Medical Journal 52 World Vol

G 20438 Medical Journal 52 World Vol. No. 1, March 2006

Contents

Editorial Evolution of Health Professions 1 European Developments presage Worldwide Activities 2 Medical Ethics and Human Rights Avian influenza 3 “Caring Physicians of the World” 5 Medical management of hunger-strikers 5 The Right to Health 6 Medical Science, Professional Practice and Education Human Genetics and Biomedical Research 7 Health Care Policy Reform – the UK National Health Service 7 Collaboration with the Global Health Initiative of the World Economic Forum: Initiatives launched to address training and education needs in TB burdened countries 9 WMA WMA General Assembly, Santiago Presidential Valedictory Address, Yank D. Coble 11 Statement on reducing the global Impact of Alcohol on Health and Society 14 From the Secretary General’s desk Working together for health – Human Resources for Health World Health Day 2006 16 WHO Counterfeit medicines: the silent epidemic 17 Countries representing three-quarters of the world’s population meet in Geneva to plan the effective implementation of the tobacco control treaty 18 WHO welcomes United Kingdom, Gates Foundation funding for global action to stop TB 19 World Cancer Day, February 2006 20 Medical costs push millions of people into poverty across the globe 20 Foundation for Innovative New Diagnostics and WHO collaborate to improve diagnosis of sleeping sickness 21 Measles cases and deaths fall by 60% in Africa since 1999 22 Chernobyl: the true scale of the accident 23 Regional and NMA News IMA launches rural health plan 28 Physicians speak out on prisoner forced feeding 28

OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. WMA OFFICERS OF NATIONAL MEMBER MEDICAL ASSOCIATIONS AND OFFICERS President-Elect President Immediate Past-President Dr K. Letlape Dr Y. D. Coble Dr J. Appleyard South African Med. Assn. 102 Magnolia Street Thimble Hall P.O. Box 74789 Neptune Beach, FL 32266 108 Blean Common Lynnwood Ridge 0040 USA Blean, Nr Canterbury Pretoria 0153 Kent, CT2 9JJ South Africa Great Britain

Treasurer Chairman of Council Vice-Chairman of Council Prof. Dr. Dr. h.c. J. D. Hoppe Dr Y. Blachar Dr N. Hashimoto Bundesärztekammer Israel Medical Association Japan Medical Association Herbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome 10623 Berlin 35 Jabotisky Street Bunkyo-ku Germany P.O. Box 3566 Tokyo 113-8621 Ramat-Gan 52136 Japan Israel

Secretary General Dr O. Kloiber World Medical Association BP 63 France

Titlepage: Karolinska Hospital, Stockholm, Sweden: photos by Veijo Mehtonen.

Website: http://www.wma.net

WMA Directory of National Member Medical Associations Officers and Council

Association and address/Officers

ANDORRA S Weihburggasse 10-12 - P.O. Box 213 BANGLADESH E Fax: (55-11) 317868 31 Col’legi Oficial de Metges 1010 Wien Bangladesh Medical Association E-mail: [email protected] Edifici Plaza esc. B Tel: (43-1) 51406-931 B.M.A House Website: www.amb.org.br Verge del Pilar 5, Fax: (43-1) 51406-933 15/2 Topkhana Road, Dhaka 1000 BULGARIA E 4art. Despatx 11, Andorra La Vella E-mail: [email protected] Tel: (880) 2-9568714/9562527 Bulgarian Medical Association Tel: (376) 823 525/Fax: (376) 860 793 REPUBLIC OF ARMENIA E Fax: (880) 2-9566060/9568714 15, Acad. Ivan Geshov Blvd. E-mail: [email protected] Armenian Medical Association E-mail: [email protected] 1431 Sofia Website: www.col-legidemetges.ad P.O. Box 143, Yerevan 375 010 Tel: (359-2) 954 -11 26/Fax:-1186 Tel: (3741) 53 58-63 BELGIUM F ARGENTINA S Association Belge des Syndicats E-mail: [email protected] Fax: (3741) 53 48 79 Website: www.blsbg.com Confederación Médica Argentina E-mail:[email protected] Médicaux Chaussée de Boondael 6, bte 4 Av. Belgrano 1235 Website: www.armeda.am CANADA E Buenos Aires 1093 1050 Bruxelles Tel: (32-2) 644-12 88/Fax: -1527 Canadian Medical Association Tel/Fax: (54-114) 383-8414/5511 AZERBAIJAN E Azerbaijan Medical Association E-mail: [email protected] P.O. Box 8650 E-mail: [email protected] 5 Sona Velikham Str. Website: www.absym-bras.be 1867 Alta Vista Drive Website: www.comra.health.org.ar AZE 370001, Baku Ottawa, Ontario K1G 3Y6 Tel: (994 50) 328 1888 BOLIVIA S Tel: (1-613) 731 9331/Fax: -1779 AUSTRALIA E Fax: (994 12) 315 136 Colegio Médico de Bolivia E-mail: [email protected] Australian Medical Association E-mail: [email protected] / Casilla 1088 Website: www.cma.ca P.O. Box 6090 [email protected] Cochabamba Kingston, ACT 2604 Tel/Fax: (591-04) 523658 CHILE S BAHAMAS E Tel: (61-2) 6270-5460/Fax: -5499 E-mail: [email protected] Colegio Médico de Chile Medical Association of the Bahamas Website: www.colmedbo.org Esmeralda 678 - Casilla 639 Website: www.ama.com.au Javon Medical Center E-mail: [email protected] P.O. Box N999 BRAZIL E Santiago Nassau Associaçao Médica Brasileira Tel: (56-2) 4277800 AUSTRIA E Tel: (1-242) 328 6802 R. Sao Carlos do Pinhal 324 – Bela Vista Fax: (56-2) 6330940 / 6336732 Österreichische Ärztekammer Fax: (1-242) 323 2980 Sao Paulo SP – CEP 01333-903 E-mail: [email protected] (Austrian Medical Chamber) E-mail: [email protected] Tel: (55-11) 317868 00 Website: www.colegiomedico.cl i see page ii Editorial

OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION Editorial

Hon. Editor in Chief Dr. Alan J. Rowe Haughley Grange, Stowmarket Evolution of Health Professions Suffolk IP14 3QT UK

Co-Editors Dr. Ivan M. Gillibrand 19 Wimblehurst Court Ashleigh Road Horsham Reading the national medical association (NMA) press over the last few months there West Sussex RH12 2AQ UK appear to be a number of broad issues which appear to occupy the medical and other professions. Two of these reflect major concerns in the care of patients and are related, name- Prof. Dr. med. Elmar Doppelfeld ly Quality of Care and Patient Safety. There has been much activity in the former for many Deutscher Ärzte-Verlag years and action in the latter has substantially increased, notably in the World Alliance for Dieselstr. 2 Patient Safety movement of WHO. The issues involve all health professions and with D-50859 Köln increasing teamwork in health care and the huge increase in general access to information Germany and the involvement of patients in decisions about their health care, these are welcome and Business Managers appropriate developments. J. Führer, D. Weber 50859 Köln At the same time in all health professions, knowledge and roles are constantly evolving and Dieselstraße 2 changing, reflecting the advances in knowledge and advances in technology. In parallel Germany there are also changes in Healthcare provision as existing national health care systems reflect both changes in demography in the professions and in the population, as well as the Publisher economic and political climate in individual countries. THE WORLD MEDICAL ASSOCIATION, INC. In the past few weeks such headlines as “New healthcare role will confuse patients” and BP 63 “physician task force confronts scope of practice legislation” have appeared the press of the 01212 Ferney-Voltaire Cedex, France some national medical associations. Both of these are referring to the changes in field of Publishing House activity of evolving health professions and suggestions of new ones both of which will Deutscher Ärzte-Verlag GmbH, Die- impact on the traditional areas of practice, hitherto those of physicians. The first headline selstr. 2, P. O. Box 40 02 65, 50832 Köln/ quoted above refers to a proposed new type of health worker to be called by suggested titles Germany, Phone (0 22 34) 70 11-0, such as “medical care practitioner” or “surgical care practitioner” in the United Kingdom Fax (0 22 34) 70 11-2 55, Postal Cheque Health Service. The second reference is to pending legislation in a number of states in the Account: Köln 192 50-506, Bank: Com- merzbank Köln No. 1 500 057, Deutsche USA to formally expand the role of 20 non-medical health professions. Apotheker- und Ärztebank, As long ago as the early 1970s this topic was one of concern, at least in Europe, when the 50670 Köln, No. 015 13330. At present rate-card No. 3 a is valid. first Chairs of Nursing were being established. There have been substantial developments in that profession over the intervening years, accompanied by positive changes in attitudes, The magazine is published quarterly. in relationships, and the increase in teamwork referred to above. Increasing technology, Subscriptions will be accepted by knowledge, training and professional co-operation have benefited both the professions and Deutscher Ärzte-Verlag or the World patients Medical Association. But the apprehensions expressed above arise substantially from concerns related to some Subscription fee € 22,80 per annum (incl. health professionals undertaking roles for which they are much less extensively prepared as 7 % MwSt.). For members of the World those who have undertaken the long and rigorous medical training. Whilst it is possible to Medical Association and for Associate members the subscription fee is settled provide special training for specific activities or diseases, there is concern that patient safe- by the membership or associate payment. ty could be affected. Whilst each professional has a duty to work only within their area of Details of Associate Membership may be competence, with the introduction of extended new roles this is causing concern It is par- found at the World Medical Association ticularly important that where new health professionals are being introduced, patients website www.wma.net should be aware of their professional role and the limits of their training. This certainly Printed by means that the professional title should not be open to misinterpretation or imply in any Deutscher Ärzte-Verlag way that the competence is that of a fully qualified medical practitioner. This issue is a now Köln — Germany matter of concern to NMAs in many countries.

ISSN: 0049-8122 The role of medical and paramedical health professionals is complementary It has been so for many years, and in many countries and within countries this has substantially increased,

1 Editorial

with a real feeling of partnership between this end the health professions, faced with in the sensitive area of health care. In the professionals. With the global crisis of the changing spheres of activity, need to re- recognition of this fact many nations have human health resources which will be the examine their own scope of practice and begun the planning and development of topic of WHO for this year, and for a decade engage in active productive dialogue to health professional cards for their own of action “Human Resources for Health”, it achieve this and ensure that the resources of medical community. is vital that all the health professions work the health professions are used in the best In the last years quite a number of national together to ensure that maximum use is way, even if this involves some change in smart card projects with major impact were made of the potential of each profession, traditional roles. initiated worldwide. Compiled as part of a and that roles and functions are clearly Alan Rowe Trailblazer project, the White Paper on defined and adequate training provided. To “Open Smart Card Infrastructure” (OSCIE) gives an excellent overview of activities in Europe2. With a special focus on health professional cards the following projects Health Professional Card were especially formative for current technology and trends: European Developments presage • France (Groupement d’intérêt Public, Carte de Professionnel de Santé), Worldwide Activities • Germany (Heilberufsausweise für Ärzte, Zahnärzte, Apotheker und Psychothera- Dr. med. Christoph F-J Goetz peuten), • Netherlands (NICTIZ, Nationaal ICT Today it is clear to everyone that telecommunications will be the new driving force for eco- Instituut in de Zorg) and nomic and social systems worldwide. The paradigms of communication are currently • Slovenia (Profesionalna kartica, ZZZS, evolving at an enormous pace away from paper-based methods directly towards electronic Zavod za zdravstveno zavarovanje mechanisms, at all levels. This entails massive changes everywhere which can rightly be Slovenje). compared to the industrial revolution with all of its social and economic upheavals. While up to now most national regulations have been dominated by regional interests, it Early on it was recognised that functional comes as no surprise that these are becoming ever more strongly influenced by internation- interoperability and widespread acceptance al aspects and interactions with foreign structures. Until today every physician practised as will be crucial for this new technology, and a doctor basically only within his/her own national context. Spurred on by the increasing standardisation activities initiated. rise in cross border traffic and telecommunications in medicine, this will no longer be the In Europe, the Technical Committee 251 case in the foreseeable future. A World-Wide trend has been initiated. “Health Informatics” (TC 251) of the Comité Européen de Normalisation (CEN) The European Community1 recognized this fact and has recently adopted Directive focuses its activities concerning “Security, 2005/36/EC on the Recognition of Professional Qualifications. This expressly mandates Safety and Quality” in Working Group III. “the abolition of obstacles to the free movement of persons and services” and in this con- In the year 2000 this Group III put togeth- text explicitly gives each professional “the right to pursue a profession, in a self employed er the first version of the European pre- or employed capacity, in a member state other than the one in which they have obtained their professional qualifications”. It is obvious that these regulations will also have a massive impact on the medical community. However, in a separate directive, liberalising the provision of services in other member states, the European Parliament in February this year, voted to exclude the health sec- 1 The European unification started 1957 with six states. Through various expansions the European tor. MEP’s also voted to reject article 23 of the Directive, which would have given cross- Community now has 25 members since May 2004. border patients guarantees of reimbursement of treatment costs. The motivation can pre- These are: Austria, Belgium, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, sumably be found in differing basic premises of the various health care systems which Germany, Greece, Hungary, Ireland, Italy, Latvia, entail major differences in health care management. In some countries enormous waiting Lithuania, Luxemburg, Malta, Netherlands, Poland, Portugal, Slovakia, Slovenia, Spain, lists already dominate medical diagnostics and therapy as a last resort to curtail rising costs, Sweden and the United Kingdom. In addition, four while in contrast, these services remain readily available in other countries. In this context nations are currently also planning entry to the EC: “health tourism” is the last thing any nation wants to foster. However, the trend towards Bulgaria, Croatia, Rumania and Turkey. mobility of patients and providers cannot be stopped. 2 Open Smart Card Infrastructure for Europe, White Paper of the eEurope Smart Card Trailblazer 11, The technological mainstay of the secure exchange of medical data in the future will indis- OSCIE, Volume 1, Part 4, March 2003. Latest version of OSCIE papers are available from putably be the methods of authentification and signature as they are offered by health pro- “www.eeurope-smartcards.org” and fessional cards. Only these can achieve a sufficiently high level of security as to be usable “www.eurosmart.com”.

2 Medical Ethics and Human Rights

standard ENV 13729 “Health informatics – equivalent requirements and qualifications. Dr. med. Christoph F-J Goetz Secure user identification – Strong authen- Standardisation makes faster and easier Director Telemedicine tication using microprocessor cards”. This transfer of knowledge and innovation pos- Bavarian Administration of Statutory is currently undergoing revision under the sible, and thereby lowers cost and increases Office Based Physicians leadership of the author, with support of the availability. These commercial truisms also Elsenheimer Strasse 39, D-80687 Munich, KVB (Bavarian Administration of Statutory hold true for medical care. It is clear that Germany Office Based Physicians) and the BAEK the functional interoperability of secure Phone: +49.89.57093-2470 (German Medical Chamber). Due to the authentification and information transfer in Fax: +49.89.57093-61470 broad range of interoperability issues fore- medicine will be the indispensable corner- Mobile: +49.172.9544621 seeable in this context, and because of stone for future applications and deserves [email protected] national healthcare responsibilities and dif- our unmitigated support. fering (or even currently non-existent) technical frameworks, it has been deemed necessary to gather an up-to-date and encom- passing overview of salient information regarding national activities for healthcare professional cards in the member states of the EC before starting this revision. Medical Ethics and Human Rights The following aspects will be covered in this study: 1) Identification of institutions responsi- Avian influenza: A possible new human ble for planning and rollout of national healthcare professional cards, pandemic with old ethical problems 2) identification and enumeration of involved healthcare professions, Prof. Urban Wiesing MD, PhD, Georg Marckmann MD, MPH 3) identification of industrial solutions and product providers, Currently nobody knows exactly whether increased health care needs. They lack the 4) documentation of the status of current we will face a new human pandemic with a necessary reserves. Their medical capaci- plans and development, mutated avian influenza virus or not. So far, ties are already insufficient to cope with the pandemic is mainly an animal disease their daily health problems, let alone to 5) identification of technical correspon- and the cases of infected human beings are cope with a new human pandemic flu. Less dents for HPC queries, and finally linked to direct contact with infected ani- developed health care systems face two 6) collection of design frameworks mals. But if the H5N1-virus mutates into a options, both of which pose serious dilem- and/or guides of national HPC’s. strain which can easily pass between human mas; they can either concentrate on fighting beings resulting in a new human pandemic the new human pandemic at the expense of The output of this agenda will be a techni- with dramatic effects, we are sure to be con- other urgent health care needs, or they can cal report to support ENV 13729 and it is fronted with serious ethical decisions, in neglect the new pandemic trying to main- expected (depending on the rapidity of addition to huge other problems They can tain the level of other health care services. feedback) that the work can largely be be anticipated and are not new – the coming In any case, the consequences will be dev- completed within 2006. It has already been ethical problems are well known. astating for the people involved, the avian decided that the results of this European First of all, a global human influenza pan- influenza victims or those with other sick- report will be shared with the correspond- demic will bind enormous capacities in the nesses. And the choice between these two ing Working Group 5 “Health Cards” of the health care systems all over the world. options is a difficult one, with ethical impli- Technical Committee 215 “Health Highly developed medical systems in cations. On the one hand the responsible Informatics” (TC 215), which is part of the wealthy countries might be able to cope health care officials have to decide under International Standards Organization with the challenges of treating an extremely conditions of some uncertainty based on (ISO), so that a world-wide overview can high number of sick people in a more vague data about the outcome of their mea- be expected to be available by 2007. acceptable way. They might have enough sures, on the other hand they have to choose To summarise, it is essential to recognise human and material resources to react in a the appropriate aim of their strategy: Should that in medicine, as everywhere else, stan- way that minimises the number of people one follow the utilitarian goal to minimize dardisation enables the national and inter- infected and dying from the disease. But the number of fatalities, or should other national exchange of products and services most health care systems in the world will considerations govern the decisions, e.g. and reduces their costs by specifying not be able to respond adequately to the egalitarian considerations that give all indi-

