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WorldMedicalJournalVol.
No.
4,December200551OFFICIALJOURNALOFTHEWORLDMEDICALASSOCIATION,INC.
G20438wmaSantiagoGeneralAssembly–ReportsContentsEditorial2005–aLesson:"Humanity'sneedforCare"85MedicalEthicsandHumanRightsSponsorshipGuidelines86EnhancingtheWMADeclarationsonHumanRights86MedicalScience,ProfessionalPracticeandEducationHealthCareSystemReforminJapan88TheU.
S.
HealthSystem:AQuestionofAccess90WMAAssemblyCeremonialSession,Santiago200593GeneralAssembly,Santiago200594171thWMACouncilSession95ResolutiononAvianInfluenza97StatementonGeneticsandMedicine98StatementonDrugSubstitution100StatementonMedicalLiabilityReform101GeneralAssemblyAssociates'Meeting102Beyondstatementsandresolutions–WorkingattheWMASecretariatinFerney-Voltaire103FromtheSecretaryGeneral'sdesk"Don'tforgettheothers"104WHOFAO/OIE/WB/WHOMeetingonAvianInfluenzaandHumanPandemicInfluenza105Massiveinternationaleffortstopspolioepidemicacross10WestandCentralAfricancountries107TelemedicineviaSatellite108RegionalandNMANewsEuropeanRegion108LatinAmericaandtheCaribbean109KoreanMedicalAssociation109LetterstotheEditor110Review111Website:http://www.
wma.
netWMADirectoryofNationalMemberMedicalAssociationsOfficersandCouncilAssociationandaddress/OfficersWMAOFFICERSOFNATIONALMEMBERMEDICALASSOCIATIONSANDOFFICERSiseepageiiPresident-ElectPresidentImmediatePast-PresidentDrK.
LetlapeDrY.
D.
CobleDrJ.
AppleyardSouthAfricanMed.
Assn.
102MagnoliaStreetThimbleHallP.
O.
Box74789NeptuneBeach,FL32266108BleanCommonLynnwoodRidge0040USABlean,NrCanterburyPretoria0153Kent,CT29JJSouthAfricaGreatBritainTreasurerChairmanofCouncilVice-ChairmanofCouncilProf.
Dr.
Dr.
h.
c.
J.
D.
HoppeDrY.
BlacharDrN.
HashimotoBundesrztekammerIsraelMedicalAssociationJapanMedicalAssociationHerbert-Lewin-Platz12TwinTowers2-28-16Honkomagome10623Berlin35JabotiskyStreetBunkyo-kuGermanyP.
O.
Box3566Tokyo113-8621Ramat-Gan52136JapanIsraelSecretaryGeneralDrO.
KloiberWorldMedicalAssociationBP63FranceANDORRASCol'legiOficialdeMetgesEdificiPlazaesc.
BVergedelPilar5,4art.
Despatx11,AndorraLaVellaTel:(376)823525/Fax:(376)860793E-mail:coma@andorra.
adWebsite:www.
col-legidemetges.
adARGENTINASConfederaciónMédicaArgentinaAv.
Belgrano1235BuenosAires1093Tel/Fax:(54-114)383-8414/5511E-mail:comra@sinectis.
com.
arWebsite:www.
comra.
health.
org.
arAUSTRALIAEAustralianMedicalAssociationP.
O.
Box6090Kingston,ACT2604Tel:(61-2)6270-5460/Fax:-5499Website:www.
ama.
com.
auE-mail:ama@ama.
com.
auAUSTRIAEsterreichischerztekammer(AustrianMedicalChamber)Weihburggasse10-12-P.
O.
Box2131010WienTel:(43-1)51406-931Fax:(43-1)51406-933E-mail:international@aek.
or.
atREPUBLICOFARMENIAEArmenianMedicalAssociationP.
O.
Box143,Yerevan375010Tel:(3741)5358-63Fax:(3741)534879E-mail:info@armeda.
amWebsite:www.
armeda.
amAZERBAIJANEAzerbaijanMedicalAssociation5SonaVelikhamStr.
AZE370001,BakuTel:(99450)3281888Fax:(99412)315136E-mail:Mahirs@lycos.
com/azerma@hotmail.
comBAHAMASEMedicalAssociationoftheBahamasJavonMedicalCenterP.
O.
BoxN999NassauTel:(1-242)3286802Fax:(1-242)3232980E-mail:mabnassau@yahoo.
comBANGLADESHEBangladeshMedicalAssociationB.
M.
AHouse15/2TopkhanaRoad,Dhaka1000Tel:(880)2-9568714/9562527Fax:(880)2-9566060/9568714E-mail:bma@aitlbd.
netBELGIUMFAssociationBelgedesSyndicatsMédicauxChausséedeBoondael6,bte41050BruxellesTel:(32-2)644-1288/Fax:-1527E-mail:absym.
bras@euronet.
beWebsite:www.
absym-bras.
beBOLIVIASColegioMédicodeBoliviaCasilla1088CochabambaTel/Fax:(591-04)523658E-mail:colmedbo_oru@hotmail.
comWebsite:www.
colmedbo.
orgBRAZILEAssociaaoMédicaBrasileiraR.
SaoCarlosdoPinhal324–BelaVistaSaoPauloSP–CEP01333-903Tel:(55-11)31786800Fax:(55-11)31786831E-mail:presidente@amb.
org.
brWebsite:www.
amb.
org.
brBULGARIAEBulgarianMedicalAssociation15,Acad.
IvanGeshovBlvd.
1431SofiaTel:(359-2)954-1126/Fax:-1186E-mail:usbls@inagency.
comWebsite:www.
blsbg.
comCANADAECanadianMedicalAssociationP.
O.
Box86501867AltaVistaDriveOttawa,OntarioK1G3Y6Tel:(1-613)7319331/Fax:-1779E-mail:monique.
laframboise@cma.
caWebsite:www.
cma.
caCHILESColegioMédicodeChileEsmeralda678-Casilla639SantiagoTel:(56-2)4277800Fax:(56-2)6330940/6336732E-mail:sectecni@colegiomedico.
cWebsite:www.
colegiomedico.
clTitlepage:SemmelweisHospital.
Prof.
I.
Semmelweisworkedinthishospital,laternamedafterhim,whenheleftViennaaftertheinitialrejectionofhisideasaboutthetransmissionofinfection.
Editorial2005–aLesson:"Humanity'sneedforCare"TheeditorialintheSeptemberissuewasentitled"Backwardstothefuture".
Asthisyeardrawstoitscloseitisnaturaltolookbackoverthepast12monthsandtoconsiderwhereweareandwherewearegoing.
Internationallytherehasbeenmuchactivityinthehealthfieldtacklinglongstandingdis-easeproblems,assuchHIV/AIDSandMalaria.
Preventivepoliciessuchasbasicimmuni-sation,theprovisionofimpregnatedmosquitonetscontinuetoreducemorbidityandsavemanylives,whentheresourcesavailablepermittheiruseandprovision.
Despitetheef-fortstoeliminatepoliomyelitismajoreffortsarestillneededtodealwiththethreatofsud-denoutbreaksrequiringrapidlargescaleimmunisationprogrammes,andthedeclarationbyWHOofTuberculosisinAfricaasanemergency,bothhighlighttheneedforconstantvigilanceandcontinuingaction.
Atthesametimetheunderlyingproblemofpovertyinmanypartsoftheunderdeveloped,thedevelopingandeventheso-calleddevelopedworld,appearasfaraseverfromsolutionalthoughtheglobalsummitmeetingsmayassist.
Allthishasbeencomplicatedbynaturaldisasters,suchasthosearisinginSoutheastAsia,PakistanandeveninsuchahighlydevelopedandaffluentcountryastheUSA,andmadesuddendemandsonhealthcareresourcesbothintermsofmaterialsandskilledper-sonnel.
Attentionhasbeenfocusednotonlyontheglobalshortageofhealthcarepersonnelbutalsoontrainingandretentionofphysicianpoliciesinthefaceofdevelopmentssuchasthe"skillsdrain"phenomenon.
HealthServicesReformremainsahighpriorityinmanycountriesand,bothatnationalandinternationallevels,continuestoexercisethosere-sponsible–healthprofessionals,administratorsandpoliticians–astohowtoproceed,atwhatcostandatwhatspeedchangecanorshouldbeeffected.
Alloftheabovearehavingmajorimpactsonmanyhealthprofessionals,includingthephysicians.
Longstandingtraditionsofpracticearebeingabandonedintheeffortstomeetthehugedemandsbothofdeprivedpopulationsandofthoseinmorefortunatecir-cumstances,inarapidlychangingsocietywherespeedofaccesstoknowledgeandscien-tificdevelopmentsareleadingtonewexpectations.
Positivedevelopments,increasingscientificknowledge,provenhealthcarereformpoli-ciesareofcoursetobewelcomed,andthephysicians,likeothers,shouldbepreparedtoadapttheirprofessionalstyleofpracticeappropriately–pointswehavesoughttoempha-siseinthesecolumns.
Thechangesare,however,oftenveryradical.
Reformofthebasicmedicalcurriculum,thechangingroleofindividualhealthprofessionalsandprofessionalworkingpracticesarenoteasytoadapttothespeedwhichsomepoliticiansconsiderpos-sible.
Adequateconsultationandco-operationonallsidesisessentialtoachievethem.
Onethinghoweverremainsconstantregardlessoftheproblemsandissuesmentionedabove,itisthecontinuingneedforcareandreliefofhumanity'ssickandsuffering.
This,themedicalprofessionclearlyrespondedtothecrisesofthepastyear.
Throughthemanychallengeswhichitwillcontinuetoface,thismustremainatthecentreofallitsactivityinthefuture.
AlanRoweEditorial85OFFICIALJOURNALOFTHEWORLDMEDICALASSOCIATIONHon.
