inBelgium (last year) and Germany (ongo-ing) showed an overwhelming support by
the public for the strikes and demonstra-tions of the doctors.
Other national or regionalmeetings
WMA officers or the Secretary Generalattended national meetings of the followingWMA member associations or their region-al groups:
• Colegio Médico de México
• Indian Medical Association
• Medical Associations of the South EastAsian Nations (MASEAN)
• Standing Committee of EuropeanDoctors (CPME),
On-line Course on treatmentof multi-drug resistant tuber-culosis (MDR-TB)
Following the success of the online coursefor prison medicine,WMA decided to trans-late the new WHO guidelines for the treat-ment of multi-drug-resistant tuberculosisinto a course that would help doctors whotreat patients with MDR-TB. The guide-lines were finally published with a consid-erable delay in the fall of last year.
The development of an online course on thetreatment of multi-drug-resistant tuberculo-sis has been nearly completed. The finalproduct will be launched in mid-June. Theproject is a cooperation with the Foundationfor Professional Development of the SouthAfrican Medical Association and theNorwegian Medical Association. It wasmade possible by a grant from Eli Lilly, Inc.
Assignment to regions
The Indonesian Medical Association hasbeen reassigned to the Pacific Region ontheir own request. This assignment is effec-tive from the beginning of 2006.
The new member, the Singapore MedicalAssociation, has been assigned to thePacific Region.
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national sources, as well as from interna-tional development partners. The Reportrecommends that of all new donor funds forhealth, 50% should be dedicated tostrengthening health systems, of which 50%should be dedicated specifically to training,retaining and sustaining the health work-force.
At least 1.3 billion people worldwide lackaccess to the most basic healthcare, oftenbecause there is no health worker. Theshortage is global, but the burden is greatestin countries overwhelmed by poverty anddisease where these health workers areneeded most. Shortages are most severe insub-Saharan Africa, which has 11% of theworld's population and 24% of the globalburden of disease but only 3% of theworld's health workers.
The Report calls for prompt and innovativeinitiatives to improve efficiency. For exam-ple, HIV/AIDS, TB and other priority dis-ease programmes have implemented waysfor health workers with limited formaltraining to successfully carry out specifichealth tasks. These experiences should bedrawn upon to develop national healthworkforce strategies.
The World Health Report recommends thatin order to achieve the goal of getting “theright workers with the right skills in theright place doing the right things,“ countriesshould develop plans that include the fol-lowing:
• Acting now for workforce productivity:better working conditions for health work-ers, improved safety, better access to treat-ment and care;
• Anticipating what lies ahead: a well-developed plan to train the health work-force of the future;
• Acquiring critical capacity: workforceplanning; development of leadership andmanagement; standard setting, accredita-tion and licensing as drivers for qualityimprovement.
Beyond the national strategies the reporturges global cooperation:
• Joint investment in research and informa-tion systems;
WHO
Health workforce crisis is having a deadlyimpact on many countries’ ability to fightdisease and improve healthWorld Health Report outlines need for more investment in health workforce toimprove working conditions, revitalize training institutions and anticipate futurechallenges
GENEVA/LUSAKA/LONDON – A seriousshortage of health workers in 57 countries isimpairing provision of essential, life-savinginterventions such as childhood immuniza-tion, safe pregnancy and delivery servicesfor mothers, and access to treatment forHIV/AIDS, malaria and tuberculosis. Thisshortage, combined with a lack of trainingand knowledge, is also a major obstacle forhealth systems as they attempt to respondeffectively to chronic diseases, avianinfluenza and other health challenges,according to The World Health Report 2006- Working together for health, published bythe World Health Organization.
More than four million additional doctors,nurses, midwives, managers and publichealth workers are urgently needed to fillthe gap in these 57 countries, 36 of whichare in sub-Saharan Africa, says the Report,which is highlighted by events in manycities around the world to mark WorldHealth Day. Every country needs toimprove the way it plans for, educates andemploys the doctors, nurses and supportstaff who make up the health workforce andprovide them with better working condi-tions, it concludes.
“The global population is growing, but thenumber of health workers is stagnating oreven falling in many of the places wherethey are needed most,“ said WHO Director-General Dr LEE Jong-wook. “Across thedeveloping world, health workers face eco-nomic hardship, deteriorating infrastructureand social unrest. In many countries, theHIV/AIDS epidemic has also destroyed thehealth and lives of health workers.“
The World Health Report sets out a 10-yearplan to address the crisis. It calls for nation-
al leadership to urgently formulate andimplement country strategies for the healthworkforce. These need to be backed byinternational donor assistance.