3 Medical Ethics and Human Rights

viduals an equal chance of treatment ability of surviving. A possible human interest of their patients first and treat the regardless of the overall outcome? influenza pandemic will show once again patients who are most in need. Certainly, the unjust distribution of health services health care workers voluntarily assume a Even well-funded health care systems will around the world. special responsibility by choosing to be confronted with a shortage of antiviral become a health professional, a responsibil- drugs, vaccines, hospital beds and health Another set of ethical issues arises from the ity that includes increased health risks. But care professionals for the treatment of avian restriction of individual rights in the inter- do they have to take any risk no matter how influenza patients. Who should receive the est of the public health. During the history threatening it is? Do they have the right to available drugs, who be vaccinated first, or of medicine it has always been a problem to refuse to treat infected patients if they are who get the needed hospital beds? Those what extent individual rights may legiti- not willing to risk a life-threatening infec- who are able to pay the price – which will mately be restricted to protect the health of tion themselves? The answer remains open. highly increase? Or the professionals who other people. Under what circumstances is At least, any available precautions should are responsible for the public health system it permisable to put infected or other people be taken to minimize the health risk for and for the treatment of infected people? in quarantine? As long as the quarantine is health professionals by providing protec- Should the drug be distributed by ability to short and does not reduce the survival rate tive equipment, preventive immunizations pay in a free market or in a regulated way of those infected, most people will probably and preferential access to antiviral drugs if for the benefit of the greatest number? The agree voluntarily to quarantine. But if the they have been infected. Still, considerable answer is dearly in favour of maximising restriction of individual freedom is exten- health risks remain and so far professional the overall benefits. Consequently, most sive and if the restriction leads to signifi- codes do not provide sufficient guidance on pandemic plans give priority to health care cant financial disadvantages or even the what can be demanded from health care workers and other professionals who help loss of a job, the ethical balancing seems workers. Even the detailed recommenda- to maintain public order. Understandably, it more difficult. How far can the freedom of tions of the University of Toronto's Joint always places a heavy burden on a physi- movement be restricted, in particular if peo- Centre of Bioethics remain vague on these cian to decide between two patients in the ple are not infected but live in an area in difficult ethical issues [2] absence of capacitiesy to treat both. which cases of avian influenza occurred? Therefore, the World Medical Association To what extent may the daily living of so However some procedural ethical values has defined a clear priority in its “Statement far uninvolved people be restricted to pre- are undisputed in open democratic soci- on Medical Ethics in the Event of vent a human pandemic? Restrictive action eties: The ethical choices involved in a Disasters” (1994) [3] When the circum- for public health purposes may also include human pandemic of avian influenza should stances do not allow the treatment of every overriding the right to privacy. The Council be discussed publicly, openly and in patient who under normal conditions could on Ethical and Judicial Affairs of the advance. Any measures should be based on be treated, the “decision to 'abandon an American Medical Association set up a rec- the available scientific evidence and explic- injured person' on account of priorities dic- ommendation that tries to balance the pro- it ethical reasoning. It is better to involve tated by the disaster situation cannot be tection of “individual rights of liberty and the public before the crisis than during the considered 'failure to come to the assistance self-determination” and “the public health crisis. It will increase the success of all of a person in mortal danger It is justified requirements”. As a general rule, “quaran- measures if people realize that the fight when it intends to save the maximum num- tine and isolation should use the least against a pandemic flu is also their concern: ber of victims.” (3.3.e) restrictive measures available that will min- Their contribution is necessary for success- imize negative effects on the community ful interventions against the pandemic and In addition to the ethical problems of allo- through disease control, while providing they, as individuals, will benefit from these cating scarce resources within a health care protections for individual rights”. [1] In concerted actions. Apart from concrete system, there will be even more dramatic addition, any quarantine or isolation mea- plans for early response and containment, a problems regarding the distribution of sures should be based on sound scientific broad societal discourse about the underly- health services between health care systems. evidence and the people should be ing ethical choices that will have to be It can be expected that people in wealthy informed about the rationale behind the made is probably crucial for a successful countries with highly developed medical restrictive public health interventions, fight against a new influenza pandemic. We systems will have a better chance to survive which in turn will increase the likelihood should rather start this public dialogue than those in low-income countries. What that they comply voluntarily with the sooner than later, on a national as well as on can be seen in the HIV pandemic will most restraints. an international level. probably also happen in a possible – and hopefully never arriving – human influenza Finally, what can be legitimately demanded Literature pandemic: the survival rates will depend on from health care workers? On the one hand, the wealth of a country, region or group of health professionals will have an increased [1] American Medical Association, Council people within a certain state. Only the pure risk to being infected while caring for on Ethical and Judicial Affairs. (2005) The chance of living in one or the other country influenza patients. On the other hand, they Use of Quarantine and Isolation as Public leads to tremendous differences in the prob- have the professional obligation to put the health Intervention. http://www.ama

4 Medical Ethics and Human Rights

assn.org/ama/pub/upload/mm/3l/quarantine/57726.pdf “Caring Physicians of the World” [2] University of Toronto Joint Centre for Last year’s WMA President’s project was marked during the 2006 WMA meeting in Bioethics, Pandemic Influenza Working Santiago by the launch of the book “Caring Physicians of the World”. This beautifully Group. Stand on Guard for Thee Ethical written and illustrated book presents the sixty five “Caring Physicians of the World” considerations in preparedness planning for selected by a WMA panel from the several hundred nominations made by National pandemic influenza 2005, http://www. Medical Associations utoronto.ca/jcb/home/documents/pandemic. pdf In his introduction, Dr Yank Coble, while referring to the importance of individual physicians’ commitment to knowledge of medical science, its utilisation, and the observance [3] World Medical Association Statement of the principles of medical ethics, stresses the primary importance of “Caring” with the on Medical Ethics in the Event of Disasters quotation “I don’t care how mach you know about (science and ethics) until I know how (Adopted by the 46th WMA General much you care” (anon). The book also quotes Sir William Osler as also quoted in the Assembly Stockholm, Sweden, September book “The most important thing is caring, so do it first, for a caring physician best 1994) (http://www.wma.net/e/policy- inspires hope and trust” This quality is clearly illustrated by the description of work and /d7.htm) activities of those whose names appear in this book The book covers a wide spectrum of individuals whose devotion and work as “Caring Physicians” encompasses not only their care of individuals, but also extends to “social leadership on behalf of the Public Health, scientific progress, society’s resources and the Adress for correspondence: welfare of human kind”. It includes not only some internationally recognised names but many who are little or generally recognised, whose caring qualities have been applied to Prof. Urban Wiesing, MD PhD those in need in all corners of the earth, both urban and remote, isolated and sometimes Georg Marckmann, MD, MPH otherwise uncared for. Tübingen University Institute for Ethics and History of Medicine It is little wonder that this book, honouring those chosen by their colleagues for their exem- Schleichstr. 8 plary care, not only makes fascinating and inspiring reading, has also stimulated great D-72076 Tübingen worldwide interest and attention. It merits reading by both doctors and their patients alike Germany (for details visit www.wma.net.) Email: [email protected]

to doctors the decision on whether to artifi- Medical management of hunger-strikers cially feed hunger strikers. This Mr. J. N. Johnson, M.D., FRCS, FRCP, FDSRCS Declaration which deals exclusively with hunger-strikes, resulted from South African doctors appealing for more detailed guidance on the subject. The Declaration elo- Doctors around the world look to the WMA of doctors’ involvement in torture. It says quently raises, but fails to answer, the for definitive guidance on professional that doctors should not resuscitate victims dilemma of whether “sanctity of life” or ethics. Recent controversy over the medical to allow torture to continue, but also says “respect of individual autonomy” should be management of hunger strikes, however, that they should not resuscitate prisoners the key issue. has not only re-opened the issue of whether who fast in order to end their lives in a bid Clear WMA guidance on this matter is in doctors can ever ethically feed protesters to escape further torture. According to the demand since the Malta Declaration is against their will but highlighted the fact Tokyo Declaration, which is now a key increasingly quoted on both sides of the that the WMA has two different approaches, human rights text, artificial feeding should debate about whether or not protesters can and indeed two different policies, on the not be instated “where a prisoner refuses be force fed or artificially fed against their issue. This is leading to some confusion and nourishment and is considered by the physi- expressed wishes. Hunger strikes have also needs urgently to be addressed by the cian to be capable of forming an unim- become more complex in the 15 years since WMA. paired and rational judgement concerning the Malta Declaration. Distinctions the consequences”. It is widely recognized that the WMA’s between prisoners determined to fast to 1975 Declaration of Tokyo never intended Contrary to this clear prohibition on feeding death and those calculating to prolong their to provide guidance on the management of when prisoners refuse it, the WMA’s 1991 protest but ultimately survive, was blurred hunger strikes. Its remit was the prohibition Declaration of Malta, ambiguously leaves by the Turkish hunger strikers of the 1990s.

5 Medical Ethics and Human Rights

They showed that they could lengthen the clearly prohibited by the WMA. Artificial aspect is the participation of the population protest by partial fasts. Deaths occurred, feeding without coercion can be an accept- in all health-related decision-making at the but only after extra months allowed consid- able way to defuse a hunger strike situation. community, national and international lev- erably more pressure to be put on the els.” According to the Committee, States The BMA is calling on the WMA to review authorities. Collective hunger strikes, such have the following obligations in relation to and upgrade its guidance. The guidelines as those in Spain and Turkey, also raised the right to health: “The right to health, like must be made clearer and a background questions about whether prisoners could all human rights, imposes three types or document exploring the complex issues in make truly voluntary decisions in situations levels of obligations on States parties: the greater depth is also needed. Doctors are where there was likely to be considerable obligations to respect, protect and fulfil. In hoping that the WMA will firmly uphold its peer pressure. The WMA Declaration of turn, the obligation to fulfil contains oblig- commitment to promulgating consensus Malta does not provide guidance to doctors ations to facilitate, provide and promote…. ethics around the world. faced with such cases. The obligation to respect requires States to refrain from interfering directly or indirect- Another problematic aspect of current Mr. J. N. Johnson, M.D., ly with the enjoyment of the right to health. WMA guidance is that it conflates artificial FRCS, FRCP, FDSRCS The obligation to protect requires States to feeding and forced feeding. Many would Chairman of Council take measures that prevent third parties argue that any medical intervention based British Medical Association from interfering with article 12 guarantees. on force, coercion or intimidation must be Tavistock Square, London WC1H 9JP Finally, the obligation to fulfil requires States to adopt appropriate legislative, administrative, budgetary, judicial, promo- tional and other measures towards the full realization of the right to health.”

The Right to Health Also in 2000 the United Nations General Assembly adopted the United Nations Mil- lennium Declaration that includes eight The Constitution of the World Health Orga- countries accept and promote this right Millennium Development Goals to be nization states that the “enjoyment of the while in others, access to health care is large- achieved by 2015. Five of these relate to the highest attainable standard of health is one ly dependent on one’s financial resources. right to health: halve extreme poverty and of the fundamental rights of every human hunger, reduce under-five mortality by being…” International statements on Even where the right to health is accepted, it two-thirds, reduce maternal mortality by human rights, such as the International is often difficult to implement because of a three-quarters, reverse the spread of dis- Covenant on Economic, Social and Cultural severe shortage of resources. This is clearly eases, especially HIV/AIDS and malaria, Rights and the Convention on the Rights of the situation in many developing countries, and ensure environmental sustainability. the Child, support the right to health and although some of these countries (e.g., Sri require signatory nations to secure its obser- Lanka) have managed to promote equitable In 2002 the United Nations Commission on vance. access to their limited health care resources, Human Rights appointed, for a period of with extremely positive results for the over- three years, a Special Rapporteur whose Despite the widespread, although by no all health status of the population. mandate focuses on the right of everyone to means universal, acceptance of the right to the enjoyment of the highest attainable health, both its meaning and its application In 2000 the Committee on Economic, Social standard of physical and mental health. The are problematic. It cannot mean a right to be and Cultural Rights, which was created to mandate was extended in 2005 for three healthy, since much illness is impossible to monitor the International Covenant on Eco- years, and the Special Rapporteur was prevent or cure. Nor can it mean that indi- nomic, Social and Cultural Rights, issued a asked, among other things, “To gather, viduals have a right to all needed health care report on the right to health. It interpreted request, receive and exchange information services, since the demand for such services this right “as an inclusive right extending from all relevant sources, including Gov- is greater than the supply in even the not only to timely and appropriate health ernments, intergovernmental organizations wealthiest countries. There seems to be gen- care but also to the underlying determinants and non-governmental organizations, on eral agreement that the right to health entails of health, such as access to safe and potable the realization of the right of everyone to a minimum requirement that individuals water and adequate sanitation, an adequate the enjoyment of the highest attainable should be protected from actions that under- supply of safe food, nutrition and housing, standard of physical and mental health.” mine their health. There is much disagree- healthy occupational and environmental ment as to whether individuals have a fur- conditions, and access to health-related edu- Medical associations have not been particu- ther right to equal access to needed health cation and information, including on sexual larly outspoken on the right to health in care in their country or elsewhere. Some and reproductive health. A further important general but have tended to focus on specif-

6 Medical Science, Professional Practice and Education

ic rights. The WMA's principal documents conditions for the exercise of this right, Affecting about one person in every million, in this respect are the Declaration of Lisbon especially access to good quality health the mutations that cause dyskeratosis con- on the Rights of the Patient and the Declara- care. genita disrupt telomeres the tips of the chro- tion of Ottawa on the Right of the Child to mosomes, rather like the plastic cap on the Health Care. In 1998 the WMA General Readers are invited to provide information tips of shoelaces which keep the whole Assembly adopted a Resolution on on other medical association or research structure together. When chromosomes are Improved Investment in Health Care that, activities related to privacy and confiden- copied during cell division, telomeres tend while not mentioning a right to health, nev- tiality of personal health information to to get shorter, from which remaining life ertheless urged governments and intergov- [email protected] span can be predicted. In order to compen- ernmental agencies to provide the requisite sate for this winding down effect, actively dividing cells can synthesise the enzyme telomerase, which repairs telomeres. Indeed, Medical Science, Professional Practice and Education close analysis of telomere structure can calculate when a rare inherited disorder will strike. Without telomerase, the cells will go Human Genetics And Biomedical Research through a certain number of divisions, as far as the Hayflick Limit, and then die. The human genome sequence, now almost silence genes very effectively. Generally Mutant genes, when switched on, such as complete, is a driving force behind research, they act by triggering a massive destruction that coding for telomerase, mean that chro- focussing on the impact of genetic differ- of the intermediate messenger RNA as it is mosome repair is faulty. Tissues with rapid- ences between people, many of which affect read from a gene. Small RNA molecules ly proliferating cells, such as skin, gut and health. Another key theme is how genetic can somehow insert themselves causing bone marrow, are the first to be affected. information is translated into biological tightlypacked DNA to shut down its gene The earliest sign of accelerated wear and function, whether in terms of the ‘biological action. tear is usually abnormal skin pigmentation, clock’ governing cell division in tissues, or followed years later by cancer, premature gene expression in health and disease. ageing and bone marrow failure, which Premature ageing often proves fatal. But why do children’s symptoms appear at Beyond the helix Dyskeratosis congenita is a devastating dis- an earlier age than their parents? This phe- ease that leads to premature ageing, bone It is now calculated that humans have only nomenon is also seen in some other genetic marrow failure and cancer. Over the past about 23,000 genes operating, some of disorders, where a 3 letter fragment of DNA few years, Professor Inderjeet Dokal and which have died out or are dying out over multiplies in successive generations. The colleagues at Imperial College, London, the course of evolution. Thus our biological length of a patients telomeres show when have identified the genetic basis of this rare complexity is more likely to be related to symptoms will first emerge – the shorter the inherited disorder. They have clarified why how these genes are used, incorporating telomere, the sooner symptoms appeared. symptoms appear earlier in successive gen- feedback to ensure maximum effectiveness, erations. Ivan M. Gillibrand in the solution to problems of how and where the genes can be switched on and off during development. Many different mechanisms of gene control are being discovered – indeed the higher order arrangement of Health Care Policy Reform – the UK National DNA is turning out to be particularly important. For example, it has been found that the Health Service DNA of active genes is not linear, as typically drawn in textbooks, but rather is Mr James Johnson, MD, FRCS, Chairman of Council, British looped, with control proteins shared Medical Association. between the start and end points of the gene. Such looping of the structure is essential for the activation of the gene. The substance of this paper was presented forecast for the current year. If unit costs at the WMA Santiago meeting 2005. cannot be reduced over the next two years Almost sixty years after the start of the there will be serious doubts as to whether Gene control UK’s National Health Service, the NHS is we can sustain an NHS free at the point of RNA interference (RNAi) is an exciting in trouble. Despite unprecedented levels of use and offering comprehensive services to area of study, as these tiny RNAs can investment, a massive financial deficit is all. That would be a tragedy.