EditorinChiefDr.
AlanJ.
RoweHaughleyGrange,StowmarketSuffolkIP143QTUKCo-EditorsDr.
IvanM.
Gillibrand19WimblehurstCourtAshleighRoadHorshamWestSussexRH122AQUKProf.
Dr.
med.
ElmarDoppelfeldDeutscherrzte-VerlagDieselstr.
2D-50859KlnGermanyBusinessManagersJ.
Führer,D.
Weber50859KlnDieselstrae2GermanyPublisherTHEWORLDMEDICALASSOCIATION,INC.
BP6301212Ferney-VoltaireCedex,FrancePublishingHouseDeutscherrzte-VerlagGmbH,Die-selstr.
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Atpresentrate-cardNo.
3aisvalid.
Themagazineispublishedquarterly.
SubscriptionswillbeacceptedbyDeutscherrzte-VerlagortheWorldMedicalAssociation.
Subscriptionfee22,80perannum(incl.
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FormembersoftheWorldMedicalAssociationandforAssociatemembersthesubscriptionfeeissettledbythemembershiporassociatepayment.
DetailsofAssociateMembershipmaybefoundattheWorldMedicalAssociationwebsitewww.
wma.
netPrintedbyDeutscherrzte-VerlagKln—GermanyISSN:0049-8122Editorialnote:Pleaseacceptourapologiesthatunfortunately,duetotechnicalproblems,ithasnotbeenpossibletoincludeallthereportsoftheSantiagoWMAmeetinginthisis-sue.
Therestwillappearinthenextissue.
NMAsandfinancialrelationshipswithalloutsideorganisationsneededtobeconsid-eredDr.
Appleyard(ImmediatePastPresident)madethepointthatinany'rela-tionship'therewaspotentialfor'influence'bothways,TheWMAwasnotapassivepartnerandweshouldnevercompromiseourowninternationallyacceptedethicalstandards,weshouldratheruseanypart-nership'platform'topromotethem.
Dr.
HMiyazaki(Japan)emphasisedtheimpor-tanceoftransparencyinallourfinancialarrangementsDr.
Kloiber,theSecretaryGeneral,saidthatspecificguidancehadbeendevelopedforsponsorshipbycom-mercial,governmentalandcharitablepart-nershipsforspecificprojectsorpiecesofworkwhichwereconsistentwithexistingWMApolicies.
HewasadvisedbytheSponsorshipAdvisoryCommittee,whichreviewedallpotentialdevelopments.
Dr.
Kloibersaidthathepersonallyhadbeenoneofthegreatestcriticsofcommercialsponsorship.
Inresponsetothequestionabouthowmuchexistingsponsorshadattemptedto'influence'theWMA,hesaidhehadnotexperiencedanyattempttoinfluencetheassociationwhatsoever.
Dr.
KloiberfeltthataWorkGroupcouldiden-tifytheconcernsexpressedandreviewtheexistingguidelinesThecommitteeagreedunanimouslytorec-ommend"ThatCouncilestablishaWorkGroupconsistingoftheChairsoftheMedicalEthicsandFinanceandPlanningCommittees,toreviewtheWMACorporateRelationshipGuidelines".
Thiswassubse-quentlyAGREEDbyCouncil.
Thisissuewasdiscussedduringthemeet-ingoftheWMAEthicsCommitteeinSantiago.
Wefeelittobeofsufficientgen-eralinteresttoincludeintheJournal.
(ThefollowingreportisbasedonnoteskindlyprovidedbyDr.
Appleyardtowhomwearemostgrateful.
Edit.
)Dr.
BagenholmintroducedtheissueoftheacceptancebytheWMAofcommercialsponsorshipfunding.
SheindicatedthatthecurrentfinancialsituationfortheWMAwasdifficultinthatmembershipduesdidnotcovertheWMA'sexpenses.
SomememberorganisationshadapproachedherwiththeirconcernsthattheWMAhadbecomedependentonfinancialsponsor-shipfromthepharmaceuticalindustryformanyofitsactivities.
Posingthequestionastowhysuchindustrieswanttosponsorouractivities,shesaidtheybecameinvolvedsothattheycouldinfluenceus.
IftheWMAwasthoughttobeinfluencedbythepharmaceuticalindustry,itwouldlooseitscredibility.
Dr.
Bagenholm,recognizedthattherewereguidelinesagreedbytheCouncilforsuchsponsorship,butfeltthattheyneededtoberevisitedtoconsiderwhetheritisethicaltoreceivesponsorship,fromthepharmaceuticalindustryandwhatwouldbethefinancialimplications.
ThedelegatefromDenmarkagreedthattheeth-icalandfinancialaspectsshouldberecon-sideredandsuggestedasmallgroupcom-prisingtheChairofEthicsandtheChairofFinanceandPlanningbesetupwhocouldreceiveinformationabouthowNMAsarecopingwiththeseproblemsintheirowncountries.
(ThiswassubsequentlyapprovedbyCouncil.
)HefeltthattheWMAmissionwastofostertheindepen-denceoftheprofessionandsetthehighestpossibleethicalstandardsforphysiciansworldwide.
EthicsandHumanRightswerefundamentaltoourprofession.
NationalMedicalAssociationsfoundedtheWMAwiththeseissuesforemostintheirmindsMedicalEthicsandHumanRights86andweareonlyasstrongastheindividualcomponentsofthe'chain'ofourmember-shipassociations.
JonSnaedal,(Iceland)IcelandicMedicalAssociationandformerchairofEthicsagreedthattheWMAneededtobefinan-cially'autonomous'andshouldnotrelyonothersourcesoffinance.
IfwewereseentobeinfluencedbyourSponsorstheWMAwouldceasetoberespected.
Dr.
Johnson(UK)agreedthattheidealwouldbethattheWMAwasselffunding.
WiththecostofalltheactivitiesatInternationallevelwithallourpartnersthiswasnotpossibleandheaskedwhatwastheevidenceoftheWMAbeinginfluencedbythecurrentsponsorsDr.
KgnosiLetlape,PresidentElect,toldthemeetingthatthereweredifferentissuesindifferentcountries,InSouthAfricathemaininfluenceontheProfessionwasthatofGovernmentandhefeltthatIndustrywasmuchmoreunder-standingoftheimportanceoftheindepen-denceoftheProfession.
Withouttheirpart-nershipandsupport,theAssociationwouldnotbeabletofunctionthewayitdoesasanadvocateforitsmembers.
Ms.
Wapner(Israel)saidthatwherethereweremattersofethicsandfinance,ethicswaspreemi-nent.
Sherecognizedtheconcernsraised.
AnychangeinstandardsshouldapplytoallMedicalEthicsandHumanRightsSponsorshipGuidelinesTheWMAwasfoundedin1947toattempttoensurethatneveragainwoulddoctorsbecomplicitinhumanrightsabuses.
The"bigthree"WMAdeclarations–Geneva,HelsinkiandTokyo–aimtoraiseethicalstandardsglobally,andtoprotecttherightsofthevulnerable.
Despitethesecarefullydraftedwordsstoriesofmedicalinvolve-mentinhumanrightsabusesstillemerge.
CurrentdraftamendmentstotheDeclara-tionsofTokyoandGenevaandtotheRegu-lationsinTimesofArmedConflictarethelatestattempttofortifythisglobalconsen-sus.
EnhancingtheWMADeclarationsonHumanRightsV.
NathansonMedicalEthicsandHumanRights87Thesadfactisthatprisonersaresubjectedtohumanrightsabuses–bothtortureandcruelinhumananddegradingtreatmentinverymanycountries.
Involvementbydoc-tors,whenitoccurs,isoftenapartoftheprocess;doctorsresuscitatethetorturesur-vivorsothatheorshecanbetorturedagain.
Theycertifyfitnessforharshinter-rogationsandforfranklyabusivepractices.
Theyfalsifydeathcertificatesorotherkeypartsofmedicalandlegalrecords.
Atthesametimeotherdoctorsareputtingthem-selvesatriskindecryingthetorturers,doc-umentingabuse,givingevidenceincourts,opposingsystematicandepisodicpracticesthatputpeopleatriskofabuseandusingmedicalknowledgeandexpertisetoprotectthevulnerableandchallengetheabusers.
AllegationshaveemergedfromavarietyofsourcesabouttheabuseofprisonersinAbuGhraibandinGuantanamoBay.
1Whilenocaseshavebeenbroughtagainstdoctorstherearestoriesincirculationofdoctorin-volvementthatwould,iftrue,amounttose-riousethicalfailures.
Whilethesearenottheonlyplaceswheresuchmedicalabusesareallegedtheyareimportantastheyhigh-lightapparentweaknessesincurrentWMApolicy.
TheBMAhasledaWMACouncilworkinggroupthathaspreparedamend-mentstoexistingpolicythatwill,webe-lieve,strengthentheappropriateprohibi-tions.
2Oneissuethathasariseninrelationtotheseallegationsaswellastothosefromsomeothercountries,isthatmedicalrecordsarebeingprovidedtointerrogatorstoaidintargetingofharshinterrogationortorture.
AlthoughtheDeclarationofTokyoisreadbymostpeopleasdisallowingthispractice,itdoesnotcurrentlysaysoex-plicitly.
Intoomanycountriesphysicians'notes,recordedtohelptheirpatientsandtoinformotherhealthcareworkersabouttheirfindingsandtreatmentplans,arein-steadusedtounderminethesafetyandse-curityoftheindividual.
Somephysiciansappearwillingtohandoversuchnotes,oreventohelptheprisonauthoritiesusemedicalinformationtodeviseapro-grammethatwillunderminethementalorphysicalhealthofadetainee.
Theyarguethatasthecodeissilentontheprohibition,itdoesnotinfactexist.
3Forthatreasonanamendmenthasbeensuggestedtomakethisprohibitionexplicit.