Infectious diseases and complications ofpregnancy and delivery cause at least 10million deaths each year. Better access tohealth workers could prevent many of thosedeaths. There is clear evidence that as theratio of health workers to populationincreases, so in turn does infant, child andmaternal survival.
“Not enough health workers are beingtrained or recruited where they are mostneeded, and increasing numbers are joininga brain drain of qualified professionals whoare migrating to better-paid jobs in richercountries, whether those countries are nearneighbours or wealthy industrializednations. Such countries are likely to attracteven more foreign staff because of theirageing populations, who will need morelong-term, chronic care,“ said WHOAssistant Director-General Dr TimothyEvans.
To tackle this crisis, more direct investmentin the training and support of health work-ers is needed now. Initial costs will be forthe training of more health workers. As theygraduate and enter the workforce, fundswill be needed to pay their salaries. Healthbudgets will have to increase by at leastUS$10 per person per year in the 57 coun-tries with severe shortages to educate andpay the salaries of the four million healthworkers needed to fill the gap. To meet thattarget within 20 years is an ambitious butreasonable goal, the Report concludes.
Financing this gap will require significant,dedicated and predictable funding from
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• Agreements on ethical recruitment of andworking conditions for migrant healthworkers and international planning on thehealth workforce for humanitarian emer-gencies or global health threats such as aninfluenza pandemic;
• Commitment from donor countries toassist crisis countries with their efforts toimprove and support the health workforce.
for example that the number of treatmentsites in Malawi increased from three inearly 2003 to 60, and in Zambia increasedfrom three to more than 110 facilities in justover two years.
Globally, 18 developing countries met the “3by 5” target of providing treatment to at leasthalf of those in need by the end of 2005, andare now concentrating their efforts on mov-ing towards universal access to treatment.While other countries fell short of this target,lessons learned in expanding treatmentaccess and overcoming critical weaknessesin health systems are informing new initia-tives to further scale-up HIV prevention,treatment and care services. Increased avail-ability of ART averted an estimated 250 000to 350 000 premature deaths in the develop-ing world in 2005 alone.
Launched by WHO and UNAIDS on WorldAIDS Day, 1 December 2003, “3 by 5“aimed to provide treatment to 3 million peo-ple in low- and middle-income countries bythe end of 2005. This ambitious target wasbased on a 2001 analysis of what could beaccomplished with an optimal combinationof funding, technical capacity building,health systems strengthening and politicalwill and cooperation. The initiative con-firmed that HIV treatment can be deliveredeffectively in a wide variety of health sys-tems, including those in poor countries andrural settings, and that large-scale ARTaccess is both achievable and increasinglyaffordable.
Between 2003 and 2005, global expenditureon AIDS increased from US$ 4.7 billion toan estimated US$ 8.3 billion. Significantproportions of this funding were providedby the US President’s Emergency Plan forAIDS Relief, the Global Fund to FightAIDS, TB and Malaria and the World Bank.During the same period, the price of first-line treatment decreased by between 37%and 53%, depending on the regimen used.
Progress: Treatment Accessby Region
Between end-2003 and 2005, HIV treat-ment access expanded in every region of theworld. Sub-Saharan Africa and East, South
Global Access to HIV Therapy Tripled in PastTwo Years, But Significant Challenges Remain1.3 Million People Now Receiving Treatment in Low- and Middle-incomeCountries; Sub-Saharan Africa Leads in Treatment Scale-up. Lessons learned in “3 by 5” should guide efforts to move towards Universal Access to Treatment by 2010
GENEVA, 28 MARCH 2006 – A newreport by the World Health Organizationand the Joint United Nations Programme onHIV/AIDS (UNAIDS) shows that the num-ber of people on HIV antiretroviral treat-ment (ART) in low- and middle-incomecountries more than tripled to 1.3 million inDecember 2005 from 400 000 in December2003. Charting the final progress of the “3by 5“ strategy to expand access to HIV ther-apy in the developing world, the report alsosays that the lessons learned in the last twoyears provide a foundation for global effortsnow underway to provide universal accessto HIV treatment by 2010.