7 Medical Science, Professional Practice and Education

The NHS was founded on an assumption Hospitals in particular have been slow to services. Its duties include giving local that once patients’ “need” had been satis- take advantage of new technology, and in Trusts and NHS bodies a rating to reflect fied, demand and costs would fall, over General Practice, a multiplicity of IT sys- their performance. Initially this was a star time. It was introduced with the promise of tems mean that we still have not got the rating system which my Association has universal and efficient delivery of health ability to transfer patient records between condemned as far too crude to offer any services. In reality, instead of demand and practices electronically – let alone between useful information to patients or to the costs falling, there have been rising hospital and GP. NHS. The star ratings are being replaced by demands, costs and expectations. These are new measures which will separately look at To combat all this, the government has global pressures experienced by health ser- a Trusts’ financial management. commissioned a National Programme for vices all over the world. IT for the NHS (NPfIT) run by Connecting These Healthcare Commission ratings are The UK’s NHS is an experiment in health for Health. The initial budget for the NPfIT important to NHS hospitals seeking to reform. Almost every conceivable lever has project was £6 billion sterling but commen- become Foundation Hospitals, which are been pulled to try to influence the system, tators predict this will be substantially free from the normal constraints under for example by reducing waiting times and exceeded. Described as the world’s largest which the majority of NHS Trusts operate. increasing quality. Although when elected civil computer programme, NPfIT includes Only three star Trusts are eligible to apply in 1997 the Labour Party was critical of an a national care records system to provide a for Foundation status. internal market created by the previous central database for the electronic health As incentives to drive these changes to the (Conservative) government, it is interesting records of 50 million patients. It also NHS, the Government has introduced choice that after seven years in office, the Labour includes “Choose and Book”, a software and commissioning policies. Patient choice government has recreated the basic model system to allow people to select hospital is to drive the reform agenda, with people and returned to incentives as the main appointments from a choice of dates and given more say in how when and where model of reform. locations when they are referred to sec- they access treatments. Money will follow ondary care by their GP. Suffice to say there Recent NHS reforms have included a pledge the patient’s journey through the NHS and have been problems implementing the sys- to increase the numbers of health profes- this will be effected via Payment by tems and neither is fully operational. sionals, including doctors, and the moderni- Results. A fixed national tariff will be sation of the infrastructure and services. The The British Medical Association has criti- payable to NHS providers – including the number of medical school places has been cised the IT project for failing to engage growing number of independent sector increased and we are attracting more doc- with clinicians from the start. Quite late on, organisations providing NHS care – for tors from other parts of the European Union the Department of Health appointed clinical each treatment. At present only Foundation and elsewhere. Nevertheless there are still advisors who have been helpful, but by the Trusts are covered by Payment by Results shortages in some specialities and in some time they came on board a great many doc- but the intention is for all NHS hospitals to branches of the profession such as general tors felt alienated. operate under the system from April 2006. practice. It’s also true that in general prac- In terms of other NHS Reforms, clinical At the same time the government wants to tice the majority of the extra doctors recruit- governance was tightened and a raft of bod- take the role of commissioning services ed elect to work less than full time and ies brought in to implement it and to sup- away from local NHS bodies and hand it to choose portfolio careers. port learning activities. These included the other commissioners, notably general prac- Improvements in NHS infrastructure have Modernisation Agency, the National titioners under a scheme called Practice been largely secured via the Private Patient Safety Agency and the short-lived Based Commissioning. The hope is that by Finance Initiative (PFI) using private sec- NHS University. Hierarchical reforms to giving clinicians the commissioning role, tor money to build and staff new hospitals the NHS include setting national standards costs will be constrained and more patients which are then leased back to the NHS for and targets, inspection and regulation from will be treated nearer to home in a commu- a limited period, typically 30 or 35 years. the centre, published information on perfor- nity setting, rather than in expensive acute Critics of PFI , and they are vociferous, say mance and other central interventions. hospitals and other secondary care. this is a very expensive way of accessing The National Institute for Clinical Excel- So far, take up on Practice Based Commi- money and while it saves on capital costs it lence (NICE), was set up to examine new ssioning has been patchy and somewhat leaves Hospital Trusts with a heavy debt drugs and treatment to determine whether lukewarm. Potential commissioners are burden for many years. On the more posi- they should be available on the NHS. dubious about assuming the role in the face tive side, clinicians have welcomed the National Service Frameworks emerged to of large-scale deficits in local NHS bud- chance to move from outdated, deficient, direct clinicians towards best treatments for gets. Payment by Results has the potential hospital buildings to modern purpose- certain conditions, and the Healthcare to attract even more care into the hospital designed ones, albeit often with fewer beds. Commission (formerly CHI, the Commi- sector, driving up NHS costs, and the gov- It isn’t just NHS buildings which are old ssion for Health Improvement) is an inde- ernment clearly hopes that Practice Based fashioned and in need of modernisation. pendent organisation which inspects health Commissioning with contain that.

8 Medical Science, Professional Practice and Education

Key Changes in the UK employers and while there is a shortage of increase in the number of elderly people in doctors, more freedom to move around. the population, many of whom will have The future picture of health policy is uncer- multiple morbidity. In future the NHS will have less emphasis tain, but incentives ensure that service pro- on the state’s role as provider and more as vision will change radically. a purchaser of care. It will be less directive of local services and act more as a regula- The NHS has seen a huge increase in fund- Challenges for policy makers tor, setting the framework for a competitive ing in the past five years so that by 2007/08 The Finance Ministry and the Department market in the provision of healthcare. it will have risen to approach 10% of total of Health have two key priorities. They GDP. Britain will by then be spending on We will see greater devolvement of man- must enhance productivity and they must health sums comparable to other countries agerial responsibility, while retaining cen- increase self management of care. The first, of the Western world, with the exception of tral direction through the use of financial they plan to tackle by changing service pro- the USA. Certainly in recent years we have incentives and quality standards. vision and patterns of working within the seen a marked change in the proportion of NHS. Their approach to increasing self Most importantly there will be plurality of GDP we spend on health. Five years into management of care is through giving provision with health care delivered by this investment, people are questioning patients greater choice of care pathways both public and private sectors, still free at whether there has been commensurate outside hospital. the point of use. Independent Sector improvement. Treatment Centres have been introduced in The current level of NHS investment People ask where has the money gone. secondary care to bring down waiting times growth will cease in 2008 and we will Rectifying the legacy of historic under- and lists, amid many concerns among NHS return to the relative low annual increases funding has absorbed some of it. New tech- staff that their introduction risks destabilis- of around 2.5%. If the system is not work- nology and new buildings account for ing existing hospitals which train staff and ing well by then, people will question more. New contracts for NHS staff account provide round the clock NHS care in all its whether a “free-at-the-point-of-use” model for half of the resources, and incentives to aspects. is sustainable. We have two years left to reach government targets have swallowed sort out the financial problems and demon- General Practice is also changing. A new up an appreciable amount. strate that the NHS can work. contract for GPs introduced in 2004 con- Despite higher numbers of doctors, the UK tains a Quality and Outcomes Framework Mr James Johnson is still relatively low in the league table of rewarding GPs according to the quality of M.D., FRCS, FRCP, FDSRCS practising physicians per 1000 population. services they provide. General practice is Few westernised countries have lower Chairman of Council, now said to have “over-delivered” causing ratios than the UK. Yet we face increasing British Medical Association the contract to cost more than the govern- pressures on the NHS resulting from an Tavistock Square, London, WC1H 9JP ment expected. GPs are able to point to the high quality care they provide for patients. Nevertheless a national shortage of GPs means that some areas are “under-doc- tored”. The government is opening up the service to commercial providers for the Collaboration with the Global Health Initiative first time. It is providing wider access with walk-in centres and plans to bring more of the World Economic Forum: Initiatives care out of hospitals closer to patients’ homes. launched to address training and education There is an ideological debate taking place in the UK over whether the “socialised” needs in TB burdened countries model of healthcare is being dismantled Nobel Peace Laureates and representa- highlighting the need to provide the neces- and the NHS privatised. The financing of tives of 20 million health care providers sary human resources to fight the growing UK healthcare has not changed. The gov- call on governments to fund the scale up TB threat in high burden countries. They ernment pledges that money will continue of human resources needed to fight TB called on governments to immediately com- to come from general taxation. We are mit to fund, train and scale-up the health experiencing a privatisation of provision. GENEVA, 21 March 2006 – Nobel Peace care workforce to combat TB and help pre- The change is in provision and delivery of Laureates Archbishop Desmond Tutu and vent 5 000 daily deaths from this curable UK healthcare Betty Williams joined forces with global disease. At this special event, Eli Lilly & Doctors see threats and opportunities in healthcare organizations representing more Company and six leading global health and this – more providers means a choice of than 20 million health care providers in relief organizations launched a number of

9 Medical Science, Professional Practice and Education

initiatives to tackle the human resources Archbishop Tutu, speaking from his per- World Economic Forum crisis in TB treatment. sonal experience with TB, said “I urge the G8, governments of TB burdened countries, As part of its Global Health initiative Though 90% of the world’s population live and international donors to address this gap launched in January 2002, the World in countries that have adopted the interna- in funding for human resources urgently.” Economic Forum (WEF) has developed a tionally recommended strategy for control- The Archbishop, who contracted the dis- unique TB Awareness Workplace Toolkit. ling TB, an adequately trained health care ease as a child in South Africa, continued The toolkit, consisting of educational mate- workforce is required to fully implement “Without well-trained health care providers rials, awareness programs, and suggested control programmes and save an additional in the field we cannot possibly combat this prevention techniques for teaching in the 14 million lives over the next ten years. curable disease which kills so many so workplace, will help employees, and com- According to the Stop TB Partnership, it is needlessly, and the Global Plan will fail. pany health-care staff better understand estimated that US$250 million is needed Fourteen million lives can be saved and 50 symptoms of TB and seek timely diagnosis every year to provide technical assistance to million people treated in the next 10 years and care. countries to provide the training and if we address this crisis now and ramp-up strengthening of TB control services to mil- The International Council of Nurses training and education in high burden coun- lions of care providers. (ICN), the International Hospital tries.” Federation (IHF) and the World Medical To address this, the International Council of Association (WMA), have all produced Nurses (ICN), the International Hospital Eli Lilly and Company has committed $70 training programmes which include detect- Federation (IHF), and the World Medical million to a ground breaking global partner- ing, planning and implementation of treat- Association (WMA) their new on-site and ship to fight multi-drug resistant tuberculo- ment for both TB and MDR-TB. distance learning TB training programmes sis (Lilly MDR-TB Partnership**). Rich for nurses, hospital managers, doctors and Pilnik, Lilly President of Europe, Africa, Heroki Minami, President of ICN stated laboratory technicians, which are being Middle East and CIS, comments: “The suc- “Nurses are usually and often the only rolled-out in the high-burden countries. The cessful treatment and prevention of this health care professionals to see a person World Economic Forum and the silent killer is above all dependent on suffi- with TB or MDR-TB, particularly in strug- International Federation of the Red Cross cient well trained, mobilized and motivated gling health systems in developing coun- and Red Crescent Societies outlined their health providers, particularly for multi-drug tries where we are seeing TB re-emerging new programs to introduce TB prevention resistant tuberculosis. As some of the pro- dramatically.” and treatment into the workplace and com- grams launched today show, we are begin- The Director General of the IHF (Per- munities, so that workers and families can ning to build the defences, but now we need Gunnar Svensson, said, “It is vital to recog- be diagnosed correctly and the social stig- to fight this war with welltrained profes- nise that there is a need to include managers ma of the disease reduced. sionals.” of hospitals and health services in planning * High burden countries (the top 22 and implementation of disease prevention This event follows the announcement of the ranked by number of new TB cases) and control systems. Ignorance and non- Global Plan to Stop TB 2006-2015 at the include: Afghanistan, Bangladesh, involvement/exclusion can lead to adoption Annual Meeting of the World Economic Brazil, Cambodia, China, DR Congo, and implementation of counter-productive Forum in Davos, and aims to raise aware- Ethiopia, India, Indonesia, Kenya, decisions and actions” ness of the urgent need to expand and Mozambique, Myanmar, Nigeria, strengthen human resources to deliver the A TB Distance-learning course is being pre- Pakistan, Philippines, Russian Global Plan. Tuberculosis is re-emerging as pared by the WMA, whose manual is being Federation, South Africa, Tanzania, a serious global health threat that causes 9 converted into a web-based course by the Thailand, Uganda, Viet Nam, Zimbabwe. million new cases and 2 million deaths Norwegian Medical Association for WMA, every year. Of these new cases, 400 000 are ** The Lilly MDR-TB Partnership is a and will provide Continuing Medical of increasingly virulent drugresistant public-private initiative led by Eli Lilly Education (CME) accreditation. While strains (MDR-TB), which are often & Company to address the expanding focusing on the quality of clinical care spawned by improper or incomplete treat- crisis of multi-drug resistant tuberculo- needed to treat tuberculosis Dr. Otmar ment of normal TB. In several countries of sis (MDR-TB) The partnership is pursu- Kloiber, Secretary-General of the WMA, Eastern Europe and Central Asia, MDR-TB ing a comprehensive strategy to fight recognising the fundamental causes of this has increased to 15 % of new cases, while MDR-TB through increasing drug sup- disease and other global pandemics, said in several African countries with high HIV ply and discounting prices, providing “Tuberculosis is a disease that is strongly prevalence, rates of TB have tripled. training in prevention, treatment, and related to social circumstances and living According to the WHO, fewer than 1 in 50 surveillance, and sharing drug manufac- conditions” and explained “To improve the people who develop MDR-TB currently turing technology with nations most at economic situation of the affected popula- have access to effective treatment and the risk. For further information www.lil- tions must be a central aim of any develop- vast majority die. lymdr-tb.com. ment, in other words: Fight Poverty”.

10 WMA

WMA In this global village, we need to support each other. We need to provide a balance to a politics of scarcity that views medical care WMA General Assembly, Santiago Presidential and medical professions not as a value to be cherished and protected but as a cost to be Valedictory Address, Yank D. Coble, cut, and controlled. It was in that spirit that I approached my MD, MACP, MACE, October 14, 2005 term as president. As you know, we sometimes cannot accom- plish everything that we wish for in our I am honored to be here, to share my per- depends on the health of nations. And it is organization. But while our finances may be spective on some of the World Medical we, as physicians, who are the instruments limited, our imaginations are not, nor need Association’s initiatives this past year. used to fulfill those hopes, address those our influence or example. What was accomplished where we’ve made needs and meet those expectations. progress and the work yet to be done. When I assumed the WMA presidency, my The Canadian physician Sir William Osler, goal was to continue to communicate the Among you, I see many familiar faces. Old who was a philosopher as much as he was a unique, enduring traditions and values of friends and new. I am proud to be associat- doctor, described the heart and soul of what the medical profession – that is caring, ed with all of you, who care so much for we do more than 100 years ago, no matter ethics and science. These three values are your patients, practice medicine with such where we live. “The practice of medicine is shared by physicians throughout the passion and who work so hard to live out an art, not a trade; a calling, not a business; world. and uphold the ethics of our profession. a calling in which your heart will be exer- cised equally with your head. Often the best As physicians we are committed to science As WMA president, I tried to be true to that part of your work will have nothing to do and the life-long process of learning. It mission. We want medical care everywhere with potions and powders, but with the gives us a unique authority and perspective. to be the best care anywhere. We promote exercise of an influence of the strong upon the highest standards of medical education, Ethics compel us to put the interests of the the weak, of the righteous upon the wicked, ethics and science. And we expect the same patient or the public health first. of the wise upon the foolish.” from the other players in our respective Caring, as Osler said, “is the most important health care systems – be they in the private It was just these sort of ethical issues that thing – so do it first. For it is the caring or public sectors. led to the founding of the World Medical physician who most inspires hope and trust.” Association in 1947. It’s stated purpose: ”to And we have to expect something from our serve humanity by endeavoring to achieve These traditions enable physicians to pro- patients, as well. the highest international standards in med- vide value, hope and trust to patients and We cannot speak too much, or too often, of ical education, medical science, medical art, society. They make us powerful advocates the paramount importance of individual and medical ethics and health care for all for our patients, our profession and the pub- health. It has been said that “He who has people of the world”. lic’s health. They give us a common lan- health, has hope. And he who has hope, has guage of action and behavior. They are, in Behind its founding was a sad fact of life – everything.” short, what unify us. that the same rapid advances in medical In the last century, a mere instant in the technology and innovations in care that has I wanted to let the world know about the timeline of human history, the rapid brought hope to millions could be twisted to good work we do as an organization – and advance of medical progress and innova- bring suffering to millions if conducted in the great work done by physicians around tions in care has supplied that hope for an ethical vacuum. the world. To remind people that there’s a thousands of millions of people in need. human face on the concept – on the act – of Since 1947, time and again, we’ve seen the healing. That science, ethics and caring Herophilus, a physician in ancient Greece, importance of National Medical Asso- aren’t just words but a way of life. said “When health is absent, wisdom cannot ciations acting in their role as nongovern- reveal itself, art cannot manifest, strength mental organizations, acting together as the cannot fight, wealth becomes useless, and vanguard for medical ethics. We saw it in intelligence cannot be applied.” the aftermath of World War II, and we saw “Apology: We apologise for the misprint in it during the dictatorship in Iraq. WMJ 51(4) which, in the report of the Associ- You cannot put a price tag on hope, but ates’ meeting, referred to a paper by the late researchers have placed a value on the eco- As our world becomes smaller with more Dr. Doppelfeld. We are pleased to report that nomic return of investments in better health, intertwined interests, so also, the medical Dr. Doppelfeld recovered from his spell in higher quality medical care and medical associations of the world need to tighten hospital and we very much regret any distress research. It tells us the wealth of nations their mutual bonds. this may have caused”.