Thiswillnotonlystrengthenthehandofthosedoctorswhorefusetohandoverrecordstoprisonauthorities,butitmayalsohelpdoctorswhoworkforagenciesvisitingprisonsanddetentioncentresaspartofthechecksandbalancessystemofinternationalregulation,includingtheRedCross,theUNHCHR,AmnestyInternationalandMSF.
ThisspecificamendmenthasalsobeenrepeatedintheRegulationsinTimesofArmedConflict,tomakedoublycertainthatthisprohibitionexistsregardlessofcur-rentpoliticalandsecuritycircumstances.
ThecarefullyconstructedlanguageofWMAdeclarationsandregulationscanalsobecomeobscureovertimeascommonlan-guageusagechanges.
Thisiswhythesug-gestionsforamendmentsincluderemovingtheconceptthatphysicians'consciencesshouldbetheirguidesanditsreplacementwitharequirementtoadheretointernation-alconventionsonhumanrights,interna-tionalhumanitarianlawandWMAdeclara-tionsonmedicalethics.
Theinternationallawsareeasilyfound;theyaretheGenevaConventionsandassociatedprotocolsofwhichtheICRCactsasguardian.
"Theoth-erlawsandconventionsareavailableon-linefromtheUNortheWMAitself.
"Allareclear;tortureisprohibited,andweeachhaveanabsoluterightnottobesubjectedtosuchtreatment.
SoarethesechangesaresponsetoasyetunprovenallegationsaboutAbuGhraibandGuantanamoBayNo;notonlytothese,butalsotosimilarallegationstosimilarabusesinmanyplacesManyassociationsreadingthesechangesmaywonderiftheyarenecessary.
Ibelievethattheyare;thenumberofreportsAmnestyandotherscanproduceofmedicalinvolve-mentinabusemakeschangeandreinforce-mentofhighnormsessential.
Theygiveus,asdoctors,achancetorededicateourselvestostoppingabusebydoctors,ormedicalcomplicity.
Theygiveusachancetoap-plaudthosecolleagueswhosticktheirheadsabovetheparapet,puttingthemselvesatriskbyadheringtothehigheststandards.
Theygiveusanopportunitytocondemnthosewethinkunworthyoftheirmedicallicences.
Theycanactasacalltoarmsforallofustodefendvulnerablepeoplearoundtheworld.
Inshort;theyareanopportunityfortheWMAtoreassertitscorereasonforexisting.
Prof.
VivienneNathansonDirectorofProfessionalServicesBritishMedicalAssociationvnathanson@bma.
org1See,forexample,LewisNA.
RedCrossfindsdetaineeabuseinGuantanamo.
NewYorkTimes,Nov30,2004:A1.
OkieS.
GlimpsesofGuantanamo–medicalethicsandthewaronterror.
NEJM353;2415Dec05.
2SeeWMApaperMEC/Misc/Dec20053BlocheG,MarksJ.
WhenDoctorsgotoWar.
NEJM352:3-66Jan054http://www.
icrc.
org/Web/Eng/siteeng0.
nsf/html/genevaconventions.
5http://www.
wma.
net.
NursesandPhysiciansWelcomeLibyanCourt'sDecisiontoReverseDeathSentencesTheInternationalCouncilofNursesandtheWorldMedicalAssociationhavewelcomedthedecisionofLibya'sSupremeCourttoreversethedeathsentencesandorderaretrialforfiveBulgariannursesandaPalestiniandoctor,accusedofdeliberatelyinfectingmorethan400childrenwithAIDS.
Thesupremecourthasquashedthesentencesandacceptedtheappealagainstthelowercourtrulingonbothsub-stanceandprocedure.
Prosecutorsagreedwithdefencelawyersthattherewere"irregularities"inthearrestsandinterrogationsoftheaccused.
Expertevidencethatthecausewasprobablypoorhygieneatthehospitalappearedtohavebeenignored.
Indeed,infectionswerebelievedtohaveoccurredbeforetheaccusedstartedworkatthehospital,andcontinuedaftertheirarrests.
ICNandWMAcallforaspeedyretrialthatwillconsidertheevidencepresentedbyinternationalexpertsandliberatethehealthprofessionals.
Japanisexperiencingaloweringofthebirthrateandanagingofthepopulation.
In1985,populationfrom0to4-year-oldaccountedfor6.
2%ofthetotalpopulation.
In2004,thefiguredeclinedto4.
5%.
Ontheotherhand,theelderlyover65yearsoldaccountedfor10.
3%ofthetotalpopulationin1985andincreasedto19.
5%in2004.
Asthisindicates,thepopulationstructureisrapidlychanging.
Inthecurrentyear,2005,populationaged4yearsoldorbelowis4.
5%ofthetotalpopulation,andthisfigureisestimatedtodecreaseto3.
6%in2025.
Peopleaged65yearsorover,however,accountfor19.
9%ofthetotalpopulationinthecurrentyear,2005,andthisisestimatedtoincreaseto28.
7%in2025.
Thesetrendsofdecliningbirthrateandagingpopulationareexpectedtocontinueatanevenmoreacceleratedrateinthefuture.
Thissituation,combinedwiththedeterioratedfinancialbasisofthenation,iscallingforsocialsecurityreform.
Healthcaresystemreformiscurrentlyunderwaytokeepthesystemsustainableinthefuture,supportedbybal-ancedeconomicandfiscalfoundation.
Thegovernmentproposesabasicpolicyplanforhealthcaresystemreform.
Itisnecessarytoradicallychangeallpartsofthehealthcaresystem,whiletakingintoaccountchangesinthemedicalenviron-ment,therapidlydecliningbirthrateandagingpopulation,andthecurrentstagnanteconomy,aswellasadvancesinmedicaltechnologiesandshiftsinthepublic'satti-tude.
Itisalsoessentialtoreformthehealthcaresystem,healthcaredeliverysystem,medicalfeeprogramme,andthehealthinsurancesystem.
Inotherwords,ahealthsystemthatmeetsthedemandsofthechangingenvironmentisrequired.
Inaddi-tiontothebasicpointsforreform,thegov-ernmentalsoproposesthefollowingimprovement,Theyare,theimportanceofrespectingthepatients'pointofview,pro-motionofdisclosureofhealthinformation,reestablishmentofsafeandassuredhealthcare,provisionofqualityandefficienthealthcare,establishmentofahealthcaredeliverysystemofhighqualityandeffi-ciency,separationofrolesbetweenmedicalinstitutionsformorefocusedandefficientmedicalservices,ensuringnecessaryhealthservicesincommunities,cultivationofhumanresourceinhealthcareandimprove-mentoftheirquality,improvementofthestructuralbasisforhealthcare,andtheimprovementofthefoundationforhealthcaretosupportlivesinthe21stcentury.
However,thegovernmentispushingpoli-ciesto"containhealthcosts"to"ensureappropriatehealthcosts"becauseofwors-eningnationalfinances.
Itistryingtointro-ducethetotalbudgetsystemofhealthcarecostsaswellascontrollingtheincreasingcoststosuppressthegrowthofsocialsecu-ritycostslowerthantheeconomicgrowth.
Whatisneededforhealthcarefromthegeneralpublicisimprovedqualityandsafe-tyofhealthcare.
Fromthegovernment'spointofview,however,itiscontainmentofhealthcosts.
Theproblemmaybehowwellthemedicalprofessioncanmeettheseneeds.
TheJapanMedicalAssociation(JMA)advocatesthatitisfundamentallynecessarytoensurethehealthinsurancesystemwhichpermitseverycitizentoequallyreceivehealthserviceswithaninsurancecard,anytimeandanywhere,whichmaybemostcharacteristicofJapan'shealthsystem.
TheJMAconsidersthatallthepeoplehavearighttoleadahealthylife,andenhance-mentofsocialsecurityforthispurposeisanobligationofthegovernment.
Healthcareisanassetforthepublicgood,anddevelopmentofthefoundationofthehealthcaresystemistheresponsibilityofthenation.
ThegovernmentshouldnotfitMedicalScience,ProfessionalPracticeandEducation88healthcaretotheeconomy.
Theeconomyshouldbefittedtohealthcare.
Tosecurequalityhealthcareandprovidesafehealthservices,financialresourcestocoverthehealthcostsarenecessary.
Wemaintainthatthepoliciestocontainhealthcostssurelyleadtoloweredqualityofhealthcareandmayblockthepromotionofsafermedicalservices.
InrelationtothehealthstatusofJapan,accordingtothereportbyWHO,Japanretainsthelongestaveragelifeexpectancyintheworld.
Asforthehealthcarecosts,whentotalhealthcarecostsarecomparedwithGDP,Japanhasthe17thlowesthealthcarecostamongtheOECDcountries.
Furthermore,incomparisonwithothercountriesforhealthachievement,JapanrankedNo.
1inlifeexpectancyandinoverallratingofhealthachievement.
Japan'shealthinsurancesystemisanexcellentsystemwithhighperformanceatlowcost.
Lookingatthetrendsofnationalhealthcareexpenditureandliveexpectancy,thegrowthofexpenditureandaveragelifeexpectancyforfemales,isinproportion.
Ofcourse,thereareotherfactorssuchasadvancesinmedicaltechnologiesandincreasediseaseintheelderly.
However,theincreaseinexpenditureisobviouslylinkedandcorrespondswiththegrowthofaveragelifeexpectancy.
Thecontainmentofhealthexpenditurecould,therefore,shortenlifeexpectancy.
ThefinancialresourcesofJapan'shealthcostsconsistofpublicexpenditure(taxes),premiumfromemployersandtheinsured,andpatientcostsharing.
From1990to2002,thepercentageofpublicexpenditureshowedlittlechanges.
Asforthepremi-ums,theburdenontheemployersdecreased,whilethepercentageofpatientcostsharingincreased.