Progress in treatment scale-up, while sub-stantial, was less than initially hoped. Thereport notes, however, that treatment accessexpanded in every region of the world dur-ing the “3 by 5” initiative, with approxi-mately 50 000 additional people beginningART every month in the past year. Sub-Saharan Africa, the region most severelyimpacted, led the scale-up effort, with thenumber of people receiving HIV treatmentthere increasing more than eight-fold to 810000 from 100 000 in the two-year period.By the end of 2005, more than half of allpeople receiving HIV treatment in low- andmiddle-income countries resided in sub-Saharan Africa, up from one-quarter twoyears earlier.
“Two years ago, political support andresources for the rapid scale-up of HIV
treatment were very limited,” said WHODirector-General, Dr LEE Jong-wook.“Today “3 by 5“ has helped to mobilizepolitical and financial commitment toachieving much broader access to treatment.This fundamental change in expectations istransforming our hopes of tackling not justHIV/AIDS, but other diseases as well.”
In July 2005, the G8 nations endorsed agoal of working with WHO and UNAIDSto develop an essential package of HIV pre-vention, treatment and care, with the aim ofmoving as close as possible to universalaccess to treatment by 2010, a target subse-quently endorsed by the United NationsGeneral Assembly in September 2005. Thenew WHO/UNAIDS report outlines a num-ber of steps that must be taken to continueand expand treatment scale-up towardachieving this goal.
Substantial increases in HIVtreatment access
Countries in every region of the world madesubstantial gains during the “3 by 5” periodin closing the gap between those in need oftreatment and those receiving it. The num-ber of public sector treatment sites in low-and middle-income countries increasedfrom fewer than 500 providing ART tomore than 5100 operational treatment sitesby the end of 2005. A recent survey showed
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and Southeast Asia, the regions most heavi-ly affected by the epidemic, achieved themost rapid and sustained progress.
• More than 810 000 people in sub-SaharanAfrica, or 17% of those in need of ART,had accessed treatment by the end of2005. Well over half the people on ART inthe developing world live in this region.This substantial increase in ART availabil-ity in sub-Saharan Africa occurred despiteconsiderable regional challenges: theregion is home to over 20 of the world’s25 poorest countries, and suffers a short-age of some 1 million professional healthworkers, with an additional 20 000 trainedstaff lost each year to emigration.
• East, South and Southeast Asia recordedsignificant gains in ART access from end-2003 (70 000 people) to 2005 (180 000people), with coverage in the regionexpanding more than 75% in 2005.Thailand was a major driver of thisincrease, particularly during 2004 and thefirst half of 2005.
• Latin America and the Caribbean, withmore than 315 000 people on ART (upfrom 210 000 at the end of 2003), is pro-viding treatment to approximately 68% ofits population in need – the highest cover-age of any region in the developing world.Thirteen countries in this region providetreatment to more than half of the popula-tion in need.
• Despite gains in overall numbers on treat-ment, ART access in low- and middle-income countries in Eastern Europe,Central Asia, the Middle East and NorthAfrica was lower than in other regions,with just 21 000 people in Eastern Europeand Central Asia and 4000 in the MiddleEast and North Africa receiving treatmentas compared to 15 000 and 1000 respec-tively at the end of 2003. Virtually allcountries in these regions are experienc-ing low-level epidemics that involve diffi-cult-to-reach populations such as injectingdrug users (IDUs) and sex workers.
Reaching Women, Childrenand Vulnerable Populations While the new report found no systematicbias against women in ART access, rates of
coverage for women varied. In some coun-tries, more women receive treatment; inothers, more men. One notable area of con-cern is access to therapy to prevent mother-to-child HIV transmission, which remainsunacceptably low. Between 2003 and 2005,fewer than 10% of HIV-positive pregnantwomen received antiretroviral prophylaxisbefore or during childbirth. As a result,1800 infants were born with HIV every day.Each year, over 570 000 children under theage of 15 die of AIDS, most havingacquired HIV from their mothers. In 2005,660 000 children under the age of 15 werein need of immediate ART, representingmore than 10% of unmet global need. Nineout of ten children needing treatment live insub-Saharan Africa.
While an estimated 36 000 injecting drugusers (IDUs) were receiving ART by theend of 2005, more than 80% (30 000) ofthese are in Brazil. The remaining 6000patients were distributed among 45 othercountries. These figures suggest a largeunmet need, particularly in Eastern Europeand Central Asia, where IDUs represent70% of HIV cases, but just 24% of patientscurrently on treatment.