11 WMA

To me, that idea is represented in the Caring Emily Chan, President of the Hong Kong Association and the leadership of national Physicians of the World Initiative. section of Medecins Sans Frontieres; medical specialty associations, state med- Nanshan Zhong, China’s top expert on ical associations, health related organiza- With the help of the Pfizer Medical Severe Acute Respiratory Syndrome, who tions, and government agencies. Humanities Initiative (PMHI) team, led by played such a vital role in the SARS epi- Director Mike Magee, we decided to pro- If you want to read some positive reviews demic in 2002; duce a publication profiling physicians and widespread publicity, type the words Benito Atienza of the Philippines, who cre- among those nominated by National “Caring Physicians of the World” into a ated the Child Community Health Workers Medical Associations around the world. Google search. These are physicians who carry on the tra- Foundation; dition of caring ethics and science while Hoang Dinh Cau, who is the chairman of All of this – the extraordinary expressions of practicing or teaching medicine in an array the Committee for Investigation of the gratitude by the nominees - and by their of circumstances, some difficult, some dan- Consequences of Chemicals Used in the associations, families and friends, suggest gerous, all of them a challenge. And all the Vietnam War; that physicians appreciate this sort of recog- while, they give of themselves in service to Mamphela Ramphele, who was imprisoned nition. For some, it is what helps them perse- patients or students. for her anti-apartheid political activities, vere through often difficult circumstances. and went on to become the first black NMA response has been equally gratifying. Our national medical associations were woman Vice Chancellor at a South African Two of the largest NMAs in terms of physi- interested, but assembling this book would University and then a managing director of cian numbers, who are WMA members but require a lot of resources, including trips to the World Bank. were inactive and non dues paying for sev- often remote locations to photograph this And John Awoonor-Williams from Ghana, eral years, nominated physicians for inclu- international array of physicians and learn who works in one of the remotest areas of sion, subsequently paid dues, and request- their stories. Again, the PMHI Team the world as the only doctor serving a vast ed presentation of the book at an annual stepped forward with generous support. At area. the same time, they left all decisions on meeting. Heroes all, immortalized not just in their selection, writing and editing to us. We pre- The WHO has requested that the “Caring work, but now in words and pictures, as well. sented the idea at WMA gatherings Physicians of the World” book be presented throughout 2004, and in November of that We made our deadline. The book cleared on April 7 during World Health Day and year, requests for nominations were sent to customs in Santiago less than 24 hours presented to press conferences in London national associations. before our scheduled launch two days ago, or Lusaka. For our part, the WMA will hold We asked for rapid response so we could October 12, 2005. a press conference for the Ministers of Health of all nations participating in the complete the publication within one year When we unveiled “Caring Physicians of and launch the book during the WMA WHA in Geneva in May 2006. We’ll be the World,” the event was attended by more showing off the book and making sure that Annual meeting in Santiago, Chile in than 200 people .and we presented the first October, 2005. the WHO delegations get a copy. Beyond volumes to our hosts, the Chilean Medical that, plans are in the works to distribute the The response was overwhelming. Within Association and their nominee profiled in book to English language medical schools, two months, 55 national associations nomi- the book. and we’re seeking new venues to get this nated more than 200 physicians. We heard A separate web site was linked to the WMA message out. not only from members, but from NMAs web site and described in detail the purpose that were not yet members. We also received “The Caring Physicians of the World,” behind the book – how it came to be pub- nominations from people outside the med- through photographs and words, conveys a lished – and why we believe it’s an important ical professions, particularly for physicians compelling story about the impact of med- glimpse into the lives of physicians the world who performed so admirably following the ical professionals on their communities and over. All nominees and all National Medical South Asian tsunami of December, 2004. their countries. I am confident that it will Associations have received the “Caring continue to be a useful resource and refer- Of the 200 nominees, 65 physicians were Physicians of the World” book. Some of you ence for our organization and for those selected, interviewed, photographed in their have used the book in press conferences and organizations we engage. home environments and profiled. meetings with government officials and related health professions and organizations. Physicians such as Valentin Pokrovsky, a NMA Survey & CPWI: Out- leading expert on AIDS and the first person More than 250 copies of the book were dis- in Russia to describe HIV-infection and tributed to health and medical leaders in reach and Regional Meetings AIDS; Geneva at the World Health Organization Otar Toidze, a neurologist and epileptolo- and other groups. In the United States, But this book was only one way the World gist who became a Member of Parliament copies have been distributed widely among Medical Association is opening its lines of in Georgia; the leadership of the American Medical communication.

12 WMA

In the summer of 2004 the WMA complet- the Portuguese Medical Association, and the Africa in January 2005. The second highly ed a survey of its member associations that British Medical Association. successful regional meeting was among revealed that we share many of the same The WMA took part in the WHO Executive Latin American NMAs here in Santiago concerns and needs, such as diminished Board meetings in January and March, four days ago. access to quality, safe, affordable medical 2005, which focused on the tsunami res- Regional meetings are planned for South care, limited patient choice, reduction of ponse effort; and also participated in the East Asian NMAs in November in Bang- professional prestige, and appropriate WHO strategic workgroup on Diet, Fitness kok, European NMAs in Prague in autonomy and compensation. These are and Health. December 2005, and North American problems for our profession that cross all NMAs in Florida March 2006. The WMA also reached out to the World national and cultural borders. Each of these regions and each of these Health Assembly (WHA) in May. Knowing this helps the WMA better organizations have different needs and approach our priorities and communicate Other events of note include: interests and capabilities. Each can teach us better with our member national associa- • Keynoting of the WMA World Oceans something new about the practice and value tions. It also helps us communicate better Forum November, 2004 in New York; of medicine. Each can tell us more about with outside organizations, and the public. • Chairing the WMA Ethics Manual why it is so important – to rally around the launch in Geneva, Switzerland in banner of science, ethics and caring. Outreach January, 2005 (the ethics manual has already been translated into more than a Science, Ethics and Caring Our Caring Physicians of the World out- half-dozen languages); reach effort is striving to re-introduce the • Addressing the World Bank Forum on These are the three enduring traditions. WMA to those national medical associa- Counterfeit Drugs; Science – ethics – caring. tions that have been inactive. • Meetings with the World Bank leader- We see these exemplified in the 65 of our This included the associations from two of ship on Global response to AIDS, colleagues profiled in the “Caring Phy- the most populous nations on the planet. Tuberculosis and Malaria; sicians of the World” book. We see it prac- In the space of a single one-year period, we • Participation in formation meetings of ticed by physicians everywhere. had four meetings with the Chinese the Iraqi Physicians Society and the They are what make us effective advocates Medical Association and other medical Project Hope Basra, at the Iraq Pediatric for patients and for our profession, no mat- groups there – including the Shanghai First Hospital; ter where we live. They give us an anchor – World Medical Summit and the Shanghai • And addressing the US DHHS/DOD a sense of permanence – in an imperfect Medical University. Forum on disaster response for tsunami and transitory world of political upheavals, The World Medical Association’s Caring effected countries. policy shifts and spasms of public opinion. Physicians of the World initiative also Get involved – become an activist in nation- reached out to India – I spoke in February Regional Meetings al and international organizations that affect to the Indian Medical Association and your patients and your calling. That way, Medical Council of India in Delhi, and The third component of the CPWI, stimu- you make an impact as an individual and as addressed officials of their association lated by NMA response to our WMA ques- part of chorus of powerful voices, singing as again in December. tionnaire the summer of 2004, was the one. A voice that makes entities in govern- The initiative’s outreach support also gave establishment of WMA/CPW Regional ment and industry which may seem distant the new Secretary General and President the Meetings of NMAs around the world These and unresponsive, sit up and take notice. opportunity to visit jointly with NMAs, a meetings enable WMA to listen and learn Also to learn what we do, what we stand for key representation benefit that would have how to best serve their membership and and the values we embrace. All in the ser- been otherwise impossible.These included advocate on behalf of patients and the pro- vice of our patients and the public health. the annual meeting of the American Medical fession, enhance exchange of information We are the global face of medicine. We Association, the inaugural ceremony of the between WMA and NMAs, and among share a commitment to the best science – to Canadian Medical Association, the NMAs in regions, and enhance NMA’s caring and compassion – and to the highest Confederation of Latin American Nations effectiveness and growth. ethical standards. We are by now familiar and the Caribbean (CONFEMEL) in Costa The concerns expressed by NMAs reflected with those profiled as Caring Physicians of Rica, the Israel Medical Association, the the concerns of Physicians worldwide: the World what they do every day to change South African Medical Association, and the diminishing access to safe, affordable med- the course of health care in their communi- Thailand Medical Association. We carried ical care; limited patient choice; erosion of ties and in their countries. our message of the Caring Physicians of the professional prestige, and appropriate Our challenge, each and every one of us , is world as well to the Hungarian Medical autonomy and compensations. to effect that change wherever we may live. Association, the Taiwan Medical The first regional meeting was among Sub- Because all of us are the “Caring Physicians Association, the Colegio Medico de Mexico, Saharan NMAs in Johannesburg, South of the World.”

13 WMA

The World Medical Association Statement on reducing the global Impact of Alcohol on Health and Society Adopted by the WMA General Assembly, Santiago 2005

Preamble demonstrated the harmful effects of hol beverage sales are sensitive to consumption prior to adulthood on the prices, i.e., as prices increase, demand 1. Alcohol use is deeply embedded in brains, mental, cognitive and social declines, and visa versa. Price can be many societies. Overall, 4% of the functioning of youth and increased influenced through taxation and effec- global burden of disease is attributable likelihood of adult alcohol depen- tive penalties for inappropriate sales to alcohol, which accounts for about dence and alcohol related problems and promotion activities. Such policy as much death and disability globally among those who drink before full measures affect even heavy drinkers, as tobacco or hypertension. Overall, physiological maturity. Regular alco- and they are particularly effective there are causal relationships between hol consumption and binge drinking among young people. alcohol consumption and more than in adolescents can negatively affect 60 types of disease and injury includ- school performance, increase partici- 7. Heavy drinkers and those with alco- ing traffic fatalities. Alcohol con- pation in crime and adversely affect hol-related problems or alcohol sumption is the leading risk factor for sexual performance and behaviour. dependence cause a significant share disease burden in low mortality devel- of the problems resulting from con- oping countries and the third largest 4. Alcohol advertising and promotion is sumption. However, in most coun- risk factor in developed countries. rapidly expanding throughout the tries, the majority of alcohol-related Beyond the numerous chronic and world and is increasingly sophisticat- problems in a population are associat- acute health effects, alcohol use is ed and carefully targeted, including to ed with harmful or hazardous drinking associated with widespread social, youth. It is aimed to attract, influence, by non-dependent ‘social’ drinkers, mental and emotional consequences. and recruit new generations of poten- particularly when intoxicated. This is The global burden related to alcohol tial drinkers despite industry codes of particularly a problem of young peo- consumption, both in terms of morbid- self-regulation that are widely ignored ple in many regions of the world who ity and mortality, is considerable. and often not enforced. drink with the intent of becoming intoxicated. 2. Alcohol-related problems are the 5. Effective alcohol social policy can put result of a complex interplay between into place measures that control the 8. Although research has found some individual use of alcoholic beverages supply of alcohol and/or affect popu- limited positive health effects of low and the surrounding cultural, econom- lation-wide demand for alcohol bever- levels of alcohol consumption in some ic, physical environment, political and ages. Comprehensive policies address populations, this must be weighed social contexts. legal measures to: control supply and against potential harms from con- demand, control access to alcohol (by sumption in those same populations as 3. Alcohol cannot be considered an ordi- age, location and time), provide public well as in population as a whole. nary beverage or consumer commodi- education and treatment for those who ty since it is a drug that causes sub- need assistance, levy taxation to affect 9. Thus, population-based approaches stantial medical, psychological and prices and to pay for problems gener- that affect the social drinking environ- social harm by means of physical tox- ated by consumption, and harm-reduc- ment and the availability of alcoholic icity, intoxication and dependence. tion strategies to limit alcohol-related beverages are more effective than There is increasing evidence that problems such as impaired driving individual approaches (such as educa- genetic vulnerability to alcohol depen- and domestic violence. tion) for preventing alcohol related dence is a risk factor for some individ- problems and illness. Alcohol policies uals. Fetal alcohol syndrome and fetal 6. Alcohol problems are highly correlat- that affect drinking patterns by limit- alcohol effects, preventable causes of ed with per capita consumption so that ing access and by discouraging drink- mental retardation, may result from reductions of use can lead to decreasing by young people through setting a alcohol consumption during pregnan- es in alcohol problems. Because alco- minimum legal purchasing age are cy. Growing scientific evidence has hol is an economic commodity, alco- especially likely to reduce harms.

14 WMA

Laws to reduce permitted blood alco- sale and the number of sales outlets, systematically by qualified person- hol levels for drivers and to control increasing alcohol taxes, and imple- nel using evidence-based screening the number of sales outlets have been menting effective countermeasures for tools that can be used in clinical effective in lowering alcohol prob- alcohol impaired driving (such as low- practice; lems. ered blood alcohol concentration limits for driving, active enforcement of b. promote self-screening / mass 10. In recent years some constraints on the traffic safety measures, random breath screening with questionnaires that production, mass marketing and pat- testing, and legal and medical inter- could then select those needing to terns of consumption of alcohol have ventions for repeat intoxicated dri- be seen by a provider for assess- been weakened and have resulted in vers). ment; increased availability and accessibility of alcoholic beverages and changes in 13. Be aware of and counter non-evi- c. provide brief interventions to moti- drinking patterns across the world. dence-based alcohol control strategies vate high-risk drinkers to moderate This has created a global health prob- promoted by the alcohol industry or their consumption; and lem that urgently requires governmen- their social aspect organizations. d. provide specialized treatment, in- tal, citizen, medical and health care cluding use of evidence-based phar- intervention. 14. Restrict the promotion, advertising maceuticals, and rehabilitation for and provision of alcohol to youth so alcohol-dependent individuals and Recommendations that youth can grow up with fewer assistance to their families. social pressures to consume alcohol. The WMA urges National Medical Support the creation of an independent 17. Encourage physicians to facilitate epi- Associations and all physicians to take the monitoring capability that assures that demiologic and health service data following actions to help reduce the alcohol advertising conforms to the collection on the impact of alcohol. impact of alcohol on health and society: content and exposure guidelines 18. Promote consideration of a Frame- 11. Advocate for comprehensive national described in alcohol industry self-reg- work Convention on Alcohol Control policies that ulation codes. similar to that of the WHO Framework Convention on Tobacco Control that a. incorporate measures to educate the 15. Work collaboratively with national took effect on February 27, 2005. public about the dangers of haz- and local medical societies, specialty ardous and unhealthy use of alcohol medical organizations, concerned 19. Furthermore, in order to protect cur- (from risky amounts through depen- social, religious and economic groups rent and future alcohol control mea- dence), including, but not limited to, (including governmental, scientific, sures, advocate for consideration of education programs targeted specif- professional, nongovernmental and alcohol as an extra-ordinary commod- ically at youth; voluntary bodies, the private sector, ity and that measures affecting the and civil society) to: b. create legal interventions that focus supply, distribution, sale, advertising, primarily on treating or provide evi- a. reduce harmful use of alcohol, espe- promotion or investment in alcoholic dence-based legal sanctions that cially among young people and beverages be excluded from interna- deter those who place themselves or pregnant women, in the workplace, tional trade agreements. others at risk, and and when driving; c. put in place regulatory and other b. increase the likelihood that every- environmental supports that pro- one will be free of pressures to con- mote the health of the population as sume alcohol and free from the a whole. harmful and unhealthy effects of drinking by others; and 12. Promote national and sub-national policies that follow ‘best practices’ c. promote evidence-based prevention from the developed countries that with strategies in schools. appropriate modification may also be 16. Undertake to effective in developing nations. These may include setting of a minimum a. screen patients for alcohol use dis- legal purchase age, restricted sales orders and at-risk drinking, or policies, restricting hours or days of arrange to have screening conducted