Thisisbecauseoftheincreaseinthepatient'sco-paymentformedicalservicesfrom20%to30%afterApril2003andtheestablishmentofthefixedamountofpaymentbytheelderlywhichstartedinOctober2002.
InJapan,alimitissetforpatients'co-paymentat72,300yen(approximately650USdollars)forthegeneralpublic,exceptforlow-incomeearners.
However,thegovernmentMedicalScience,ProfessionalPracticeandEducationHealthCareSystemReforminJapanHidekiMiyazaki,MD,Ph.
DVicePresident,JapanMedicalAssociationPresentedatWMAScientificSession,Santiagohasbeentakingpoliciestoincreasethecoststobepaidbythepatientinthepastfewyears.
Itiscontrarytotheprinciplesofinsurancewhenyouconsiderthattheinsuredwhopaysthepremiumstobecov-eredbytheinsurancehastopayextracoststoreceivehealthservices.
Thereisalargegapbetweentheemploy-ee'spensioninsurancerateandthehealthinsurancerate.
Thispartlyaccountsforthedeficitofthehealthcosts.
Thehealthinsur-anceratehashardlychangedsince1980.
In2003,theemployee'spensioninsuranceratedroppedbecausepremiumswerechargedfortotalremuneration,includingbonuses.
Theinsurancerateuptotheyear2018hasbeensetbylaw.
However,thereisnopolicytoincreasethehealthinsuranceratefurtherandwhencomparedwiththeemployee'spension,itisundervalued.
Thehealthinsurancerate,ifincreased,willhelptosecureresourcesforthehealthcosts.
Japan'snationalcontributionratiowhichistheratiooftaxburdenandsocialsecurityburdenhasbeenshowingaround37%forthepast18yearswhichisverylow.
Inthegovernment'spolicy,therateshouldbesuppressedbelow50%atthehighest,butitisalreadyatalowlevel,comparedwithotherdevelopedcountries.
ThecomparisonoftheratioofnationalhealthexpenditurestoGDP,andthebreak-downofpublicandprivatespendinginmajorcountries,suggeststhathealthcostsinJapanneedanincreaseof1to2%ofpub-licspendingtoGDPwhencomparedwithSweden,France,andGermany.
Fromthispointofview,thegovernmentshouldallo-catemoreofitsmoneyonhealthcareareas.
IhavejustexplainedthecurrentsituationinJapan.
Theprobleminthehealthcaresys-temreformtobediscussedhereisthatthenumberofinsurersinJapanisextraordinar-ilylargewhencomparedwithhealthcareinsurancesystemsofothercountries.
IntheRevisedHealthInsuranceActenacted2yearsago,integrationandunificationofdifferentkindsofinsurancesisoneoftheitemstobestudiedinthefuture.
In2004,thenumberofinsurersmanagedbythenationalgovernmentis1,whilethosemanagedbyhealthinsurancesoci-etiesis1,674andthosemanagedbysea-men'sinsuranceis1.
Asforthemutualaidinsurance,thenumberofinsurersmanagedbythenationalgovernmentemployeesmutualaidassociationsis23;thoseman-agedbylocalgovernmentemployeesmutu-alaidassociationsis54;thosemanagedbyprivateschoolteachers&employeesmutu-alaidis1.
Asfornationalhealthinsurance,thenumberofinsurersmanagedbymunic-ipalitiesis3,224andthosemanagedbyassociationsis166.
Thetotalnumberofinsurersis5,144withthetotalofinsuredpersonsbeing94,248,000.
Currentlythereisadiscussiontointegrateandreorganizetheinsurersineachprefec-ture,anditissuggestedfirstlytointegratethosemanagedbymunicipalitiesandbynationalgovernment.
TheJapanMedicalAssociationispropos-ingbasicpoliciesforthehealthcaresystemreform.
Wefirstlyandstronglyadvocateformain-tainingtheuniversalhealthinsurancesys-tem.
WearealsosuggestingthecreationofnewMedicalInsuranceSystemfortheElderlytoaddresspublicconcerns.
Thesystemwiththenationalgovernmentasinsurerwouldcoveronlythoseaged75yearsandolder.
However,thesystemwillbemanagedbythelocalgovernmentafteracertainperiodoftime.
Weareproposingforthefinancialsourcesofthissystemspecial;10%ofthecontributionfromthepatient,10%frominsurancepremiums,with–con-siderationforlow-incomeearners,and80%frompublicexpensesandnationalmutualassistancesuchasconsumptiontaxandcig-arettestax.
Ifahealthinsurancesystemisseenasapartofsocialsecuritysystem,itisnecessarytoincreasepublicfundingortaxtomeetitsneedforfinancialsources.
Comparedtootherinmajorcountries,thepriceofcigarettesisthelowestforJapananditisnecessarytodiscussvariousrelat-edmattersincludingaconsumptiontaxschemeandaproposalforanearmarkedtaxforhealthcar.
Ariseincigarettepricesmaybethemostefficientmeasurestocutthenumberofsmokers.
Weareproposingtoutilizetheincreasedtaxforfinancialresourcesforhealthcare.
Healthcareshouldnotberegulatedbyage.
Thisisnaturalwhenyouthinkaboutchar-acteristicsoftheelderlyandtheirpotentialdiseases.
TheMedicalInsuranceSystemfortheElderlywillbebasedonself-help,andmutualandpublicassistance.
ThehealthinsurancesysteminJapanprovidesbenefitsinkindsufficientlytomeetpeople'sneedsforhealthcare.
InJapan,theLong-termCareInsuranceSystemwasestablishedforthoseagedover40yearsofagein2000,whichprovidescashbenefitstosupportlong-termornursingcare.
Thefundcomesfromthepremiumsandpublicspending.
Thelevelofnursingcarerequiredisdivid-edinto5levels,eachhavingasetquota.
Wedistinguishbetweenalong-termornursingcareandmedicalcare.
Andnecessaryarrangementsarebeingmadebetweenthetwoareasofcare.
Therefore,theLong-termCareInsuranceSystem,whichprovidescashbenefits,andthehealthinsurancesys-temcannotbeintegrated.
ControlofthegrowthrateofhealthcostsbasedontheeconomicindicatorssuchasGDPshouldnotbepermittedbecauseitdisturbsneces-saryandsafehealthcare.
Toenhancethelevelofhealthservicesfortheelderly,itisimportanttopromotepre-ventativemeasuresagainstlifestyle-relateddiseasestokeeptheelderlyhealthy.
Co-pay-mentbypatientsshouldbedecreasedandshouldnotexceedthecurrentlevel.
Thegovernmentshouldextendtheretirementageofworkersto65yearsofage.
AllretiredemployeesshouldjointheNationalHealthInsurancewhichprovidesbenefitswhichwillbecoveredbypatients'co-payment,premiumsandmutualassistancebetweenemployee'shealthinsurancesystems.
ThegovernmentmanagedhealthinsurancesystemhasbeenenlargedbytheSocialInsuranceAgencyandbeenestablishingandmanaginghospitals.
Retiredbureau-cratsoftheHealth,LabourandWelfareMinistryhavebeenobtainingjobsatthesehospitals.
Areformisgoingtoabolishthesehospitals.
Asforthehealthcaredeliverysystem,inacomparisonoftheaveragenumberofvisitsperpersonperyearinmajorcountries,itisMedicalScience,ProfessionalPracticeandEducation8921highertimesinJapan,thehighestfigure.
However,healthcostperonevisitinJapancomparedwithothercountriesin63USdol-lars,whichisverylow.
Tosumitup,itcanbesaidthathealthcostinJapanisverylow.
Inaninternationalcomparisonofthehealthcaredeliverysystemin1998,thenumberofbedsper1,000peoplewashighat13.
1inJapan,whilethenumberofphysiciansper100bedswaslowat12.
5.
Furthermore,thenumberofnursingstaffper100bedswasalsolowat43.
5,withthelongestaveragenumberofhospitalstaysbeing31.
8.
Therateofoutpatientvisitsstandat16.
0.
ThisrevealsthefactsthatinJapanthepeoplehavemanyopportunitiestovisitanykindofmedicalinstitutionsundertheuniversalhealthinsurance,theperiodofhospitalstayislong,andapatientisattendedbyasmallnumberofphysiciansandnursingstaff.
Toshortenthehospitalstay,wearetryingtoreviewtheorganizationalproblemsrelat-edtotheinpatientsettings,healthcaredeliverysystem,andtherevisionofthemedicalfees.
TheJapanMedicalAsso-ciationismakingitsutmosteffortstomain-taintheuniversalhealthinsurancewhichJapanisproudof,toprovidenecessaryandsaferhealthcareservicesforallthenationofJapan.
MedicalScience,ProfessionalPracticeandEducation90IamdelightedtobeheretodayonbehalfoftheAmericanMedicalAssociation.
Myvisitwithyoucontinuesadecades-longtra-ditionofmutualfriendshipandsupport.
Andourfriendship,nowandinthefuture,isevenmorevitalthanithasbeeninthepast.
Together,wefacepotentialpandemicsandterroristthreats.
Publichealthchal-lengesfromtsunamis,hurricanes,earth-quakesandfloods.
Wearesubjecttoeco-nomicandpoliticaldecisionsmadefarawaythathaveimmediateimpactinourcommunities–thataffectaccesstocareandqualityofcareforourpatients.
Morethanothers,perhaps,werecognizethatdiseaseanddiscord,thatepidemicsandterrorists,alike,respectnoboundaries.
Wealsoknowthatknowledgeandourmutualcaringforourpatientsknownoboundaries,either.
Noboundariesandnolimits.
Insuchaworld,cooperationamongourassociationsandwithintheWMAismoreimportantthatever.
Ishineslikeabea-con–amodelforethicalbehaviorforallotherprofessionsandassociations.