“Misinformation about the disease and stig-ma against people living with HIV stillhamper prevention, care and treatmentefforts everywhere,” said Dr Peter Piot,UNAIDS Executive Director. “If we are toget ahead of the AIDS epidemic, we musttackle stigma, ensure that the availablefunds are spent effectively to scale-up HIVprevention, care and treatment pro-grammes, and mobilize more resources.”
Moving toward universalaccess
While important advances in HIV treatmentaccess have been achieved in the past twoyears, the report also acknowledges that,despite the efforts of many partners and sig-nificant funding from a number of donors,the “3 by 5“ strategy fell short of its ambi-tions. Obstacles to scaling up HIV treatmentand prevention highlighted in the reportinclude poorly harmonized partnerships;constraints on the procurement and supply
of drugs, diagnostics and other commodi-ties; strained human resources capacity andother critical weaknesses in health systems;difficulties in ensuring equitable access;and lack of standardized systems for themanagement of programmes and monitor-ing progress.
“The past two years have provided a wealthof experience and information on which wemust now continue to build,” said Kevin DeCock, Director, HIV/AIDS Department atthe World Health Organization. “We intendto utilize this knowledge to focus futureefforts on overcoming persistent challengesand obstacles. It is particularly importantthat scaling-up HIV prevention, treatmentand care services contributes to strengthen-ing of health systems overall.”
A number of lessons learned in treatmentscale-up efforts and outlined in the newreport provide a valuable roadmap forefforts to achieve universal access to treat-ment. Among these are:
• The positive impact of targets in creatingand sustaining momentum for action andin increasing accountability among stake-holders. A key element of the “3 by 5”strategy was developing bold country-level targets that encouraged national gov-ernments to expand capacity beyond whatwas previously considered possible.Moving forward, targets for treatmentmust be complemented by achievable tar-gets for other elements of a comprehen-sive response to AIDS, including preven-tion and mitigating impact.
• The need to strengthen health systems.Building universal access to HIV treat-ment will require significant ongoingefforts to re-build, reinforce and expandunder-staffed and under-funded healthcare systems that are already severelychallenged in many countries.
• Promoting a 'public health approach' tohealth care delivery that emphasizes ser-vice decentralization, community mobili-sation and education, team-basedapproaches and the delegation of routinetasks to trained nurses and health workers.The approach also promotes use of mech-anisms to ensure the consistency and qual-ity of supplies of drugs and diagnostics as
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well as the routine offer of voluntary test-ing and counselling to increase knowledgeof HIV status in settings where there ishigh HIV prevalence.
• The ongoing need to intensify preventionefforts and to integrate prevention andtreatment scale-up, using all effectiveapproaches and paying particular attentionto the needs of vulnerable groups.Epidemiological modelling consistentlyshows that more deaths can be avertedwith a comprehensive response includingboth prevention and treatment, than byfocusing on treatment or prevention alone.
• The need for substantial increases inresources and sustainable financing.UNAIDS estimates that the gap betweenavailable resources and those needed isUS$18 billion for the period 2005-2007,and that at least US$22 billion per yearwill be needed by 2008 to fund compre-hensive national HIV prevention, treat-ment and care programmes.
• Long-term donor commitments are essen-tial to ensuring sustainable treatmentscale-up, as placing large numbers of peo-ple on ART is impractical for many coun-tries without firm funding. The reportencourages the use of innovative financ-ing mechanisms to fund increasedresources for AIDS. These include a pro-posal by France to introduce an airline sol-idarity contribution and the UK’sInternational Finance Facility, which aimsto “front-load” additional funds leveragedfrom international capital markets to makethem immediately available for sustain-able investments that support the achieve-ment of the Millennium DevelopmentGoals.
The new report emphasizes that WHO andUNAIDS will continue to build upon theselessons learned, as well as on the priorities,strategies and partnerships of “3 by 5“ inaccelerating the AIDS response. UNAIDSis currently facilitating the development ofnationally agreed plans and targets to movetowards universal access to HIV preven-tion, treatment, care and support. WHO'scontribution to realizing the goal of univer-sal access will be based on a set of priorityinterventions in the following five strategicdirections known to be able to significantly
influence the epidemic in different epidemi-ological contexts: - enabling people to know their HIV status
through HIV testing and counselling;- accelerating the scale-up of treatment and
care;
- maximizing the health sector's contribu-tion to HIV prevention;
- investing in strategic information to guidea more effective response; and
- strengthening and expanding health sys-tems.