15 From the Secretary Gerneral’s desk

From the Secretary General’s desk income after specialization. Today physicians, male and female, are in relationships with spouses who have their own profes- Working together for health – Human sional life. Burdens are to be shared between equal partners, nor do young Resources for Health World Health Day 2006 physicians do, or want to have. The same work load as their predecessors regardless of whether they are male or female. As WHO invites governments and institu- young physicians has been suggested. tions to celebrate World Health Day 2006 Bonding means to oblige a person to pro- “Work-life balance” is a phrase that our under the theme „Working together for vide a service in return e,g, for the educa- slave-like profession is slowly learning to health“, the people working in health care tion they have received. Bonding could also recognize. Although senior physicians in many countries of this world may have be seen as part of a social contract, when often see it as a kind of mutiny, those who the feeling that there is not very much to physicians return a service for the state paid are asking for more private time and rea- celebrate. Actually there is rather a ques- education they received. However there are sonable working hours, are only asking for tion, “Where to go?” and the answer has many problems with bonding other than what other professions see as their natural already been given: “from East to West and that young workers or college graduate stu- right since decades. from South to North”. The migration of dents are not being paid. One could argue The traditional expectation of a good health professionals is soaring and clearly that the return has already been made, it is income in a late part of our professional life follows an economic gradient from poor their commitment to study and not receive has for a long time led us to often tolerate countries to rich countries. While in Europe a salary for that work. Also, each nation inadequate payment and unacceptable the migration from East to West is partly that believes in equality before the law working conditions, Often to the extent compensated by an oversupply of physi- would have to demand the same bonding that the average salary of a young physician cians in East and Central Europe, and the from every other student as well. is lower than that of a factory worker. And brain drain from African countries in partic- Yet good examples of voluntary bonding with the increasing tendency of employers ular, reaches catastrophic dimensions. exist and bonding can serve to guarantee a to be unwilling or able to pay for over- But to believe that money is the only dri- workforce. For those who promise to serve hours worked, the misery does not start, but ving force for health professionals to in certain areas, special benefits or prefer- becomes visible. migrate falls short of reality. There are ential treatment could be awarded. But that Grave as are the failures of governments, many other reasons that make physicians only works if there are focal shortfalls, e.g. politicians, insurances, managed care orga- (and other health professions) go or stay. in a certain rural area or in the military. nizations, hospital owners and other out- Working conditions, amongst them the When there is a general shortage of physi- siders in regulating the health care labour availability of material local items that lead cians, voluntary bonding is meaningless. In market, we have to acknowledge that we to a decision whether to go or to stay. The these cases a better payment and better made mistakes ourselves. There are certain environment in which the physician and his working conditions would be the straight- myths and misunderstandings we have to or her family have to live certainly is anoth- forward approach. clarify ourselves: er. However, cross border migration is not There is a decreasing willingness to accept the only move that is possible. Young physi- 36 hours shifts, there is a demand for 1. A good physician is always available. cians leave medicine and search other fields parental leave and there is a higher demand Physicians have the same physiology as of work in their country, sometimes imme- for more private time in general. To blame other humans. There is a point when an diately after passing their final exams. this trend on a feminisation of medicine is overworked person doing a danger- Established physicians retire early or they shortsighted. It is true that medicine is no prone work becomes a danger him or simply discover that there is “life beyond longer a male domain. In many countries herself. That is what every physician medicine” and decide to reduce their work- the majority of graduates now are female would tell an employer. It’s now time to load at the expense of a lower income. and new gender mix reaches the workplace. tell it our employers. And when we But a suggestion that women go off the job indeed believe in the equality of men Countries with an emigration of physicians because they marry and have children and and women, and when we indeed value have to try very hard to do whatever they therefore reduce the workforce, is far too the family, we have to change the med- can to offer better conditions to physicians easy. ical work place now. (and other health professions) and their families, if they wish to retain them. The Thirty years ago the typical physician was 2. The more experience you get – the more expenses of educating physicians alone male and provided the single income of the you learn – that is wishful thinking. One should make it a necessity for all countries family. He would work 150 to 200 % of can have a lot of experience and still to retain as many of the physicians they what was a normal workload and (in the make everything wrong. Learning is pri- have trained as is possible. Bonding of western world) would receive a decent marily not a question of quantity but of

16 WHO

quality. Burying young physicians under resources management, truly earning the are taking something which will make work does not mean that they learn a lot title of a disaster. We are in no position them well, when it may instead make them – unless you take frustration as a learn- to blame them. But often senior physi- sicker or even kill them. ing experience. Those senior physicians cians simply exploit young doctors for „People don’t die from carrying a fake who believe that their assistants or their own profit The more hierachical handbag or wearing a fake t-shirt. They can interns only learn when working long the organizational structure is the more die from taking a counterfeit medicine,” hours, have probably missed the most this becomes a danger. The exploitation says Howard Zucker, Assistant Director important lesson of their life, namely of physicians by senior physicians is not General for Health Technology and how to teach. acceptable. Pharmaceuticals at WHO. “International 3. It is similar with our (specialist) educa- police action against the factories and dis- 5. We don’t talk about money. That is fine tion. Whatever is new in medicine sim- tribution networks should be as uncompro- – as long as you have enough of it. In ply adds up to medical education. Every mising as that applied to the pursuit of nar- many countries of this world physicians one of us knows examples of things we cotic smuggling.” are underpaid, absolutely and in relation learnt as being essential at the beginning to the general population. More and Counterfeit medicines are part of the of our professional career, (some of more often this happens in the western broader phenomenon of substandard phar- which were outdated even before we fin- world as well. Whoever thinks that a maceuticals. The difference is that they are ished formal education). With an ever highly valuable service can be delivered deliberately and fraudulently mislabelled faster evolving knowledge, the exten- for token payment lives an illusion. with respect to identity and/or source. sion of training duration is exactly the Waiting lists, “under the table pay- These products mostly have no therapeutic wrong strategy. Instead of prolonging ments” and emigration, are the immedi- benefit; they can cause drug resistance and our basic and specialist training ever ate answer. Whoever organizes such a death. more, we would be better off to reduce system betrays both the physicians and these periods and admit that we have to Trade in counterfeits is extremely lucrative, the patients. Being silent about this is a undergo (structured) education as part of thus making it more attractive to criminal shame. our professional development for our networks. A report released by the Centre whole lifetime. for Medicines in the Public Interest, in the Sir William Osler said: „The most impor- United States, projects counterfeit drug 4. Those responsible for the working con- tant thing is caring, so do it first, for the car- sales to reach US$ 75 billion in 2010, a ditions of physicians are often physi- ing physician best inspires hope and trust.“ 92 % increase from 2005. cians themselves. Sometimes they are Let’s do our part, to give our young col- reacting to a miserable shortage of leagues a chance to care. The presence of fake drugs is more prevalent in countries with weak drug regulation control and enforcement. However, no single country is immune to the problem. WHO Reports from the pharmaceutical industry and governments clearly indicate that the methods and channels used by counterfeit- ers are becoming more sophisticated, mak- Counterfeit medicines: the silent epidemic ing detection more difficult. Measures for WHO convenes stakeholders to find global solutions to a growing combating counterfeit medicines so far have included support to under-resourced health threat drug regulatory authorities; simple, easily interpretable and cheap markers of authen- ticity such as barcoding; transnational sur- The World Health Organization (WHO) enforcement, trade, risk communications veillance for fake and substandard drugs; calls for immediate concrete action against and innovative technology solutions, and education of patients, healthcare work- the growing epidemic of counterfeit medi- including public-private initiatives for ers, and pharmacists. cines. In a bid to accelerate the war on fake applying new technologies to the detection drugs, the agency pushed for stronger glob- of counterfeits and technology transfer to “These measures need to be intensified,” al cooperation, political commitment and developing countries. adds Dr Zucker. “Countries should think creative solutions at a meeting in Rome The counterfeiting of medicines is present about ways to make the necessary techno- 16 – 18 February, 2006. in all countries and is thought to represent logical, legislative and financial adjust- WHO aims to create a global task force 10% of the global medicines trade. ments as quickly as possible to guarantee involving all major interested parties. The Particularly insidious, counterfeit medi- the availability of quality assured essential task force will focus on legislation and law cines dupe sick people into believing they drugs.”

17 WHO

WHO would also like to see more developments in the areas of innovative high and Countries representing three-quarters of the low tech solutions for prevention at the manufacturing stage and for detection in world’s population meet in Geneva to plan the distribution chain. the effective implementation of the tobacco Simple, inexpensive methods to identify fakes can be effective. For example, simple control treaty colorimetric assays developed for artemisinins have been used successfully to identify fake artesunate antimalarials. Countries around the world are taking same. In Ireland, Norway, and now in effective measures to curb tobacco use, Spain, smoking has been banned in indoor WHO set up the world’s first web-based including strong legislation, graphic warn- public places. These, and other similar system for tracking the activities of drug ing labels and advertising bans. These posi- steps, will result in a major reduction in cheats in the Western Pacific Region in tive changes reinforce the commitment tobacco deaths. 2005. The Rapid Alert System (RAS) com- made by the more than 110 countries who munications network transmits reports on New York State passed a smoking ban. It met to decide on the detailed implementa- the distribution of counterfeit medicines to termed this act its “strongest public health tion of the World Health Organization the relevant authorities for them to take policy ever”. Ironically, now it’s said that Framework Convention on Tobacco rapid countermeasures. That system should the only place you can smoke with impuni- Control (WHO FCTC). be expanded to include all regions. ty in New York City is the United Nations At the opening of the first session of the Building. Radio frequency identification (RFID) and Conference of the Parties (COP) to the more sophisticated technologies for prod- Both Ann Veneman and I have said that this WHO Framework Convention on Tobacco uct tracking within supply chain manage- is wrong. Smoking should be banned in all Control, in Geneva /Feb 6–17m, 2006) Dr ment systems are being experimented with UN premises. Also, cigarette sales should LEE Jong-wook, WHO Director General in some countries. Means must be sought to be banned in all United Nations premises. said. make these more sophisticated tools avail- After all, the people who are smoking in able and workable in developing countries. “One hundred and twenty one countries are the UN building sometimes are the repre- now contracting parties to the Convention. sentatives of the same Member States who Information on fake drug identity and dis- Of these, 110 are here today, with full pow- have signed up to the Framework tribution needs to be shared nationally and ers of participation. You represent nearly Convention. But it can be hard to put agree- internationally between government drug three quarters of the world’s population. ments into practice. We will all face this. regulatory authorities, customs and police You represent nations at all levels of income organizations, pharmaceutical companies, When we know that, in an Irish pub a and all stages of development. In this pow- non-governmental organizations, and con- smoking ban can really work, then we erful gathering, we have three of the five sumer groups. Risk communications, know that anything is possible. top tobacco-leaf exporting countries, and involving the media, should be practised to four of the five top cigarette-exporting Smoking is an advance contract. Those raise public awareness. countries. This group of countries repre- who smoke don’t pay now, but will do so The Rome conference was hosted by the sents 69% of the world’s cigarette con- 30 to 40 years later, when their health fails. Italian Pharmaceutical Agency (AIFA) and sumption. It might seem astonishing that They pay with lung cancer, with obstruc- Italian Cooperation, and organized with the this group is also preparing to put into tive airways disorders, with cardiovascular support of the International Federation of action the roadmap for countries to control diseases. One in two smokers pays with Pharmaceutical Manufacturers & tobacco. But this group has already changed their life. We have to help them stop smok- Associations (IFPMA) and the German history. ing. We have to prevent them from starting. Government. Participants in the conference This convention is something that we all When the process began there was some included experts from national govern- committed to. Its provisions are bold. They scepticism over its success. The sceptics ments and regulatory authorities, industry, are based on knowledge of what is effec- were wrong. intergovernmental organizations, and con- tive. sumer and patient groups. You are driving change forward. To name We will make it work.” some examples: India has introduced com- Contact: prehensive tobacco advertising bans. The COP is the governing body of the Daniela Bagozzi Australia, Brazil, Canada, Singapore and Treaty. It serves as the authority to oversee, Telephone: + 41 22 791 45 44 Thailand have introduced highly visible monitor and evaluate progress of the Treaty, Mobile phone: + 41 794 75 5490 graphic warnings on cigarette packets. The in order to reduce tobacco consumption and E-mail: [email protected] European Union is on its way to doing the tobacco-related deaths globally.

18 WHO

Concrete measures included in the Treaty • To allow the Conference of the Parties to “The urgency of the problem of tobacco use could help save 200 million lives by the assess progress made by countries in is shared by all of us, and the commitment year 2050 if a progressive 50% reduction in implementing the measures required by from countries and civil society to take uptake and consumption rates is achieved. the Treaty through a pilot reporting action is very strong. I felt the positive spir- Many measures in the WHO FCTC have questionnaire agreed by the Parties dur- it throughout the Conference, which clearly deadlines and clear guidelines. For exam- ing the Conference. contributed to its success, helping countries ple, from the Treaty’s entry into force, to reach consensus quickly on the basic • To establish an ad-hoc group of experts countries have three years to enforce health issues, so we can concentrate our efforts in that will study economically viable warnings on tobacco products, and five the implementation. I am confident we are alternatives to tobacco growing and pro- years to implement comprehensive bans on on track to save millions of lives in the near duction, with a view to making recom- tobacco advertising, promotion and spon- future thanks to this Treaty.” mendations on diversification initiatives sorship. for those countries whose economies More information about the first session of depend heavily on tobacco production. Other measures, such as those regarding the COP, including day to day overview, illicit trade or cross-border advertising, The President of the Conference, documents and presentations: www.who. have not yet been detailed in the Treaty. Ambassador Juan Martabit from Chile said, int/tobacco/fctc/cop/en/index.html The COP could decide to develop protocols and specific guidelines and requirements for countries to implement these measures.

In February 2007, the first Contracting Parties will submit to the COP initial reports on their progress, specifying what actions they have taken to implement the Stop TB tobacco control measures established in the Treaty. “This is a crucial time for people suffering the consequences of tobacco WHO welcomes United Kingdom, Gates use,” said Dr Yumiko Mochizuki- Kobayashi, Director of the WHO Tobacco Foundation funding for global action to stop Free Initiative. “Tobacco is still the top preventable cause of death. The goal is to see tuberculosis it fall from that position in our New tools to fight the disease lifetime.With continued commitment from Member States, we will achieve that goal.” The conference having adopted the follow- The World Health Organization welcomed „This funding from the UK government ing decisions: the announcement by the United Kingdom and from the Gates Foundation shows real, government that it will give £41.7 million long-term commitment to the global effort • To establish the permanent secretariat of (US$ 74 million) to help fight tuberculosis to stop tuberculosis,“ said Dr LEE Jong- the Treaty within the World Health (TB) in India and by the Bill and Melinda wook, WHO Director-General. “The glob- Organization, located in Geneva. Gates Foundation that it will triple funding al TB action plan shows clearly what must Delegates agreed on a budget of US$ 8 for tuberculosis to more than US$ 900 mil- be done to tackle the burden of TB. We million for its functioning during the lion by 2015. must now act urgently to raise all the funds next two years. Parties agreed to fund it needed to put the plan into action.“ Announcement of the two funding commit- through voluntary assessed contribu- Key objectives of the plan include improv- ments follows publication of the Global Plan tions. ing access to treatment in order to prevent to Stop Tuberculosis which sets out the steps 14 million deaths and provide treatment to • To create working groups that will begin that are needed to tackle the global tubercu- 50 million people; developing and distrib- development of protocols (legally bind- losis epidemic. Two million people die of uting new drugs and a new, safe and afford- ing instruments) in the areas of cross- TB every year and eight million become able vaccine; and developing new efficient, border advertising and illicit trade. To infected. The plan, prepared by the Stop effective and affordable diagnostic tests. help countries establish smoke-free Tuberculosis Partnership, calls for global places and effective ways of regulating spending on tuberculosis to triple over the WHO is a partner in the Stop TB Partner- tobacco products, Parties agreed to next ten years to increase access to tubercu- ship, which was established in 2000. The develop guidelines (non-binding instru- losis control programmes and accelerate partnership secretariat is hosted by WHO ments). research on new tools to fight the disease. in Geneva.

19 WHO

To improve early detection, treatment and World Cancer Day, February 2006: care of cancer patients, WHO’s International Agency for Research on Global action to avert 8 million cancer-related Cancer (IARC) is providing the scientific evidence for cancer causes and mechanisms deaths by 2015 of cancer development as well as developing strategies for early detection of cancer. Cancer is a leading cause of death globally: and obesity are contributing to the rise in Moreover, WHO acts in partnership with a an estimated 7.6 million people died of can- cancer rates, particularly in low- and mid- range of major stakeholders in cancer con- cer in 2005 and 84 million people will die in dle-income countries. A rapidly changing trol, including other UN organizations such the next 10 years if action is not taken. The global environment due to globalization of as the International Atomic Energy Agency World Health Organization (WHO) has pro- markets and urbanization is leading to ris- (IAEA), NGOs such as the International posed a global goal of reducing chronic dis- ing consumption of processed foods high in Union Against Cancer (UICC) and many ease death rates by 2% per annum from fats, sugars and salt, as well as tobacco national cancer institutes. 2006 to 2015. products; declining consumption of fruit and vegetables; and more sedentary activi- WHO advocates an integrated approach to More than 70% of all cancer deaths occur in ty levels. As a consequence the burden prevention, treatment and care for all lead- low- and middle-income countries, where (incidence) of cancer and other chronic dis- ing chronic diseases. Integrated approaches resources available for prevention, diagno- eases is increasing. Other preventable risk that combine cancer prevention, diagnosis, sis and treatment of cancer are limited or factors include many environmental car- management with that for heart disease, nonexistent. Tobacco use alone accounts for cinogens and infections caused by Hepatitis stroke, diabetes and other chronic diseases some 1.5 million cancer deaths per year. B Virus and Human Papilloma Virus. are necessary because the diseases share WHO is actively responding to these rising common risk factors (tobacco use, WHO is taking significant measures to pre- levels of cancer. A World Health Assembly unhealthy diet and physical inactivity) and vent cancer and other chronic diseases. A resolution adopted in May 2005 called on require similar responses from the health key achievement has been the entry into WHO and its Member States to take urgent system. Tthe integrated approach is best for force this past year of the first-ever WHO action to prevent and control cancer. As a prevention and treatment, it is also cost- global health treaty. The WHO Framework result, WHO has been developing a Global effective. It is outlined in the recently Convention on Tobacco Control (WHO Cancer Strategy and the coming year will released report, „Preventing chronic dis- FCTC), is a major step towards the goal of see the publication of “Cancer Control: eases: a vital investment“. reducing tobacco use, which is the leading Knowledge into Action – WHO Guide for preventable cause of cancer. Additionally, Effective Programmes“, a series of six mod- the Global Strategy on Diet, Physical ules aimed at supporting Member States to Activity and Health has provided a multi- For more information contact: develop strategies to improve prevention, sectoral approach to reducing key risk fac- treatment and care of cancer patients. tors for cancer and other chronic diseases. Dr JoAnne Epping-Jordan “We must, first and foremost, address the The Programme on Chemical Safety is a Senior Programme Adviser tremendous inequalities between developed worldwide WHO-guided network aimed at Department of Chronic Diseases and and developing countries in terms of cancer reducing exposure to carcinogens, and Health Promotion prevention, treatment and care,“ said Dr immunization programmes against hepati- WHO/Geneva Catherine Le Galès-Camus, Assistant tis are part of WHO global immunization Telephone: +41 22 791 46 46 Director-General for Noncommunicable strategies. E-mail: [email protected] Diseases and Mental Health. ”Despite our knowledge that many cases are avoidable, or curable when detected early and treated according to best evidence, sadly for many Social Healthcare people tumours are detected too late and adequate treatment is not available. Furthermore, the quality of life of many Medical costs push millions of people into patients with cancer can be improved sub- poverty across the globe stantially by pain control and palliative care.“ Berlin/Geneva – Each year 100 million peo- on medical expenses. That is because in many It is estimated that over 40% of all cancer ple slide into poverty as a result of medical countries people have no access to social can be prevented. However, dramatic care payments. Another 150 million people health protection – affordable health insur- increases in risk factors such as tobacco use are forced to spend nearly half their incomes ance or government-funded health services.