Today,aswediscussthestrenghtsandweaknessesofournations'healthcaresystems,wecanlearnfromeachother.
Identifythebestprac-tices–andtheworstpitfalls.
Andsteerour-selvestowardabetter,healthierworldtomorrow.
TheUninsuredThisissomethingtheAmericanMedicalAssociationistryingtodealwithinmyhomeland,theUnitedStates.
There,medicalcareisfinancedanddeliv-eredthroughbothpublicandprivatemeans.
Personsovertheageof65arecov-eredundertheMedicareprogram,adminis-teredbyournationalfederalgovernment.
Theeconomicallydisadvantagedareeligi-bleforMedicaid,administeredonthestatelevelwithpartialfederalfunding.
MostAmericanworkersgettheirhealthinsurancethroughtheiremployers,aprac-ticethatstartedduringWorldWarII,whenwageswerecontrolled.
Healthinsuranceemergedasawaytoenhancebenefitsforworkerswhocouldn'tgetsalaryincreases.
Forsomepeople,thispatchworksystemworkswell.
Forthosewithaccess,theU.
S.
offerswhatIbelieveisthehighestqualitycareintheworld,despiteoursignificantdeliveryandsystemsproblems.
Butforothers,itbarelyfunctions,ifatall.
Forinstance,therearealmost46millionAmericanswhohavenohealthinsurance.
That'sabout15percentofourpopulation–anationaldisgrace.
Theemployer-basedsystemofhealthinsuranceisshowingsignsofweakness.
Morethan80percentoftheuninsured–36millionofthem–workoraremembersofworkingfamilies.
Theyholddownjobsanddrawapaycheck.
Forthem,livingwithouthealthinsurancehasterribleconsequencesforhealthandeconomicwell-being.
Theylivesickeranddieyounger.
Often,theydelayseekinghelpuntiltheyaresufferingfromamoreadvancedstageofdisease–whentreatmentisoftenmoreexpensive–andlesseffective.
Butittakesatollonmorethantheindivid-ual.
Itextractsaheavycostonoursocietyintermsofreducedemploymentandpro-ductivity,andthefloodofuninsuredintoemergencydepartmentsandfreeclinicshasapricetag,too.
In2004,Americantaxpayersspent35bil-lionU.
S.
dollarsfromuncompensated,publicly-fundedcare.
That's$4millionperhoureveryday.
Andthisnumberdoesn'ttakeintoaccounttheadditionalbillionsofdollarsspentonprivatelygivencare,includinguncompensatedcarebyphysi-cians.
ManagedCareConcentrationSothequestionis,howdoweintheUnitedStatesrepairoursystemItisflawed,andfailstogivecoveragetoenoughpeople.
Oneofthemostsevereissues,notonlywiththosewhohavenohealthinsurance,butforallAmericanpatients,iscontinuityofcare–thepatient-physicianrelationship.
ThatrelationshiphasbeenundersiegeinrecentdecadesintheU.
S.
Inmypractice,I'veseensomeofmypatientsformanyyears.
Iknowtheirmed-icalhistories.
Icanfollowuponoldprob-lemsorseesubtlechangesthatastrangerTheU.
S.
HealthSystem:AQuestionofAccessPresentedattheWorldMedicalAssociationScientificSession,SantiagoJ.
EdwardHill,MD,PresidentAmericanMedicalAssociationMedicalScience,ProfessionalPracticeandEducation91mightnot.
Inthesecircumstances,apatientfeelscomfortable–andisbetterabletoaskquestionsandcommunicate.
Thispatient-physicianrelationshipisthecornerstoneofmedicine.
Ahealthyandcontinuousrelationshipwithaphysiciancanlowercostsbygettingapatientaccesstothehealthcaresystematanearlierstageofadisease.
Butwiththespreadofprivatelyrunman-agedcareintheU.
S.
,thiscontinuityhasbeendisrupted.
Patientsoftenmovefromphysiciantophysician–whentheiremployerschangehealthplans–orwhentheirphysiciandecidesnottocontractwithagiveninsurer.
Perhapsitisbecausewithsomeofthemoreabusiveinsurers–physiciansarepaidlesstoseemorepatientsandworklongerhours.
Itisclearthatamorecompetitiveinsurancelandscapewouldhelpprotectthequalityofmedicalcare–andultimatelylowercostsforconsumers.
Whatwehavestructuredisacost-basedcaresystem–whileweshouldbeofferingacare-basedcostsystem.
Weneedtoputdecisionsabouthealthcarecoverage–backwheretheybelong:inthehandsofpatients–andtheirphysicians.
IntheUnitedStates,ahandfulofgianthealthinsurancecompaniesdominatethemarket.
Itmakesitdifficultforanindivid-ualphysiciantonegotiatepatientcareissueswithwhatareessentiallymonopo-lies.
Managedcareorganizationshaveconsoli-datedatarecordpaceintheUnitedStates,withmorethan350mergersandacquisi-tionsinonefive-yearspan.
TheAMAisworkingtoredressthisimbal-ance.
Webelieveregulatorsshouldstartlookingmorecloselyatthebehaviorofthehealthinsuranceindustry.
Alsothatphysiciansshouldbeabletonegotiatemoreeffective-lywithlargehealthinsurancecompanies.
Becausewhenthehealthcaremarketland-scapeisdominatedbyjustafewgiantcom-panies,itforcesphysicianstoacceptunfaircontractswhichcanhaveseriousimplica-tionsforpatientcare.
Single-PayerNottheAnswerSomewouldarguethatthesolutiontotheproblemoftheuninsuredwouldbetoadoptasingle-payernationalhealthinsuranceplan.
Mostofyouinthisroompracticeundersuchasystem,inoneformoranoth-er.
Proponentsofsuchasystemarepassionateandvocal.
ButweattheAmericanMedicalAssociationrespectfullydisagree.
Webelieveasingle-payersystemintheUnitedStateswould:Requirephysicianstonegotiateabind-ingfeeschedule;Discouragehospitalexpansionsandcapitalpurchases;Eliminatethehealthinsuranceindustry,eliminatinginstitutionalmemoryandhundredsofthousandsofjobs;Forceemployerstotransfermoneyear-markedforhealthbenefitstoanationalhealthinsuranceprogram.
Anddiscouragetheinnovationthathasdrivenmedicaladvancesandinnova-tionsintheUnitedStatesoverthepastcentury.
Tous,thisrunscountertofreedom,choice,andprivateenterprise,qualitiesingrainedintheAmericanpsyche,andwhichfuelAmericansociety.
SuchasystemwouldbeexponentiallymoredifficulttomanageintheUnitedStatesthanitisalmostelsewhere,becausewehavea"meltingpot"societywitharemarkablydiverseanddiffusecharacter.
Itmakesourcountryespeciallyresistanttoone-size-fits-allsolutionsimposedfromabove.
TheAMAbelievesthatbyimplementingasingle-payersystem,theUnitedStateswouldbetradingonesetofproblemsforanother.
Wewouldseelong,detrimentalwaitsforcareandtherationingofcare.
Wewouldbeslowtoadoptnewtech-nologyandmaintainfacilities.
Wewouldbeboundbypricecontrols,whicheventuallydriveupcosts;Anditwouldcreateagiganticbureau-cracythatinterfereswithclinicaldeci-sionmaking.
Wouldasingle-payersystemsaveusmoneyWedon'tthinkso.
WebelievethatsuchaconclusionisrootedinfaultyandincompletecomparisonsofadministrativecostsbetweentheUnitedStatesandcoun-triesthatofferasingle-payersystem.
Ithaslongbeenrecognizedthatpublicinsuranceimposesavarietyofcostsonpatients,includingexcessivewaittimes,aproliferationofshortvisits,andlackofaccesstocertainservicesandprocedures.
InJune2003,theChairmanoftheBritishMedicalAssociationcharacterizedtheU.
K.
'ssingle-payerhealthcaresystemas:"Thestiflingofinnovationbyexcessive,intrusiveaudit…theshacklingofdoctorsbyprescribingguidelines,referralguide-linesandprotocols…thesuffocationofprofessionalresponsibilitybytarget-settingandproduction-linevaluesthatleavelittleroomfortheprofessionaljudgmentofindi-vidualdoctorsortheneedsofindividualpatients.
"Sosayaphysicianwithlong,first-handexperiencewithasingle-payerhealthsystem.
Wehavetorecognizethatnothingworth-while–comeswithoutaprice.
Thefactisthateffectivepricesplayaroleintheprovi-sionof,andaccessto,servicesinanyhealthcaresystem,notjustmarket-basedsystems.
Inthefinalanalysis,consumersclearlypay,inonewayoranother–regardlessofthesystem.
Anysystemthatoffersaccesstocarewith-outdirectchargestoconsumersgeneratesdemandforcarethatexceedswhatcanbedelivered.
Ultimately,thereisnoguaranteethatevenmedicallyurgentserviceswillbeavailablewhenneeded.
TheAMAhasaviablesolution–onethatdoesnotlimittheuniverseofchoicesandthatdoesnotdictateasingle-payersystemastheonlypathtowarduniversalhealthcoverage.
MedicalScience,ProfessionalPracticeandEducation92AMAPlanfortheUninsuredTheAMAhaslongadvocatedthateveryAmericanshouldhavehealthinsuranceandthusaccesstomedicalcare.
We'vebeenworkingwithothermajorplayersontheAmericanhealthcarescenetoraisethepro-fileofthisissue–andtoremindthepublicofitsurgency.
Webelievethecountrywillseriouslyaddressthisissueeventually.
AsWinstonChurchilloncesaid,"Americanscanalwaysbecountedontodotherightthing…aftertheyhaveexhaustedallotherpossibilities".
TheAmericanMedicalAssociationbelievewehaveaplanthatwouldexpandhealthinsurancecoverageinourcountry.