Intellectual property rights, Innovation and Public Health CommissionDeveloping country access needed to existingand new medicines and vaccines
GENEVA. The independent Commissionon Intellectual Property Rights, Innovationand Public Health has presented its report tothe World Health Organization. The reportrecommends key actions needed to ensurethat poor people in developing countrieshave access to existing and new products todiagnose, treat and prevent the diseaseswhich most affect them.
Over half of the people in the poorest partsof Africa and Asia lack regular access toexisting essential medicines because theycannot afford them, or because the healthsystem in their country is too weak. Apartfrom access to existing medicines, somehealth products specifically for diseaseswhich disproportionately affect developingcountries are simply not developed at alldue to the lack of a sustainable market. Therelationship between intellectual propertyrights, innovation and public health hasbeen at the heart of debate on these issues.
The report of the Commission: “PublicHealth, Innovation and Intellectual PropertyRights“ is the result of two years' analysisof how governments, industry, scientists,international law and financing mecha-nisms can work best to overcome the chal-lenges.
“There is now global momentum to addressthese issues, and we have a unique opportu-nity to build on this. There is more aware-
ness, more money potentially available,more utilization of scientific capacity indeveloping countries and new institutionssuch as public–private partnerships. TheCommission report is clear that we mustbuild on all of these to ensure that poor peo-ple in developing countries have sustainableaccess to the medicines, vaccines and diag-nostics they need now, and critically, in thefuture. The report maps out the ways thiscan be done,“ said Mme Ruth Dreifuss, theChair of the Commission.
The report was commissioned by the WorldHealth Assembly and WHO's Director-General, Dr LEE Jong-wook, establishedthe Commission on Intellectual PropertyRights, Innovation and Public Health inFebruary 2004 meeting first in April (asreported in WMJ 50(2), 50).
“We are grateful to the Commissioners forundertaking this difficult task. With thisreport, the Commission has built a solidfoundation from which countries can moveforward. I encourage all countries to giveserious consideration to their role inaddressing these critical issues,“ said DrLEE Jong-wook, today as Mme Dreifusspresented the report, which contains morethan 50 recommendations which serve as aroad map for tackling the issues in differentcountry settings. The report after considera-tion by the Executive Board, goes to theWorld Health Assembly. (see next issue)
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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
HAITI, W.I. FAssociation Médicale Haitienne1ère Av. du Travail #33 – Bois VernaPort-au-PrinceTel: (509) 245-2060Fax: (509) 245-6323E-mail: [email protected]: www.amhhaiti.net
HONG KONG EHong Kong Medical Association, ChinaDuke of Windsor Building, 5th Floor15 Hennessy RoadTel: (852) 2527-8285Fax: (852) 2865-0943E-mail: [email protected]: www.hkma.org
HUNGARY EAssociation of Hungarian MedicalSocieties (MOTESZ)Nádor u. 36 1443 Budapest, PO.Box 145Tel: (36-1) 312 3807 – 311 6687Fax: (36-1) 383-7918E-mail: [email protected]: www.motesz.hu
INDIA EIndian Medical AssociationIndraprastha MargNew Delhi 110 002Tel: (91-11) 337009/3378819/3378680Fax: (91-11) 3379178/3379470E-mail: [email protected] / [email protected]
INDONESIA EIndonesian Medical AssociationJalan Dr Sam Ratulangie N° 29Jakarta 10350Tel: (62-21) 3150679Fax: (62-21) 390 0473/3154 091E-mail: [email protected]
LITHUANIA ELithuanian Medical AssociationLiubarto Str. 22004 VilniusTel/Fax: (370-5) 2731400E-mail: [email protected]