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Paradoxically, people in the world’s poor- in the Division Health, Education, and their usual earnings for a four-month peri- est countries contribute relatively more for Social Protection at GTZ. od. Unable to pay the entire bill, Amos had health care than those in wealthy industrial- to give his motorbike as a safety deposit to “Social health protection is not only a key ized nations. In Germany, for example, the hospital. Without it, he was unable to tool in making health care accessible to all where the average GDP per capita is collect material from the wholesaler, and and to free millions of people from poverty. US$ 32 860 and almost everyone has social his business came to standstill. He had to It is also an investment in health, productiv- health protection, 10% of all medical pull the children out of school, because ity and development – an investment that is expenses nationwide are borne by house- there was no money to pay for fees and uni- a prerequisite for international competitive- holds. In the Democratic Republic of the forms; and the family is now subsisting on ness”, said Assane Diop, Executive Congo, by contrast, where GDP per capita one meal a day. Director of the ILO. is only US$ 120 and where social health protection is scant, about 70% of the Having to pay for medical treatment can A number of low-income countries – includ- money spent on medical care is paid direct- cause a farmer to lose his herd or a family ing Ghana, Rwanda and Senegal – have ly by households. to lose its business. The Chinwubas and already experimented with innovative ways their five children used to live comfortably of protecting people against the financial Experts from some 40 countries met in in Abakpa, Kenya from the earnings of a risks of ill health. Drawing on those experi- Berlin at a conference convened by the small building supply shop they owned. ences, the GTZ, ILO and WHO are offering Deutsche Gesellschaft für Technische When Gloria needed an emergency direct technical assistance to countries seek- Zusammenarbeit GmbH (GTZ), the Cesarean section they were suddenly faced ing to develop social health protection German Federal Ministry for Economic with medical bills of US$ 200 – more than plans. Cooperation and Development, the International Labour Office (ILO) and the World Health Organization and laid out strategies that they and their partners can undertake to prevent such catastrophes. “Social health protection is feasible even in the developing world, but it has not got the attention it deserves. Countries must begin now to craft well-organized schemes, and Foundation for Innovative New Diagnostics international donors will have to help. It takes years to put such a scheme into place, and WHO collaborate to improve diagnosis but if we start now, by 2015 – the target for the Millennium Development Goals – we of sleeping sickness could be well on the way to protecting people worldwide through equitable health The Foundation for Innovative New “The spread of human African trypanoso- financing,” said Dr Timothy Evans, WHO Diagnostics (FIND) and the World Health miasis has reached epidemic proportions in Assistant Director-General for Evidence Organization (WHO), with a grant from the regions of Africa. There is clearly a great and Information for Policy. Bill & Melinda Gates Foundation, today need for a simple, accurate and cost-effec- announced that they will begin work on the tive way to diagnose this disease so that it In low-income countries, it would take an development and evaluation of new diag- can be better treated and controlled,” said average of about US$ 35 per person per nostic tests for human African trypanosomi- Dr Giorgio Roscigno, CEO of FIND. year to finance a social health protection asis (HAT) also known as sleeping sickness. “FIND is committed to identifying and scheme able to provide basic health ser- implementing diagnostics for infectious vices, of which US$ 15 to US$ 25 would African sleeping sickness, a major public diseases, and we look forward to securing have to come from international donors. health threat in sub-Saharan Africa, spreads partnerships and initiating field testing.” among people bitten by the tsetse fly and is Social health protection can do more than fatal unless treated. Because early-stage “Existing diagnostics for sleeping sickness shield people against poverty – it can also infection produces few symptoms, it is are difficult to implement in remote, impov- save lives. “At least 1.3 billion people thought that only 10% of patients with the erished settings,” said Dr Jean Jannin and Dr worldwide lack access to the most basic disease are accurately diagnosed. FIND and Pere Simarro, from the Neglected Tropical healthcare. Often it is because they cannot the World Health Organization will collabo- Diseases Control Department of the World afford it. As a result, millions become very rate in seeking to identify, test and imple- Health Organization. “We look forward to sick or die every year from preventable or ment diagnostics that will increase the like- working with FIND to advance new diag- curable medical conditions said Dr. lihood of early detection of HAT and the nostic tests that could revolutionize human Rüdiger Krech, Head of Social Protection opportunity for treatment. African trypanosomiasis control.”

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“Developing point-of-care tests to direct sleeping sickness treatment will greatly Measles cases and deaths fall simplify patient care, allowing for early case detection, simpler and safer treatment, by 60% in Africa since 1999 and higher rates of cure that will improve disease management and could lead to the Ted Turner Announces $20 million “The Measles Initiative and other investments elimination of the disease as a public health Commitment from UN Foundation to in immunization not only save lives, they problem,” said Thomas Brewer, M.D., Measles Initiative Over the Next Four build economies,” said Bo Stenson of the senior programme officer, Infectious Years Global Alliance for Vaccines and Diseases division, Global Health Immunization (GAVI). “In fact, a new study The Measles Initiative partners gathered in a Programme, at the Gates Foundation. out of the Harvard School of Public Health TIME Magazine Global Health Summit in demonstrates that in the past, development Currently, diagnosis of sleeping sickness is New York this week to announce that tremen- experts have generally underestimated the made by serologic examinations followed dous progress has been made in Africa in the economic value of immunization. Investing by microscopy, which is laborious, insensi- fight against measles. Largely due to the tech- in the health of children is not only the com- tive and costly. FIND’s and WHO’s efforts nical and financial support of the Measles passionate thing to do, it is the smart thing to will be focused on developing tools that Initiative and commitment from African gov- do and will pay off for future generations in will be simple to use and effective in the ernments, more than 200 million children in their educational attainment, labor productiv- remote field conditions that exist where it Africa have been vaccinated against measles ity, income and savings.” is most prevalent. In addition to developing and one million lives have been saved since appropriate diagnostic technologies, the 1999. Measles cases and deaths have dropped Next steps for the Measles Initiative include objectives of the programme include estab- by 60%, thanks to improvements in routine additional ‘follow-up’ vaccination campaigns lishing field research sites for clinical stud- and supplementary immunization activities in in Africa, expanding vaccination campaigns ies and evaluating prototype products. Africa. The founding partners of the Measles into Asia and continuing the successful “inte- Initiative are the American Red Cross, UN grated child health campaigns” in which Foundation, World Health Organization, health workers provide not only measles vac- About FIND UNICEF and Centers for Disease Control and cines, but also insecticide-treated bed-nets The Foundation for Innovative New Prevention. (for malaria prevention), vitamin A, de- Diagnostics (FIND) was launched at the worming medication, and polio vaccines. “This is a major public health achievement,” World Health Assembly in May 2003 as a said Dr. LEE Jong-wook, WHO Director- Launched in February 2001, the Measles non-profit Swiss foundation based in General. „It is the result of the hard work and Initiative (www.measlesinitiative.org) is a Geneva. Its purpose is to support and pro- dedication of the governments of priority partnership formed to reduce and control mote the health of people in developing countries with high measles deaths and all our measles deaths. The Initiative is led by the countries by sponsoring the development Measles Initiative partners to achieve a com- United Nations Foundation, American Red and introduction of new but affordable diag- mon goal – to reduce measles deaths. Let us Cross, Centers for Disease Control and nostic products for infectious diseases. continue to build on this momentum.“ Prevention, UNICEF and the World Health FIND currently has established collabora- Organization. The Measles Initiative (MI) tions with a number of leading public and Measles is one of the leading vaccine-pre- bases its success on its far-reaching partner- private organizations for the development ventable childhood killers in the world. In ship between public and private institutions, of diagnostics for tuberculosis. For more 2003, more than 500,000 people – 470,000 of including key players such as the International information, please visit www.finddiagnos- them children under age 5 – died from the Federation of Red Cross and Red Crescent tics.org disease. Half of these deaths were in Africa Societies, the Canadian International alone. A safe and highly effective vaccine has For more information contact: Development Agency (CIDA), Becton, been available for over forty years, and it Dickinson and Company, The Bill and Melinda Dr Jean Jannin costs less than US $1 to protect a child Gates Foundation, the Church of Jesus Christ Department of Control of Neglected against measles. Despite this, millions of chil- and Latter Day Saints, Becton, Dickinson and Tropical Diseases dren still remain at risk from measles. Company (BD), the Global Alliance for World Health Organization UNICEF Executive Director Ann M. Vaccines and Immunization (GAVI) and coun- Telephone: +41 22 791 3779 Veneman said that the Initiative’s extraordi- tries and governments affected by measles. E-mail: [email protected] nary success against measles has brought the While the Measles Initiative is focused in Dr Giorgio Roscigno world closer to reaching the Millennium Africa where the majority of measles-related CEO FIND Development Goal (MDG) on child mortali- deaths occur, partners also work on a wide- Telephone: +41 22 710 0590 ty. The results in Africa can now be replicat- range of health initiatives around the world, E-mail: ed in Asia, the region that accounts for more including measles control and other vaccina- [email protected] than 180,000 deaths worldwide. tion services outside of Africa.

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• An estimated five million people current- Chernobyl: the true scale of the accident ly live in areas of Belarus, Russia and 20 years later a UN report provides definitive answers and ways to Ukraine that are contaminated with repair lives radionuclides due to the accident; about 100 000 of them live in areas classified in the past by government authorities as areas of “strict control”. The existing Geneva, 5 September 2005 - A total of up must be based on a sound consensus about “zoning” definitions need to be revisited to 4000 people could eventually die of radi- environmental, health and economic conse- and relaxed in the light of these new find- ation exposure from the Chernobyl nuclear quences and some good advice and support ings. power plant (NPP) accident nearly 20 years from the international community.” ago, an international team of more than 100 Bennett continued: “This was a very serious scientists has concluded. • About 4,000 cases of thyroid cancer, accident with major health consequences, mainly in children and adolescents at the As of mid-2005, however, fewer than 50 especially for thousands of workers time of the accident, have resulted from deaths had been directly attributed to radia- exposed in the early days who received very the accident’s contamination and at least tion from the disaster, almost all being high- high radiation doses, and for the thousands nine children died of thyroid cancer; how- ly exposed rescue workers, many who died more stricken with thyroid cancer. By and ever the survival rate among such cancer within months of the accident but others large, however, we have not found profound victims, judging from experience in who died as late as 2004. negative health impacts to the rest of the Belarus, has been almost 99%. population in surrounding areas, nor have The new numbers are presented in a land- we found widespread contamination that • mark digest report, “Chernobyl’s Legacy: Most emergency workers and people liv- would continue to pose a substantial threat Health, Environmental and Socio-Eco- ing in contaminated areas received rela- to human health, within a few exceptional, nomic Impacts,” just released by the tively low whole body radiation doses, restricted areas.” Chernobyl Forum. The digest, based on a comparable to natural background levels. three-volume, 600-page report and incorpo- As a consequence, no evidence or likeli- The Forum’s report aims to help the affect- rating the work of hundreds of scientists, hood of decreased fertility among the ed countries understand the true scale of the economists and health experts, assesses the affected population has been found, nor accident’s consequences and also suggests 20-year impact of the largest nuclear acci- has there been any evidence of increases ways the governments of Belarus, the dent in history. The Forum is made up of 8 in congenital malformations that can be Russian Federation and Ukraine might UN specialized agencies, including the attributed to radiation exposure. address major economic and social prob- International Atomic Energy Agency lems stemming from the accident. Members • Poverty, “lifestyle” diseases now rampant (IAEA), World Health Organization of the Forum, including representatives of in the former Soviet Union and mental (WHO), United Nations Development the three governments, met on September 6 health problems pose a far greater threat Programme (UNDP), Food and Agriculture and 7 in Vienna at an unprecedented gather- to local communities than does radiation Organization (FAO), United Nations ing of the world’s experts on Chernobyl, exposure. Environment Programme (UNEP), United radiation effects and protection, to consider Nations Office for the Coordination of these findings and recommendations. • Relocation proved a “deeply traumatic Humanitarian Affairs (UN-OCHA), United Nations Scientific Committee on the Effects experience” for some 350,000 people of Atomic Radiation (UNSCEAR), and the moved out of the affected areas. Although World Bank, as well as the governments of Major study findings 116 000 were moved from the most heav- Belarus, the Russian Federation and ily impacted area immediately after the Dozens of important findings are included Ukraine. accident, later relocations did little to in the massive report: reduce radiation exposure. “This compilation of the latest research can help to settle the outstanding questions • Approximately 1000 on-site reactor staff • Persistent myths and misperceptions about how much death, disease and eco- and emergency workers were heavily about the threat of radiation have resulted nomic fallout really resulted from the exposed to high-level radiation on the first in “paralyzing fatalism” among residents Chernobyl accident,” explains Dr. Burton day of the accident; among the more than of affected areas. Bennett, chairman of the Chernobyl Forum 200,000 emergency and recovery opera- and an authority on radiation effects. “The tion workers exposed during the period • Ambitious rehabilitation and social bene- governments of the three most-affected from 1986-1987, an estimated 2,200 radi- fit programmes started by the former countries have realized that they need to ation-caused deaths can be expected dur- Soviet Union, and continued by Belarus, find a clear way forward, and that progress ing their lifetime. Russia and Ukraine, need reformulation

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due to changes in radiation conditions, statistical prediction, based on estimates of from those that foster “dependency” and a poor targeting and funding shortages. the radiation doses received by these popu- “victim” mentality, and replacing them with lations. As about quarter of people die from initiatives that encourage opportunity, sup- • Structural elements of the sarcophagus spontaneous cancer not caused by port local development, and give people built to contain the damaged reactor have Chernobyl radiation, the radiation-induced confidence in their futures. degraded, posing a risk of collapse and increase of only about 3% will be difficult the release of radioactive dust; to observe. However, in the most exposed In the health area, the Forum report calls for • A comprehensive plan to dispose of tons cohorts of emergency and recovery opera- continued close monitoring of workers who of high-level radioactive waste at and tion workers some increase of particular recovered from Acute Radiation Syndrome around the Chernobyl NPP site, in accor- cancer forms (e.g., leukemia) in particular (ARS) and other highly exposed emergency dance with current safety standards, has time periods has already been observed. personnel. The Report also calls for yet to be defined. The predictions use six decades of scientif- focussed screening of children exposed to ic experience with the effects of such doses, Alongside radiation-induced deaths and radioiodine for thyroid cancer and highly explained Repacholi. diseases, the report labels the mental health exposed clean-up workers for non-thyroid impact of Chernobyl as “the largest public Repacholi concludes that “the health effects cancers. However, existing screening pro- health problem created by the accident” and of the accident are potentially horrific, but grammes should be evaluated for cost- partially attributes this damaging psycho- when they are added them up using validat- effectiveness, since the incidence of sponta- logical impact to a lack of accurate infor- ed conclusions from good science, the pub- neous thyroid cancers is increasing signifi- mation. These problems manifest as nega- lic health effects are not nearly as substan- cantly as the target population ages. tive self-assessments of health, belief in a tial as at first feared.” Moreover, high quality cancer registries shortened life expectancy, lack of initiative, need continuing government support. The report’s estimate for the eventual num- and dependency on assistance from the ber of deaths is far lower than earlier, well- state. In the environmental realm, the Report calls publicized speculations that radiation expo- for long term monitoring of caesium and “Two decades after the Chernobyl accident, sure would claim tens of thousands of lives. strontium radionuclides to assess human residents in the affected areas still lack the But the 4,000 figure is not far different from exposure and food contamination and to information they need to lead the healthy estimates made in 1986 by Soviet scientists, analyse the impacts of remedial actions and and productive lives that are possible,” according to Dr. Mikhail Balonov, a radia- radiation-reduction countermeasures. explains Louisa Vinton, Chernobyl focal tion expert with the International Atomic Better information needs to be provided to point at the UNDP. “We are advising our Energy Agency in Vienna, who was a scien- the public about the persistence of radioac- partner governments that they must reach tist in the former Soviet Union at the time tive contamination in certain food products people with accurate information, not only of the accident. and about food preparation methods that about how to live safely in regions of low- As for environmental impact, the reports reduce radionuclide intake. Restrictions on level contamination, but also about leading are also reassuring, for the scientific assess- harvesting of some wild food products are healthy lifestyles and creating new liveli- ments show that, except for the still closed still needed in some areas. hoods.” But, says Dr. Michael Repacholi, highly contaminated 30 kilometre area sur- Manager of WHO’s Radiation Programme, rounding the reactor, and some closed lakes Also in the realm of protecting the environ- “the sum total of the Chernobyl Forum is a and restricted forests, radiation levels have ment, the Report calls for an “integrated reassuring message.” mostly returned to acceptable levels. “In waste management programme for the He explains that there have been 4,000 most areas the problems are economic and Shelter, the Chernobyl NPP site and the cases of thyroid cancer, mainly in children, psychological, not health or environmen- Exclusion Zone” to ensure application of but that except for nine deaths, all of them tal,” reports Balonov, the scientific secre- consistent management and capacity for all have recovered. “Otherwise, the team of tary of the Chernobyl Forum effort who has types of radioactive waste. Waste storage international experts found no evidence for been involved with Chernobyl recovery and disposal must be dealt with in a com- any increases in the incidence of leukemia since the disaster occurred. prehensive manner across the entire and cancer among affected residents.“ Exclusion Zone, according to the Report. The international experts have estimated In areas where human exposure is not high, that radiation could cause up to about 4000 Recommendations no remediation needs to be done, points out eventual deaths among the higher-exposed Balonov. “If we do not expect health or Chernobyl populations, i.e., emergency Recommendations call for focussing assis- environmental effects, we should not waste workers from 1986-1987, evacuees and res- tance efforts on highly contaminated areas resources and effort on low priority, low idents of the most contaminated areas. This and redesigning government programmes contamination areas,” he explains. “We number contains both the known radiation- to help those genuinely in need. Suggested need to focus our efforts and resources on induced cancer and leukaemia deaths and a changes would shift programmes away real problems.”