Wethinkit'stherightthingtodo.
Theplanissimple:Givepeoplemoneytobuytheirownhealthcarecoverage.
Givewealthypeoplelessmoney.
Givemoretopoorpeople.
TheAMAplanhasthreepillars–taxcred-its,individualownershipandselectionofplans,andregulatoryreform.
Themostcentralpointtounderstand–isthesystemoftaxcredits.
UndertheAMAplan,allworkerswouldgetataxcreditlargeenoughtoensuretheycouldpurchaseaffordablecoverage.
Thetaxcreditwouldbeinverselyrelatedtoincome.
Thismeansthatthepeoplewiththelowestincomes–thosemostlikelytobeuninsured–wouldgetthebiggestsubsidy.
Thetaxcreditswouldberefundable,sofamiliesthatowelittleornotaxeswouldstillgetacredit.
Finally,thecreditswouldbeavailableinadvance,sothatfamilieswhocan'taffordmonthlypremiumsdon'thavetowaitforayear-endrefundtobyecoverage.
What'smore,Americanscouldchooseandpurchaseahealthcareplanthatfitstheirneeds.
Atpresent,ofthosecompaniesthatofferhealthcarecoverageonlyoneinsixoffersachoiceofmorethanoneplan.
UndertheAMAinsuranceproposal,employeescouldchoosetogetcoveragethroughtheiremployersornot.
Thiswouldempowerpeople.
Allowthemtodowhatfederalgovernmentemployees,includingmembersofourU.
S.
Congress,candotoday.
Thatistochoosefromawidearrayofplans.
Thisinturn,wouldcreatecompetitionandvibranthealthinsurancemarkets.
Finally,ourplansforregulatoryreformwouldalsobringsanityandreasontothecurrentmazeofmarketregulationsforhealthinsurance.
Currently,someregulationsaimedatpro-tectinghigh-riskindividualshavetheunin-tendedconsequenceofadrivingupthenumberofpeoplewhoareinsured.
Weaimtocreateamoresensibleregulato-rysystem.
Asystemthatgivesincentivestopatientstopurchasecoveragebeforetheygetsick.
Andthatgivesincentivestoinsur-erstocoverhigh-riskindividuals.
Overall,ourplantoexpandhealthcarecoverageandchoice–wouldget94percentofAmericanscovered.
Thisisjustoneexampleofhowwecouldimprovemarketregulationsforhealthinsuranceandgetmorepeoplecov-eredintheprocess.
Thesekindofmarket-basedapproachesforreformintheUnitedStatesarealreadyshowingpromise.
Theremovalofsomemandates,forexample,hasmadepossibleanewkindofplanthatcombineshighdeductibleinsurancewithhealthsavingsaccounts–HSAs.
Theseaccountsallowconsumerstousetaxfreedollarstopayforoutofpockethealthcarecosts,ortorollthosedollarsover.
Nationwide,morethanonemillionpeoplehavealreadysignedupforHSAs.
Andthebestpartisthatthesta-tisticsshowthataboutone-thirdofthemwerepreviouslyuninsured.
[U.
S.
ChamberofCommerce].
Cangroupslikefamiliesofthedevelop-mentallyandmentallydisabledbenefitfromthesekindsofmarket-drivenreforms,tooWethinkso.
That'swhyweendorsetheconceptofatax-exemptmedicaltrusttoprovideforthelong-termhealthcareneedsofdisabledfamilymembers.
AndwethinkthisconceptshouldbelinkedtoouroverallplantofinancehealthcareforallAmericans.
[H-165.
893]There'snoreasonthatanyoneshouldbeleftoutofthepicture(whenitcomestocreat-ingasystemdrivenbychoice),thathasthepotentialtoincreasequalityoflifeandreducecostsforallpatients.
TheAMA'splanofactionisagoodone.
Ifenactednationally,itcouldgivemorethan94percentofAmericanshealthcoverage.
Itisanideawithpowerfulsupport.
DuringthemostrecentU.
S.
presidentialcampaign,thecandidatesfrombothmajorpoliticalpartiesendorsedthegeneralconceptofusingtaxcreditsforindividualstopurchasehealthcarecoverage.
However,givencur-rentgovernmentbudgetchallenges,weknowit'sunlikelythatourplanwillbeenactednationallysoon.
That'swaywearewillingtosupportanincrementalapproach.
Forexample,wewouldliketoseepilotprogramsonlocalgovernmentlevelstotryoutourreforms.
Suchpilotprogramscouldfocusonparticularlyvulnerablepopula-tionssuchasalow-incomepeople,chil-dren,orthechronicallyill.
Pilotprogramshavetheaddedbenefitofallowingpolicy-makerstoguidefuturedecisionsthroughactualdataanexperienceandlettingthemseehowtheAMAplancouldworkonanationalscale.
AneditorialfromoneofAmerica'sleadingnewspaper,TheDetroitNewssaid,"TheAMAisofferingacredibleblueprintforfundamentalhealthcarereform.
ItdeservesahearinginCongress.
"Weagree.
Butweknowthatthiswon'tbeeasy.
That'swhyourleadershipisbringingourideastoagroupcalledtheSearchforCommonGround.
Thisgrouphasallthemajorplay-ersandassociationsinhealthcare–employers,healthplans,physiciansandmanymore.
Theonethingwehaveincom-monisthatwe'reallfrustratedthat45mil-lionAmericansareuninsuredand10to15millionmoreareunderinsured.
ThemissionofthisgroupTocoverasmanypeopleaspossibleassoonaspossiblethroughnon-governmentalsolutions.
Together,wecangetcoverageforthemillionsofAmericanswholackitandwecanmaintaintheintegri-tyandqualityofAmericanmedicineintheprocess.
WMA93ConclusionOnethingiscertain–whateverinsuranceplanwearriveatwillbeauniquelyAmericansystem,withuniquelyAmericancharacteristics.
Yetperhapswecanshowtheworldadifferentapproachtoprovidinghealthcoveragetoeveryoneinourcommu-nities–andourcountries.
WehaveamottointheAmericanMedicalAssociationthatgoeslikethis:"Togetherwearestronger.
"Itsoundsself-evident,butitisapowerfulidea.
Workingtogether–inmeetingsjustlikethis–weallbecomestronger.
Ourprofessionbecomesstronger.
Welearnfromeachother.
Wefindoutmoreaboutwhatworksinmedicine–andwhatdoesn't.
Andwereinforcethefoundationofscience,ethics,caringandcompassionthatsupportsallwedo.
Throughourworkourpatientsarebetteroff.
Nomatterwhatourhealthcaresystem.
Nomatterwhatourcountry.
Thecommitmentoftheworld'sphysiciantotheirpatientsisonethingthatdoesn'tneedreform.
TheceremonywasopenedbythePresident,Dr.
YankD.
CobleJr.
,whowarmlythankedtheChileanMedicalAssociationanditsleadersfortheexcellentarrangementsandthewarmthandhospitalitywhichhadbeenshowntotheparticipants.
HethencalledonDr.
JuanLuisCastro,PresidentoftheChileanMedicalAssociation,toaddresstheAssembly.
Dr.
CastroinwelcomingtheAssembly,saidthattheChileanMedicalAssociationwasavoluntaryorganisationwith20000mem-bers.
SpeakingabouttheproblemsoftheprofessioninChile,hereferredbothtotheneedtoimprovesalaries(statingthatonqualificationearningswereabout$300andafterfiveyearsmightreach$30000),butstressedthatamajorproblemwasthatoflawsuitsandliabilityHementionedthattheseresultedinabout180trialsayearandspokeofthepioneeringexperienceinLatinAmericaofcreatingtheFoundationforLegalAssistance(FALMED)tomanagelawsuitsagainstthephysiciansandavoidincreasesininsurancecosts.
AnotherimportantachievementwastherestorationofethicaldefencefortheAssociation.
Atatimewhenmanycountrieswereundergoingprocessesofhealthreform,Chilewasnoexception.
There,physiciansarewitnessingchangeswhichwillimpactgreatlyonthemedicalprofessionanditsrelationswithpatients.
ThankinghimDr.
CoblethenintroducedDr.
PedroGarcia,theChileanMinisterofHealth,whoaddressedtheAssembly.
Hewelcomeddelegatesandreferredtotheimportanceoftheprofessionmeetingtodis-cussproblems.
Asadoctorhimselfandasapoliticianhewas,ofcourse,interestedinthechallengesfacingsociety.
ReferringtothecomplexityofthegeographyofChilehesaidthisposedmanyproblemsforhealthcare,buttherewasalonghistoryofhealthcareinthecountryandtheystilllookedtophysicianstokeepupwithnewdevelop-mentsinscientificknowledgeandhealthcare.
Inhisviewitwastherewasneedforpoliticiansandphysicianstoworktogethertosolvetheseproblemsandhewasthere-foreparticularlydelightedthattheWMAhadchosentomeetinChile.
Hecongratulat-edallthebodiesresponsiblefortheorgani-sationofthemeeting,inparticular,theChileanMedicalAssociation.
Hepointedoutthat80%ofChileandoctorsweremem-bersoftheCMA,ofwhichhehadbeenoneformanyyears.
HehopedthatdelegateswouldbeabletogetsomeideaoftheChileanHealthReformsandalsothattheywouldseesomethingofthecountryduringtheirvisit.
HewouldbehappytorespondtoanyquestionsandheclosedbywishingtheWMAaverysuccessfulconference.
Dr.
Blachar,theChairofCouncil,paidatributetoDr.
YankCobleforhisoutstand-ingservicesduringhisPresidentialtermofofficeandinvestedhimwiththePastPresident'smedalfollowingwhichDr.
Coblegavehisvaledictoryaddress(ThiswillappearinWMJ52(1))Dr.
BlacharthenintroducedthenewPresidentDr.