LUXEMBOURG FAssociation des Médecins etMédecins Dentistes du Grand-Duché de Luxembourg29, rue de Vianden2680 LuxembourgTel: (352) 44 40 331Fax: (352) 45 83 49E-mail: [email protected]: www.ammd.lu
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MACEDONIA EMacedonian Medical AssociationDame Gruev St. 3P.O. Box 17491000 SkopjeTel/Fax: (389-91) 232577
MALAYSIA EMalaysian Medical Association4th Floor, MMA House124 Jalan Pahang53000 Kuala LumpurTel: (60-3) 40418972/40411375Fax: (60-3) 40418187/40434444E-mail: [email protected]: http://www.mma.org.my
MALTA EMedical Association of MaltaThe Professional CentreSliema Road, Gzira GZR 06Tel: (356) 21312888Fax: (356) 21331713E-mail: [email protected]: www.mam.org.mt
MEXICO SColegio Medico de MexicoFenacomeHidalgo 1828 Pte. Cons. 410Colonia Obispado C.P. 64060Monterrey, Nuevo LéonTel/Fax: (52-8) 348-41-55E-mail: [email protected]: www.fenacome.org
NEPAL ENepal Medical AssociationSiddhi Sadan, Post Box 189Exhibition RoadKatmanduTel: (977 1) 225860, 231825Fax: (977 1) 225300E-mail: [email protected]
PANAMA SAsociación Médica Nacionalde la República de PanamáApartado Postal 2020Panamá 1Tel: (507) 263 7622 /263-7758Fax: (507) 223 1462Fax modem: (507) 223-5555E-mail: [email protected]
PERU SColegio Médico del PerúMalecón Armendáriz N° 791Miraflores, LimaTel: (51-1) 241 75 72Fax: (51-1) 242 3917E-mail: [email protected]: www.colmed.org.pe
PHILIPPINES EPhilippine Medical AssociationPMA Bldg, North AvenueQuezon CityTel: (63-2) 929-63 66/Fax: -6951E-mail: [email protected]
ROMANIA FRomanian Medical AssociationStr. Ionel Perlea, nr 10Sect. 1, Bucarest, cod 70754Tel: (40-1) 6141071Fax: (40-1) 3121357E-mail: [email protected]: www.cdi.pub.ro/CDI/Parteneri/AMR_main.htm
RUSSIA ERussian Medical SocietyUdaltsova Street 85121099 Moscow Tel: (7-095)932-83-02E-mail: [email protected]@russmed.com
SINGAPORE ESingapore Medical AssociationAlumni Medical Centre, Level 22 College Road, 169850 SingaporeTel: (65) 6223 1264Fax: (65) 6224 7827E-Mail: [email protected]
SOUTH AFRICA EThe South African Medical AssociationP.O. Box 74789, Lynnwood Rydge0040 PretoriaTel: (27-12) 481 2036/7Fax: (27-12) 481 2058E-mail: [email protected]: www.samedical.org
SPAIN SConsejo General de Colegios MédicosPlaza de las Cortes 11, Madrid 28014Tel: (34-91) 431 7780Fax: (34-91) 431 9620E-mail: [email protected]
SWEDEN ESwedish Medical Association(Villagatan 5)P.O. Box 5610, SE - 114 86 StockholmTel: (46-8) 790 33 00Fax: (46-8) 20 57 18E-mail: [email protected]: www.lakarforbundet.se
SWITZERLAND FFédération des Médecins SuissesElfenstrasse 18 – POB 2933000 Berne 16Tel: (41-31) 359 –1111/Fax: -1112E-mail: [email protected]: www.fmh.ch
TAIWAN ETaiwan Medical Association9F No 29 Sec1An-Ho RoadTaipeiDeputy Secretary GeneralTel: (886-2) 2752-7286Fax: (886-2) 2771-8392E-mail: [email protected]
THAILAND EMedical Association of Thailand2 Soi SoonvijaiNew Petchburi RoadBangkok 10320Tel: (66-2) 314 4333/318-8170Fax: (66-2) 314 6305E-mail: [email protected]: http://www.medassocthai.org/index.htm.
TUNISIA FConseil National de l’Ordredes Médecins de Tunisie16, rue de Touraine1082 Tunis Cité JardinsTel: (216-71) 792 736/799 041Fax: (216-71) 788 729E-mail: [email protected]
TURKEY ETurkish Medical AssociationGMK Bulvary,.Pehit Danip Tunalygil Sok. N° 2 Kat 4MaltepeAnkaraTel: (90-312) 231 –3179/Fax: -1952E-mail: [email protected]
UNITED KINGDOM EBritish Medical AssociationBMA House, Tavistock SquareLondon WC1H 9JPTel: (44-207) 387-4499Fax: (44- 207) 383-6710E-mail: [email protected] Website: www.bma.org.uk
UNITED STATES OF AMERICA EAmerican Medical Association515 North State StreetChicago, Illinois 60610Tel: (1-312) 464 5040Fax: (1-312) 464 5973Website: http://www.ama-assn.org