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One key recommendation addresses the tion doses, comparable to background radi- related fatalities were much higher than fact that large parts of the population, espe- ation levels and lower than the average they actually were. cially in rural areas, still lack accurate doses received by residents in some parts of information and emphasizes the need to the world having high natural background What diseases have already occurred or find better ways both to inform the public radiation levels. might occur in the future? and to overcome the lack of credibility that For the majority of the five million people Residents who ate food contaminated with hampered previous efforts. Even though living in the contaminated areas, exposures radioactive iodine in the days immediately accurate information has been available for are within the recommended dose limit for after the accident received relatively high years, either it has not reached those who the general public, though about 100,000 doses to the thyroid gland. This was espe- need it or people do not trust and accept the residents still receive more. Remediation of cially true of children who drank milk from information and do not act upon it, accord- those areas and application of some agricul- cows who had eaten contaminated grass. ing to the Report. tural countermeasures continues. Further Since iodine concentrates in the thyroid This recommendation calls for targeting reduction of exposure levels will be slow, gland, this was a major cause of the high information to specific audiences, including but most exposure from the accident has incidence of thyroid cancer in children. community leaders and health care work- already occurred. Several recent studies suggest a slight ers, along with a broader strategy that pro- increase in the incidence of leukemia motes healthy lifestyles as well as informa- How many people died and how many among emergency workers, but not in chil- tion about how to reduce internal and exter- more are likely to die in the future? dren or adult residents of contaminated nal radiation exposures and address the The total number of deaths already attribut- areas. A slight increase in solid cancers and main causes of disease and mortality. able to Chernobyl or expected in the future possibly circulatory system diseases was In the socioeconomic sphere, the Report over the lifetime of emergency workers and noted, but needs to be evaluated further recommends a new development approach local residents in the most contaminated because of the possible indirect influence of that helps individuals to “take control of areas is estimated to be about 4,000. This such factors as smoking, alcohol, stress and their own lives and communities to take includes some 50 emergency workers who unhealthy lifestyle. control of their own futures.” The died of acute radiation syndrome and nine Have there been or will there be any Governments, the Report states, must children who died of thyroid cancer, and an inherited or reproductive effects? streamline and refocus Chernobyl pro- estimated total of 3,940 deaths from radia- grammes through more targeted benefits, tion-induced cancer and leukemia among Because of the relatively low doses to resi- elimination of unnecessary benefits to peo- the 200,000 emergency workers from 1986- dents of contaminated territories, no evi- ple in less contaminated areas, improving 1987, 116,000 evacuees and 270,000 resi- dence or likelihood of decreased fertility primary health care, support for safe food dents of the most contaminated areas (total has been seen among males or females. production techniques, and encouragement about 600,000). These three major cohorts Also, because the doses were so low, there for investment and private sector develop- were subjected to higher doses of radiation was no evidence of any effect on the num- ment, including small and medium-size amongst all the people exposed to ber of stillbirths, adverse pregnancy out- enterprises. Chernobyl radiation. comes, delivery complications or overall health of children. A modest but steady Notes Vinton, “The most important need is The estimated 4,000 casualties may occur increase in reported congenital malforma- for accurate information on healthy during the lifetime of about 600,000 people tions in both contaminated and uncontami- lifestyles, together with better regulations under consideration. As about quarter of nated areas of Belarus appears related to to promote small, rural businesses. Poverty them will eventually die from spontaneous better reporting, not radiation. is the real danger. We need to take steps to cancer not caused by Chernobyl radiation, empower people.” the radiation-induced increase of about 3% Did the trauma of rapid relocation cause will be difficult to observe. However, in the persistent psychological or mental health most highly exposed cohorts of emergency problems? Answers to Longstanding and recovery operation workers, some Stress symptoms, depression, anxiety and Questions increase in particular cancers (e.g., medically unexplained physical symptoms leukemia) has already been observed. have been reported, including self-per- How much radiation were people exposed Confusion about the impact has arisen ceived poor health. The designation of the to as a result of the accident? owing to the fact that thousands of people affected population as “victims” rather than With the exception of on-site reactor staff in the affected areas have died of natural “survivors” has led them to perceive them- and emergency workers exposed on 26 causes. Also, widespread expectations of ill selves as helpless, weak and lacking control April, most recovery operation workers and health and a tendency to attribute all health over their future. This, in turn, has led either those living in contaminated territories problems to radiation exposure have led to over cautious behavior and exaggerated received relatively low whole body radia- local residents to assume that Chernobyl health concerns, or to reckless conduct,

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such as consumption of mushrooms, berries Europe, but, given the nuclide’s short half pasture grasses from animal diets and mon- and game from areas still designated as life, this concern abated quickly. Currently itoring milk for radiation levels. Treatment highly contaminated, overuse of alcohol and for the long term, radiocaesium, pre- of land for fodder crops, clean feeding and and tobacco, and unprotected promiscuous sent in milk, meat and some plant foods, use of Cs-binders (that prevented the trans- sexual activity. remains the most significant concern for fer of radiocaesium from fodder to milk) internal human exposure, but, with the led to large reductions in contamination and What was the environmental impact? exception of a few areas, concentrations fall permitted agriculture to continue, though within safe levels. some increase in radionuclide content of Ecosystems affected by Chernobyl have plant and animal products has been mea- been studied and monitored extensively for What is the extent of forest conta- sured since the mid-1990s when economic the past two decades. Major releases of mination? problems forced a cutback in treatments. radionuclides continued for ten days and Following the accident, animals and vege- Some agricultural lands in the three coun- contaminated more than 200,000 square tation in forest and mountain areas had high tries have been taken out of use until reme- kilometres of Europe. The extent of deposi- absorption of radiocaesium, with persistent diation is undertaken. tion varied depending on whether it was high levels in mushrooms, berries and raining when contaminated air masses A number of measures applied to forests in game. Because exposure from agricultural passed. affected countries and in Scandinavia have products has declined, the relative impor- reduced human exposure, including restric- Most of the strontium and plutonium iso- tance of exposure from forest products has tions on access to forest areas, on harvest- topes were deposited within 100 kilometres increased and will only decline as radioac- ing of food products such as game, berries of the damaged reactor. Radioactive iodine, tive materials migrate downward into the and mushrooms, and on the public collec- of great concern after the accident, has a soil and slowly decay. The high transfer of tion of firewood, along with changes in short half-life, and has now decayed away. radiocaesium from lichen to reindeer meat hunting to avoid consumption of game Strontium and caesium, with a longer half to humans was seen in the Arctic and sub- meat where seasonal levels of radiocaesium life of 30 years, persist and will remain a Arctic areas, with high contamination of may be high. Low income levels in some concern for decades to come. Although plu- reindeer meat in Finland, Norway, Russia, areas cause local residents to disregard tonium isotopes and americium 241 will and Sweden. The concerned governments these rules. persist perhaps for thousands of years, their imposed some restrictions on hunting, contribution to human exposure is low. including scheduling hunting season when What were radiation-induced effects on animals have lower meat contamination. What is the scope of urban conta- plants and animals? mination? How contaminated are the aquatic Increased mortality of coniferous plants, systems? Open surfaces, such as roads, lawns and soil invertebrates and mammals and repro- roofs, were most heavily contaminated. Contamination of surface waters through- ductive losses in plants and animals were Residents of Pripyat, the city nearest to out much of Europe declined quickly seen in high exposure areas up to a distance Chernobyl, were quickly evacuated, reduc- through dilution, physical decay, and of 20-30 kilometres. Outside that zone, no ing their potential exposure to radioactive absorption of radionuclides in bed sedi- acute radiation-induced effects have been materials. Wind, rain and human activity ments and catchment soils. Because of reported. With reductions of exposure lev- has reduced surface contamination, but led bioaccumulation in the aquatic food chain, els, biological populations have been recov- to secondary contamination of sewage and though, elevated concentrations of radio- ering, though the genetic effects of radia- sludge systems. Radiation in air above set- caesium were found in fish from lakes as tion were seen in both somatic and germ tled areas returned to background levels, far away as Germany and Scandinavia. cells of plants and animals. Prohibiting though levels remain higher where soils Comparable levels of radiostrontium, agricultural and industrial activities in the have remained undisturbed. which concentrates in fish bone, not in exclusion zone permitted many plant and muscle, were not significant for humans. animal populations to expand and created, How contaminated are agricultural Levels in fish and waters are currently low, paradoxically, “a unique sanctuary for bio- areas? except in areas with “closed” lakes with no diversity.” Weathering, physical decay, migration of outflowing streams. In those lakes, levels of Does dismantlement of the Shelter and radionuclides down the soil and reductions radiocaesium in fish will remain high for management of radioactive waste pose in bioavailability have led to a significant decades and, therefore, restrictions on fish- further environmental problems? reduction in the transfer of radionuclides to ing there should be maintained. plants and animals. Radioactive iodine, The protective shelter was erected quickly, What environmental countermeasures rapidly absorbed from grasses and animal which led to some imperfections in the and remediation have been taken? feed into milk, was an early concern and shelter itself and did not permit gathering elevated levels were seen in some parts of The most effective early agricultural coun- complete data on the stability of the dam- the former Soviet Union and Southern termeasure was removing contaminated aged unit. Also, some structural parts of the

26 WHO

shelter have corroded in the past two higher costs in the form of fertilizers, addi- What has been the impact on individuals? decades. The main potential hazard posed by tives and special cultivation processes. the shelter is the possible collapse of its top Even where farming is safe, the stigma According to the Forum’s report on health, structures and the release of radioactive dust. associated with Chernobyl caused market- “the mental health impact of Chernobyl is ing problems and led to falling revenues, the largest public health problem unleashed Strengthening those unstable structures has declining production and the closure of by the accident to date.” People in the been performed recently, and construction some facilities. Combined with disruptions affected areas report negative assessments of a New Safe Confinement covering the due to the collapse of the Soviet Union, of their health and well-being, coupled existing shelter that should serve for more recession, and new market mechanisms, the with an exaggerated sense of the danger to than 100 years, starts in the near future. The region’s economy suffered, resulting in their health from radiation exposure and a new cover will allow dismantlement of the lower living standards, unemployment and belief in a shorter life expectancy. Anxiety current shelter, removal of the radioactive increased poverty. All agricultural areas, over the health effects of radiation shows fuel mass from the damaged unit and, even- whether affected by radiation or not, proved no signs of diminishing and may even be tually, decommissioning of the damaged vulnerable. spreading. Life expectancy has been reactor. declining across the former Soviet Union, A comprehensive strategy still has to be Poverty is especially acute in affected due to cardiovascular disease, injuries and developed for dealing with the high level areas. Wages for agricultural workers tend poisoning, and not radiation-related illness. and long-lived radioactive waste from past to be low and employment outside of agri- remediation activities. Much of this waste culture is limited. Many skilled and educat- How have governments responded? was placed in temporary storage in trench- ed workers, especially younger workers, es and landfills that do not meet current left the region. Also, the business environ- The resettlement and rehabilitation pro- waste safety requirements. ment discourages entrepreneurial ventures grams launched in Soviet conditions and private investment is low. proved unsustainable after 1991 and fund- What was the economic cost? ing for projects declined, leaving many Because of policies in place at the time of What impact did Chernobyl and the after- projects unfinished and abandoned and the explosion and the inflation and econom- math have on local communities? many of the promised benefits under fund- ic disruptions that followed the break-up of ed. Also, benefits were offered to broad the Soviet Union, precise costs have been More than 350,000 people have been relo- categories of “Chernobyl victims” that impossible to calculate. A variety of esti- cated away from the most severely contam- expanded to seven million now receiving mates from the 1990s placed the costs over inated areas, 116,000 of them immediately or eligible for pensions, special allowances two decades at hundreds of billions of dol- after the accident. Even when people were and health benefits, including free holidays lars. These costs included direct damage, compensated for losses, given free houses and guaranteed allowances. Chernobyl expenditures related to recovery and miti- and a choice of resettlement location, the benefits deprive other areas of public gation, resettlement of people, social pro- experience was traumatic and left many spending of resources, but scaling down tection and health care for the affected pop- with no employment and a belief that they benefits or targeting only high-risk groups ulation, research on environment, health have no place in society. Surveys show that is unpopular and presents political prob- and the production of clean food, radiation those who remained or returned to their lems. monitoring, as well as indirect losses due to homes coped better with the aftermath than removing agricultural lands and forests those who were resettled. Tensions Given significant reduction of radiation from use and the closing of agriculture and between new and old residents of resettle- levels during past twenty years, govern- industrial facilities, and such additional ment villages also contributed to the ments need to revisit the classification of costs as cancellation of the nuclear power ostracism felt by the newcomers. The contaminated zones. Many areas previous- program in Belarus and the additional costs demographic structure of the affected areas ly considered to be at risk are in fact safe of energy from the loss of power from became skewed since many skilled, edu- for habitation and cultivation. Current Chernobyl. The costs have created a huge cated and entrepreneurial workers, often delineations are far more restrictive than drain on the budgets of the three countries younger, left the areas leaving behind an demonstrated radiation levels can justify. involved. older population with few of the skills needed for economic recovery. The report identifies the need to sharpen What were the main consequences for the priorities and streamline the programmes local economy? The older population has meant that deaths to target the most needy, noting that reallo- Agriculture was hardest hit, with 784,320 exceed births, which reinforces the percep- cating resources is likely to face “strong hectares taken from production. Timber tion that these areas are dangerous places resistance from vested interests“. One sug- production was halted in 694,200 hectares to live. Even when pay is high, schools, gestion calls for a “buy out” of the entitle- of forest. Remediation made “clean food” hospitals and other essential public ser- ment to benefits in return for lump sum production possible in many areas but led to vices are short of qualified specialists. start-up financing for small businesses.