KgosiLetlapeandinvitedhimtotaketheoathofoffice.
Followingthis,Dr.
BlacharinvestedhimwiththePresident'sBadgeofOfficeandinvitedhimtoaddressthemeeting(seeInauguralPresidentialAddressp.
94).
Dr.
BlacharafterthankingthespeakersfortheiraddressesandonceagainthemembersoftheChileanMedicalAssociationforinvit-ingtheWMAtoholditsGeneralAssemblyinSantiago,adjournedthemeeting.
WMAWMAAssemblyCeremonialSession,Santiago2005WMA94HonourableMinisterofHealthDr.
PedroGarcia,Dr.
Castro,thePresidentoftheChileanMedicalAssociation,HonouredGuests,LadiesandGentlemenThankyoufortheprivilegeyouhavegivenmetoserveasPresidentoftheWorldMedicalAssociation.
Iassumethisroleonbehalfofallphysiciansonearth,butpleaseindulgemeasIsingleoutparticularlymybrothersandsistersofAfrica.
IwouldfirstlyliketocongratulateDr.
YankCobleonanextraordinaryPresidency.
ThroughhisPresidentialinitiativeof"CaringPhysiciansoftheWorld",hehasmanagedtore-establishthefundamentalvaluesofmedicine–caring,ethicsandsci-ence.
Togetherwiththebookoncaringphysicians,hehassucceededinmakingusfeelgoodaboutbeingdoctorsagain–soYank,thankyouagainforyourleadership,dedicationandcommitmenttoourprofes-sion.
Ifinditahumblingexperiencetofol-lowhimasPresidentandhopethatIwillbeabletorisetotheoccasion.
AnoldIsraelisayingstatesthatyouhavetolookbacktowhereyouhavecomefrom,tobetterseewhereyouareheading.
Lookingbackoverthelastfewyears,itisgratifyingtonotethattheWMAhasunquestionablygrownintotherepresentativevoiceofphysicians.
TheWorldHealthOrgani-zation,WorldBankandotherUNagenciesturntotheWMAiftheyneedtoheartheviewsofphysicians.
ThroughouralliancewiththeInternationalCouncilofNurses,InternationalPharmaceuticalFederationandtheWorldDentalFederationwehavealsobeenabletomakemajorbreak-throughsinthefieldofpublichealth.
WithintheWMAtherehavealsobeenverypositivedevelopments.
Ourroleasthecus-todiansofmedicalethicshasbeenrein-forcesbythesuccessfulrevisionoftheDeclarationofHelsinkiandthelaunchoftheWMAEthicsManual.
Theimpactofthemanualhasbeenimmediateandveryfrontlinephysicians.
Inaddition,theWMAcalledforTaiwantobeincludedintheWHOsurveillanceandresponsenet-work,astheyareaseparatehealthentity,notreceivinganyfundingorassistancefromChina.
Herewearein2005,withavianfluposingasapossibledisasterofaproportionwehavenotseensincetheSpanishFluepidemicin1918,whenmil-lionsdied.
Yetwedonothaveafullyfunc-tionalnetworkwherethephysiciansandmedicalassociationsaredirectlylinkedtoWHO.
Thegabintheglobalpublichealthnetwork,Taiwan,acountrywith23millioncitizens,hasnotbeenyetaddressed.
IfavianfluistransmittedfromChinatoTaiwan,ashadhappenedwithSARS,therearestillnoformalchannelsopenbetweenWHOandTaiwantoexchangetechnicaldataandprovidehelp.
Clearlyweneedtobemorevocalandactiveassocialleaderstomakesurethatallmeasurescanbetakentoincludeallthepeoplesoftheworldinpreparingforhealthdisasters.
TheUNCommandingOfficerinRwandaGeneralDallairesaidthataftershakinghandswiththedevilinRwandaheknowsthereisaGod.
NotingthatSARSnevercametoAfricain2003IhavealsocometoknowfullythatGodisthereforallofus.
Iofferyouanotherstoryfrommyowncon-tinent.
Lastyearthefundamentalistgover-norofNigeria'sKanoStatehaltedallpolioimmunisationeffortsbecauseofallegedandunsubstantiatedclaimsthatitwaspartofaplottosterilizeMuslimgirls.
Bythetimeherelented,poliohatspreadto12Africancountriesthathadpreviouslybeenfreedofthedisease,therebydramaticallysettingbackglobaleradicationeffortsandforcingtherestoftheworldtocontinuevaccinationprogrammes–anotherclassicexampleofwherepoliticsruledoverhealthimperatives.
Wherewerewe,thephysi-ciansoftheworld,inpreventingthiskindofdisasterWecanandshouldpreventthisfromhappeningagain!
InNorthernEuropeoverthelastyear,physicianshaveexpressedtheirseveredis-satisfactionwiththenewtrendofrationingofcare,everincreasingpaperwork,workhoursanddiminishingremuneration.
ThisledtoprotestactionsinFrance,GermanyWMAGeneralAssembly,Santiago2005InauguralPresidentialAddressDr.
T.
K.
S.
Letlapesignificant.
FromitspublicationinJanuarythisyear,ithasnowalreadybeendistrib-utedworldwideandtranslatedintoatleast12languages.
TheWMA'srecentcontributionsinhealthrelatedhumanrightshavealsobeenwel-comedbymycompatriotsfromAfrica.
WecannotencouragetheWMAenoughtohelpphysicianstobeinvolvedastheadvocatesandprotectorsofpatientsandthevulnera-blegroupsinsociety.
ItwillbepartofmyPresidentialplantohelppushforwardourhealth-relatedhumanrightsagenda.
IseethefutureroleoftheWMAasmoreandmorethatofsocialleaders,inadditiontoourroleastheleadersofthehealthcareteams.
IwouldliketotellyouthreestoriesfromtheNorth,SouthandEasttoillustratethispoint.
IntheEastwecurrentlyhaveanoutbreakofavianflu.
Youwillrememberthatin2003theworldenduredtheSARSepidem-ic,wherehundredsofpatientsdiedinChina,Taiwan,SingaporeandCanada.
AttheTimetheWMAarguedstronglyfortheestablishmentofaglobalsurveillanceandresponsenetworkwhichwouldincludeWMA95andBelgium.
Asgovernmentsfinditdiffi-culttofundhealthcareservices(fromthepatients'ownmoney),rationinghasincreasinglybeenusedtobalanceaccounts.
Thishasplacedgreatpressureonthepatient-physicianrelationshipandphysi-cianautonomy.
InSeptemberBelgiandoc-torsprotestedagainstaproposednewgov-ernmentpolicy,wherebytheMinistryofHealthcouldintervenewheneverthecoun-try'shealthinsurancebudgetgoesintodeficit,effectivelybeingabletoexcludefinancialbenefitsforcertaintypesofdiag-nosisortreatment.
Whatisinfacthappen-ingisthathealthcareisbeingdumpeddowntothelowestcommondenominatorofcost.
Evenmoreimportantly,rationingisslowlydestroyingtheartandprofessionalpracticeofmedicine,thepatient-physicianrelationshipandpatientaccesstoalltreat-mentoptions.
Physiciansareexpectedtoactasadministrativeclerksandaccoun-tantsandtheirprofessionalroledowngrad-edtoselecttheleastexpensive,notthebestavailable,treatmentfortheirpatients.
Thistrendofpoliticalconsiderationsdeny-ingourpatientsthebestpossiblehealthcareservicesisunacceptable.
Wecannotallowpoliticstostandinthewayofeffec-tivehandlingofepidemicsordisastersaffectingbothnationalandinternationallevels.
Ithighlightsthefactthatphysiciansneedtobecomemoreeffectiveinshapingthehealthpolicyenvironment,ratherthanbeshapedbyit.
AsImentionedbefore,thelastWMAPresidencyveryeffectivelyre-affirmedthefundamentalvaluesofmedicine.
DuringmytermasPresident,Iwouldliketoplacethefocusonpatient-centredmedicalcare.
Asphysicianswecandrawencouragementfromthefactthatpatientsstillregardusasthemosttrustedsourceofhealthinforma-tion,butascommunicatorswecandomuchbetter.
Patientsareoverawedwiththeinformationtheycannowsourcefromtheinternet,butrecentreportsshowthatphysi-ciansstilldon'tcommunicateeffectivelyenoughwiththeirpatients.
DuringmytermIhopethatwecanrevisitoutpolicyonpatientinformationandcommunicationanddevelopatrainingmanualonthesub-ject,aswehavedonesosuccessfullyforethicsandhumanrights.
Wemustremem-beralwaysthatourresponsibilitiescomebeforeourrights.
WehavetwothemesinthevisionoftheWorldMedicalAssociation,theseareethicsandaccess.
Whilstwehavebeenintheforefrontonethics,thereisstillalottobedoneonaccess.
Wehavecollectiverespon-sibilitygloballytoensureaccesstobasichealthcareforallcitizensoftheword.
TheMillenniumDevelopmentGoalsarebeingrolledbackandthosethatareneedinghelparenotnecessarilyreceivingit.
Globally,healthcareisbeingunder-fundedandphysi-cianautonomyisinterferedwith,thusunderminingpatients`rights.
Doctorsneedtoworktogetherwithcivilsocietytocreateasaferworldthatcanfundhealthcareappropriately.
IcomefromSouthAfrica,theepicentreoftheHIVandAIDSepidemic.
ThereforeIwouldliketoclosewithanimpassionedpleafortheWMAandallitsmemberstofullytakenontheresponsibilityofcombat-ingHIV.
Thisisstillagrowingdisease,wheretherolephysicianscanandshouldplayhasnotbeenoptimized.
Thisisespe-ciallytrueforourroleinprevention.
Sofaronlyalimitednumberoffullscalepreven-tioneffortshavebeendevelopedwitheffec-tivelytarget"atrisk"populations,theinfra-structureofhealthsystems,societalatti-tudesandindividualbeliefsandmotiva-tions.