27 Regional and NMA News

Indian Medical Association What the project will achieve • Orientation of professionals to village health Aao Gaon Chalen – IMA launches rural • Health awareness generation • Provision and strengthening of promotive, preventive, curative and rehabilita- health plan tive services • The Indian Medical Association (IMA) has power and infrastructure. The popular myth Community involvement and participation in health care undetaken an ambitious project “Aao gaon in the public mind is that doctors do not • Public / private partnership in rural chalen” to shoulder the responsibility of want to serve in rural areas. health care providing positive health to every village in • Co-ordination to strengthen referral link- the country. The project will enable medical The villages are unaware of the progress the ages in the health care delivery system professionals to develop a vision and under- medical profession has made and the inher- • An improved image of IMA and the take innovations to improve rural health as ent potential of qualified and dedicated doc- medical profession envisaged in the national health policy. tor. They accept all diseases as part of their Proposed activities destiny. This, coupled with poverty-gener- The project which was launched off by Health awareness activities ated helplessness, adds to considerable • Union Textile Minister Shankarsingh Community health meetings morbidity and mortality. IMA with its vari- • Debates, posters and painting competi- Vaghela at a village in Mehsana District ous branches can take the lead in this direc- entails a new scheme where IMA members tions in schools tion. • Puppets shows and magic shows will adopt a most vulnerable village accord- • Nukkad nataks ing to prevalent major health problems. Aao Ganon Chalen: Advent of a new era in rural health Medical and surgical facilities The first step of its kind by the IMA, in the • Health camps providing multi-discipli- nary care world, aims to target the 75% of the popu- IMA has undertaken this ambitious project lation which lives in the villages and also • Special clinics for expectant mothers, to shoulder the responsibility of the provi- children and elderly people the popular myth in the public mind that sion of positive health to every village in doctors do not want to serve in rural areas. • Cataract / sterilization camps the country. The project will enable medical • “Under this project each state unit of IMA Immunization services professionals to develop a vision and under- • Adolescent guidance and counseling ser- will adopt 5 villages to begin with and take innovations to improve rural health as undertake promotive health camps free of vices envisaged in the national health policy. • Family welfare services cost. The idea is to slowly make the exist- Under the project, the members of IMA will • ing healthcare available in every nook and Cancer detection clinics be adopting the most vulnerable villages Rehabilitation services corner of India”, said Dr. Kedan Desai, according to prevalent major public health • Distribution of wheel chairs, artificial Chairman of the project. problems. Major emphasis will be on the limbs and other required services to The major emphasis will be on the control control of epidemics and endemics, mater- handicapped people. ...amongst a host of of epidemics and endemics, maternal and nal and child health, geriatric care and ado- other welfare activites. child health, geriatric care and adolscent lescent health. http://www.imanational.com/AaoGaon.asp health. “The IMA with its reach and dedica- accessed on 28/2/06 tion can make a big difference to the rural health scenario and this step from the med- Physicians speak out on prisoner forced feeding – the American ical fraternity will amount to a giant leap for Medical Association speaks out. the whole country”, Dr. Desai added. As reported in American Medical News, the American Medical Association (AMA) has given pub- “Emphasis will be laid on increasing orien- licity to its condemnation of physician participation in prisoners’ forced feeding It stresses, in an tation of health professionals towards the editorial written by Dr. Duane M Cady (chair of AMA’s Board of Trustees) passed to news outlets, needs of rural population and provide pri- the AMA’s endorsement of the WMA Declaration of Tokyo, quoting “where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired, rational judgement mary care to them on a regular basis at their concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed doorsteps”. Said Dr. Vinay Aggarwal, artificially”. The AMA has met the Department of Defence over the past years raising its concerns, Secretary General, IMA. “and to offer to provide them with relevant policies and expertise, with the goal of ensuring that US policies in detainee treatment comport with ethical standards of medicine…” The Soul of India lies in the villages… The U.S.government defends its policy “We’re trying to preserve life” a spokeswoman of the Almost 75% of our population lives in vil- Defence Dept. is reported as saying. (American Medical News 49, 13) lages but 75% of the country’s health infra- The AMA House of Delegates has asked the Council on Ethical and Judicial Affairs to develop clear structure is concentrated in cities. Most of guidelines for physician participation in prisoner and detainee interrogations. (American Medical News 48, 13) the villages still fall short of health man- 28 Association and address/Officers

CHINA E ECUADOR S GERMANY E ISRAEL E Chinese Medical Association Federación Médica Ecuatoriana Bundesärztekammer Israel Medical Association 42 Dongsi Xidajie V.M. Rendón 923 – 2 do.Piso Of. 201 (German Medical Association) 2 Twin Towers, 35 Jabotinsky St. Beijing 100710 P.O. Box 09-01-9848 Herbert-Lewin-Platz 1 P.O. Box 3566, Ramat-Gan 52136 Tel: (86-10) 6524 9989 Guayaquil 10623 Berlin Tel: (972-3) 6100444 / 424 Fax: (86-10) 6512 3754 Tel/Fax: (593) 4 562569 Tel: (49-30) 400-456 363/Fax: -384 Fax: (972-3) 5751616 / 5753303 E-mail: [email protected] E-mail: [email protected] E-mail: [email protected] E-mail: [email protected] Website: www.chinamed.com.cn Website: www.bundesaerztekammer.de Website: www.ima.org.il EGYPT E COLOMBIA S Egyptian Medical Association GHANA E JAPAN E Federación Médica Colombiana „Dar El Hekmah“ Ghana Medical Association Japan Medical Association Calle 72 - N° 6-44, Piso 11 P.O. Box 1596 2-28-16 Honkomagome, Bunkyo-ku Santafé de Bogotá, D.E. 42, Kasr El-Eini Street Accra Tokyo 113-8621 Tel: (57-1) 211 0208 Cairo Tel: (233-21) 670-510/Fax: -511 Tel: (81-3) 3946 2121/3942 6489 Tel/Fax: (57-1) 212 6082 Tel: (20-2) 3543406 E-mail: [email protected] Fax: (81-3) 3946 6295 E-mail: federacionmedicacol@ E-mail: [email protected] hotmail.com EL SALVADOR, C.A S HAITI, W.I. F Colegio Médico de El Salvador KAZAKHSTAN F Association Médicale Haitienne DEMOCRATIC REP. OF CONGO F Final Pasaje N° 10 Association of Medical Doctors 1ère Av. du Travail #33 – Bois Verna Ordre des Médecins du Zaire Colonia Miramonte of Kazakhstan Port-au-Prince B.P. 4922 San Salvador 117/1 Kazybek bi St., Tel: (509) 245-2060 Kinshasa – Gombe Tel: (503) 260-1111, 260-1112 Almaty Fax: (509) 245-6323 Tel: (242-12) 24589/ Fax: -0324 Tel: (3272) 62 -43 01 / -92 92 E-mail: [email protected] Fax (Présidente): (242) 8846574 E-mail: [email protected] Fax: -3606 Website: www.amhhaiti.net [email protected] E-mail: [email protected] COSTA RICA S Unión Médica Nacional ESTONIA E HONG KONG E REP. OF KOREA E Apartado 5920-1000 Estonian Medical Association (EsMA) Hong Kong Medical Association, China Korean Medical Association San José Pepleri 32 Duke of Windsor Building, 5th Floor 302-75 Ichon 1-dong, Yongsan-gu Tel: (506) 290-5490 51010 Tartu 15 Hennessy Road Seoul 140-721 Fax: (506) 231 7373 Tel/Fax (372) 7420429 Tel: (852) 2527-8285 Tel: (82-2) 794 2474 E-mail: [email protected] E-mail: [email protected] Fax: (852) 2865-0943 Fax: (82-2) 793 9190 Website: www.arstideliit.ee E-mail: [email protected] E-mail: [email protected] CROATIA E Website: www.hkma.org Website: www.kma.org Croatian Medical Association ETHIOPIA E HUNGARY E KUWAIT E Subiceva 9 Ethiopian Medical Association 10000 Zagreb Association of Hungarian Medical Kuwait Medical Association P.O. Box 2179 Tel: (385-1) 46 93 300 Societies (MOTESZ) P.O. Box 1202 Addis Ababa Fax: (385-1) 46 55 066 Nádor u. 36 Safat 13013 Tel: (251-1) 158174 E-mail: [email protected] 1443 Budapest, PO.Box 145 Tel: (965) 5333278, 5317971 Fax: (251-1) 533742 Tel: (36-1) 312 3807 – 311 6687 Fax: (965) 5333276 E-mail: [email protected] / CZECH REPUBLIC E Fax: (36-1) 383-7918 E-mail: [email protected] [email protected] Czech Medical Association . E-mail: [email protected] J.E. Purkyne Website: www.motesz.hu LATVIA E Sokolská 31 - P.O. Box 88 FIJI ISLANDS E Latvian Physicians Association 120 26 Prague 2 Fiji Medical Association ICELAND E Skolas Str. 3 nd Tel: (420-2) 242 66 201/202/203/204 2 Fl. Narsey’s Bldg, Renwick Road Icelandic Medical Association Riga Fax: (420-2) 242 66 212 / 96 18 18 69 G.P.O. Box 1116 Hlidasmari 8 1010 Latvia E-mail: [email protected] Suva 200 Kópavogur Tel: (371-7) 22 06 61; 22 06 57 Website: www.cls.cz Tel: (679) 315388 Tel: (354) 8640478 Fax: (371-7) 22 06 57 Fax: (679) 387671 Fax: (354) 5644106 E-mail: [email protected] CUBA S E-mail: [email protected] E-mail: [email protected] Colegio Médico Cubano Libre LIECHTENSTEIN E Liechtensteinischer Ärztekammer P.O. Box 141016 FINLAND E INDIA E 717 Ponce de Leon Boulevard Postfach 52 Finnish Medical Association Indian Medical Association Coral Gables, FL 33114-1016 9490 Vaduz P.O. Box 49 Indraprastha Marg United States Tel: (423) 231-1690 00501 Helsinki New Delhi 110 002 Tel: (1-305) 446 9902/445 1429 Fax: (423) 231-1691 Tel: (358-9) 3930 826/Fax-794 Tel: (91-11) 337009/3378819/3378680 Fax: (1-305) 4459310 E-mail: [email protected] Telex: 125336 sll sf Fax: (91-11) 3379178/3379470 Website: www.aerzte-net.li E-mail: [email protected] E-mail: [email protected] / DENMARK E Website: www.medassoc.fi Danish Medical Association [email protected] LITHUANIA E Lithuanian Medical Association 9 Trondhjemsgade FRANCE F 2100 Copenhagen 0 INDONESIA E Liubarto Str. 2 Association Médicale Française Tel: (45) 35 44 -82 29/Fax:-8505 Indonesian Medical Association 2004 Vilnius 180, Blvd. Haussmann E-mail: [email protected] Jalan Dr Sam Ratulangie N° 29 Tel/Fax: (370-5) 2731400 Website: www.laegeforeningen.dk 75389 Paris Cedex 08 Jakarta 10350 E-mail: [email protected] Tel: (33) 1 53 89 32 41 Tel: (62-21) 3150679 DOMINICAN REPUBLIC S Fax: (33) 1 53 89 33 44 Fax: (62-21) 390 0473/3154 091 LUXEMBOURG F Asociación Médica Dominicana E-mail: cnom-international@ E-mail: [email protected] Association des Médecins et Calle Paseo de los Medicos cn.medecin.fr Médecins Dentistes du Grand- Esquina Modesto Diaz Zona IRELAND E Duché de Luxembourg Universitaria GEORGIA E Irish Medical Organisation 29, rue de Vianden Santo Domingo Georgian Medical Association 10 Fitzwilliam Place 2680 Luxembourg Tel: (1809) 533-4602/533-4686/ 7 Asatiani Street Dublin 2 Tel: (352) 44 40 331 533-8700 380077 Tbilisi Tel: (353-1) 676-7273 Fax: (352) 45 83 49 Fax: (1809) 535 7337 Tel: (995 32) 398686 / Fax: -398083 Fax: (353-1) 6612758/6682168 E-mail: [email protected] E-mail: [email protected] E-mail: [email protected] Website: www.imo.ie Website: www.ammd.lu

ii Association and address/Officers

MACEDONIA E NORWAY E SLOVAK REPUBLIC E TURKEY E Macedonian Medical Association Norwegian Medical Association Slovak Medical Association Turkish Medical Association Dame Gruev St. 3 P.O.Box 1152 sentrum Legionarska 4 GMK Bulvary,. P.O. Box 174 0107 Oslo 81322 Bratislava Pehit Danip Tunalygil Sok. N° 2 Kat 4 91000 Skopje Tel: (47) 23 10 -90 00/Fax: -9010 Tel: (421-2) 554 24 015 Maltepe Tel/Fax: (389-91) 232577 E-mail: ellen.pettersen@ Fax: (421-2) 554 223 63 Ankara legeforeningen.no E-mail: [email protected] Tel: (90-312) 231 –3179/Fax: -1952 E-mail: [email protected] MALAYSIA E Website: www.legeforeningen.no SLOVENIA E Malaysian Medical Association PANAMA S Slovenian Medical Association UGANDA E 4th Floor, MMA House Asociación Médica Nacional Komenskega 4, 61001 Ljubljana Uganda Medical Association 124 Jalan Pahang de la República de Panamá Tel: (386-61) 323 469 Plot 8, 41-43 circular rd. 53000 Kuala Lumpur Apartado Postal 2020 Fax: (386-61) 301 955 P.O. Box 29874 Tel: (60-3) 40418972/40411375 Panamá 1 Kampala Fax: (60-3) 40418187/40434444 Tel: (507) 263 7622 /263-7758 SOUTH AFRICA E Tel: (256) 41 32 1795 E-mail: [email protected] Fax: (507) 223 1462 The South African Medical Association Fax: (256) 41 34 5597 Website: http://www.mma.org.my Fax modem: (507) 223-5555 P.O. Box 74789, Lynnwood Rydge E-mail: [email protected] E-mail: [email protected] 0040 Pretoria MALTA E Tel: (27-12) 481 2036/7 UNITED KINGDOM E British Medical Association Medical Association of Malta PERU S Fax: (27-12) 481 2058 BMA House, Tavistock Square The Professional Centre Colegio Médico del Perú E-mail: [email protected] London WC1H 9JP Malecón Armendáriz N° 791 Website: www.samedical.org Sliema Road, Gzira GZR 06 Tel: (44-207) 387-4499 Miraflores, Lima Tel: (356) 21312888 Fax: (44- 207) 383-6710 Tel: (51-1) 241 75 72 SPAIN S Fax: (356) 21331713 E-mail: [email protected] Fax: (51-1) 242 3917 Consejo General de Colegios Médicos E-mail: [email protected] Plaza de las Cortes 11, Madrid 28014 Website: www.bma.org.uk Website: www.mam.org.mt E-mail: [email protected] Website: www.colmed.org.pe Tel: (34-91) 431 7780 Fax: (34-91) 431 9620 UNITED STATES OF AMERICA E MEXICO S American Medical Association PHILIPPINES E E-mail: [email protected] Colegio Medico de Mexico 515 North State Street Philippine Medical Association Chicago, Illinois 60610 Fenacome PMA Bldg, North Avenue SWEDEN E Hidalgo 1828 Pte. Cons. 410 Swedish Medical Association Tel: (1-312) 464 5040 Quezon City Fax: (1-312) 464 5973 Colonia Obispado C.P. 64060 (Villagatan 5) Tel: (63-2) 929-63 66/Fax: -6951 Website: http://www.ama-assn.org Monterrey, Nuevo Léon E-mail: [email protected] P.O. Box 5610, SE - 114 86 Stockholm Tel: (46-8) 790 33 00 Tel/Fax: (52-8) 348-41-55 URUGUAY S E-mail: [email protected] POLAND E Fax: (46-8) 20 57 18 E-mail: [email protected] Sindicato Médico del Uruguay Website: www.fenacome.org Polish Medical Association Bulevar Artigas 1515 Website: www.lakarforbundet.se Al. Ujazdowskie 24, 00-478 Warszawa CP 11200 Montevideo NEPAL E Tel/Fax: (48-22) 628 86 99 Tel: (598-2) 401 47 01 SWITZERLAND F Fax: (598-2) 409 16 03 Nepal Medical Association Fédération des Médecins Suisses PORTUGAL E E-mail: [email protected] Siddhi Sadan, Post Box 189 Elfenstrasse 18 – POB 293 Ordem dos Médicos Exhibition Road 3000 Berne 16 Av. Almirante Gago Coutinho, 151 VATICAN STATE F Katmandu Tel: (41-31) 359 –1111/Fax: -1112 1749-084 Lisbon Associazione Medica del Vaticano Tel: (977 1) 225860, 231825 E-mail: [email protected] Tel: (351-21) 842 71 00/842 71 11 Stato della Citta del Vaticano 00120 Fax: (977 1) 225300 Website: www.fmh.ch Fax: (351-21) 842 71 99 Tel: (39-06) 6983552 E-mail: [email protected] E-mail: [email protected] Fax: (39-06) 69885364 TAIWAN E E-mail: [email protected] / [email protected] Taiwan Medical Association NETHERLANDS E Website: www.ordemdosmedicos.pt Royal Dutch Medical Association 9F No 29 Sec1 VENEZUELA S An-Ho Road P.O. Box 20051 ROMANIA F Federacion Médica Venezolana 3502 LB Utrecht Taipei Avenida Orinoco Romanian Medical Association Deputy Secretary General Tel: (31-30) 28 23-267/Fax-318 Torre Federacion Médica Venezolana Str. Ionel Perlea, nr 10 Tel: (886-2) 2752-7286 E-mail: [email protected] Sect. 1, Bucarest, cod 70754 Urbanizacion Las Mercedes Fax: (886-2) 2771-8392 Caracas Website: www.knmg.nl Tel: (40-1) 6141071 E-mail: [email protected] Fax: (40-1) 3121357 Tel: (58-2) 9934547 Fax: (58-2) 9932890 NEW ZEALAND E E-mail: [email protected] THAILAND E Website: www.saludfmv.org New Zealand Medical Association Website: www.cdi.pub.ro/CDI/ Medical Association of Thailand E-mail: [email protected] P.O. Box 156 Parteneri/AMR_main.htm 2 Soi Soonvijai Wellington 1 New Petchburi Road VIETNAM E RUSSIA E Tel: (64-4) 472-4741 Bangkok 10320 Vietnam General Association Russian Medical Society Fax: (64-4) 471 0838 Tel: (66-2) 314 4333/318-8170 of Medicine and Pharmacy (VGAMP) Udaltsova Street 85 E-mail: [email protected] Fax: (66-2) 314 6305 68A Ba Trieu-Street 121099 Moscow Website: www.nzma.org.nz E-mail: [email protected] Hoau Kiem district Tel: (7-095)932-83-02 Website: http://www.medassocthai.org/ Hanoi E-mail: [email protected] NIGERIA E index.htm. Tel: (84) 4 943 9323 [email protected] Nigerian Medical Association Fax: (84) 4 943 9323 TUNISIA F 74, Adeniyi Jones Avenue Ikeja SINGAPORE E Conseil National de l’Ordre ZIMBABWE E P.O. Box 1108, Marina Singapore Medical Association des Médecins de Tunisie Zimbabwe Medical Association Lagos Alumni Medical Centre, Level 2 16, rue de Touraine P.O. Box 3671 Tel: (234-1) 480 1569, 2 College Road, 169850 Singapore 1082 Tunis Cité Jardins Harare Fax: (234-1) 493 6854 Tel: (65) 6223 1264 Tel: (216-71) 792 736/799 041 Tel: (263-4) 791/553 E-mail: [email protected] Fax: (65) 6224 7827 Fax: (216-71) 788 729 Fax: (263-4) 791561 Website: www.nigeriannma.org E-Mail: [email protected] E-mail: [email protected] E-mail: [email protected] iii