Remember,preventioninHIVandAIDSisABCD,thefourlettersofthealphabetcol-lectivelyandinthepropersequence;selec-tiveapplicationofthealphabetishazardoustothehealthofthepeople.
Weneedtoensurethatourdoctorsaretrainedappropriatelytofulfiltherolethattheyplayasleadersandhealers.
Medicalschoolstrainthemtobegreathealers;weneedtofindawaytoappropriatelytrainthemtobegreatleaderstoo.
Weneedapro-grammetoassistNationalMedicalAssociationstogetdoctorstobegoodlead-ersaswell.
Iwilldedicatemyyearsaspres-identtorealisethisobjectiveasafollow-ontocaringphysicians,sothatwecanemulatethosecaringphysiciansandtrulyputourpatientsfirst.
Therearethreethingstoremember:1.
Healthispoliticalevenfordoctorsbutwewillbenon-partisanandengageothers,asopposedtoconfrontingthem.
2.
Healthisafoundationforpeacenotabridge,foraswesawintheaftermathofKatrina,bridgesweresweptawaybutthefoundationsremained.
3.
AquotefromNelsonMandela:"Afterclimbingagreathill,onefindsthattherearemanymorehillstoclimb.
"HavingseenthehillsandmountainsofChile,IwonderifMr.
MandelaeverlivedinChile!
Iwouldliketoendbythankingourhosts,theChileanMedicalAssociationfortheirunforgettablewarmthandhospitalitydur-ingthisAssembly.
WeareinvitingyoualltoourAssemblyinSouthAfricanextyearwherewewilltrytoemulatethem.
(WeareparticularlyindebtedtoDr.
Appleyardforhisbackgroundnotesonthismeeting.
Ed.
)The171thCouncilmeetingtookplaceinSantiago,Chileon14thOctober2005.
ThemeetingwasopenedbytheChairman,Dr.
BlacharwhocalledontheSecretaryGeneraltogivehisreport.
SecretaryGeneral'sReportDr.
OtmarKloiberthankedthePresident,Dr.
YankCoble,forhisdedicationandforthe'addedvalue'hehadgiventotheAsso-ciationthroughthe"CaringPhysiciansoftheWorld"initiative.
Theresultingbookprovidesinsightintohowourphysician171thWMACouncilSessionWMA96colleaguesthroughouttheworldservetheirpatientsunderconditionsthatareoftenhardtoaccept.
Theinitiativehadalsosupportedconferencesindifferentpartsoftheworld.
Dr.
KloiberalsothankedallNMAsfortheirresponsetothedisastercausedbytheTsunamiandmentionedthatmoneywasstillbeingcollected.
Heexpressedhisgrat-itudetospecificNMAsfortheirsupport,inparticularforthestafftimeprovidedbytheAMA,inparticulartoSharonOstrowskiandRobinMenes,totheBMA,whichthroughDr.
VivienneNathansonprovidedsupportforWorkGroups,theCanadianMedicalAssociationandDr.
BillThouldfortheBusinessDevelopmentGroup,theGermanMedicalAssociationespeciallyforDr.
Parsa-Parsi'ssecondment,MsLeahWapnerandtheIsraeliMedicalAsso-ciation,alsototheNorwegianMedicalAssociationfortheonlinecourses.
TurningtorestructuringofWMAOfficeTeam,hereportedthatsincethelastmeetingofCouncilMs.
EmmaViaud,amemberofStaff,hadlefttheoffice.
Dr.
Parsihadbeensecondedtotheofficeforthreemonthsandhad,amongotheritems,workedonthedevelopmentoftheTBCourse,OutreachtoArabCountries,andontheRegionalOfficeforAfricainSAMA.
ThePrisonMedicalCoursehadnowbeentranslatedintoSpanishandisavailableonaCD-Rom.
Dr.
KloiberappealedtoallNMAstoassisttheOfficeinFerneyVoltairebymakingavailablesecondmentsforoneoftheirstafftoworkattheWMAforthreemonthsuntilanothermemberofstaffhasbeenemployedItwasfeltthatthiscouldprovideavaluableeducationalopportunityforNMAs'juniormedicalstaff.
Dr.
KloiberthankedJohnsonandJohnsonfortheircontinuingsupportoftheEthicsUnitandtheproductionoftheEthicsManualandtotheSouthAfrican,AustralianandNorwegianMA'sfortheirworkontheTBproject.
FollowingthesuccessfulcompletionoftheimplementationoftheIstanbulProjectinfivenationswiththeICRT,theworkwillbeextendedtoothercountriesthroughafur-thergrantfromtheEuropeanCommission.
Dr.
KloiberreportedthattheFDIhadnowjoinedtheWorldHealthProfessionsAlli-ance.
AtaverysuccessfulWHPAReceptiononPatientSafetyheldatthesametimeastheWorldHealthAssembly.
SirLiamDonaldson,ChairmanoftheWorldAllianceforPatientSafety,gavethekeynoteaddress.
Ajointseminarwillbeheldnextyearonthreetopics,theReportingofMedicalErrors,CounterfeitMedicinesandonHumanResourcesforHealth.
Turningtofinanceandorganisation,Dr.
KloibertoldCouncilthathisfirstpriorityfollowinghisappointmentwastoensuresoundfinancialgovernance.
InthishehadhadgreatsupportfromMrAdiHllmayrandDr.
KarstenVilmar,theTreasurerEmeritus.
Hehadhadtoapplythebrakestogiveanemergencystoptoexpenditure.
StatingthathismainconcernwastoknowhowmuchoftheWMAcouldbeusedforadvocacyhecommentedthattheWMAhadestablishedahighreputationinternationallyanditsopinionwasincreasinglybeingsoughtforitsprofessionalexpertise.
ConcerningForcedSterilizations,sincethelastCouncilmeetingDr.
KloiberhadbeenincorrespondencewiththeSlovakMedicalAssociationaboutallegationsthatsomePhysiciansinSlovakiahadbeeninvolvedinforcedsterilisations(anillegalpracticeinthatcountry).
TheSlovakMedicalAsso-ciationhadinvestigatedtheseallegationswiththeSlovakianGovernment.
TheBoardoftheSlovakianMedicalAssociationhadwritten,statingthattheallegationscouldnotbeconfirmedandthatnoneofthemem-bersoftheSlovakianMedicalAssociationhadbeeninvolved.
Dr.
KloiberreportedthatsincethelastCouncilSessionhehadattendedmeetingsoftheAMA,BMA,NorwegianMAandCubanMedicalAssociation.
Hevaluedthesepersonalcontactsandbyparticipatinginthemeetingshadagreaterunderstandingoflocalissues.
FurthervisitstootherNMAswillbeundertakennextyear.
DuesTheRevisionoftheDuessystemasproposedbytheTreasureEmerituswasconsidered.
Dr.
Plested(AMA)askedifthefullimplica-tionsoftheproposedchangeshadbeenexploredandwhethersomeNMAswouldusethisscheduleasanopportunitytoreducetheirdues.
Dr.
Kloiberrepliedthatheantici-patedthatthechangeswouldbecostneutral.
TheNMA'sfrompoorernationswouldbeabletoreceivemorevotesinproportiontotheirsubscriptionsandbecomemoreinvolvedintheactivitiesoftheWMA.
Thelowercostwouldencouragenonmembersfrompoorernationstojoin.
HeemphasisedthattherewouldbenochangeintheduespaidbythelargerandricherNMA's,whoprovide85%oftheWMAsduesrevenue.
AfterDr.
Johnson(BMA)agreedthattherecommendationshadtobetakenasa'pack-age',therevisedduessystemwasAGREED.
SponsorshipDr.
Plested(AMA)proposedthatthespeci-ficationfornewSponsorshipprojectsshouldbereassessedtoensurerobustprojectionsforanticipatedIncomeandExpenditure.
Hemovedamotion,secondedbyDr.
Nelson(USA),'thattheSecretaryGeneralworkwithintheexistingguidelinestomaximisenon-duesincome".
ThiswasAGREED.
MedicalEthicsCommitteeReportThiswaspresentedbytheChairman,Dr.
Bagenholm.
MinorRevisionsofDeclarationsetc.
TheDeclarationofLisbon,asrevised,wasapproved.
ItwasagreedthataworkgroupbeconvenedbytheAMAwiththeBMAtointegrateNMAcommentsonthe'StatementofEthicalIssuesconcerningpatientswithMentalIllness',whichwasre-classifiedasrequiringmajorrevision.
MajorRevisionsofDeclarationsetc.
ItwasresolvedthatalltheDocumentsclas-sifiedasrequiringmajorrevisionsbereferredtoNMA'sforcomment.
ConcerningthePolicyReviewoftheDeclarationsofGeneva,ofTokyo,andtheRegulationsinTimesofArmedConflict,Dr.
Nathansongaveanoralreportonherpro-WMA97posalstoamendthesestatements.
ItwasAGREEDthattheproposalsoftheBMAsconvenedWorkGroupbecirculatedtoNMA's.
SponsorshipGuidelinesDr.
BagenholmreportedonthediscussionwithinhercommitteeontheprincipleofacceptingsponsorshipItwasAGREEDthatCouncilestablishaWorkingGroupoftheChairsofEthicsandofFinanceandPlanningCommittees,toreviewtheWMA'sCorporaterelationshipGuidelines(seepage86forfulleraccountofthediscussion).
Socio-MedicalAffairsCommitteeReportDr.
Haddadinpresentinghisreport,intro-ducedforthefirsttimeaConsentCalendarfortheRecommendationsofhisCommittee.
ThisprocedureinvolvesthepresentationofalltheRecommendationsfromtheCommitteetogetherasonerecommenda-tion,withtheoptionthatanymemberofCouncilcouldrequestthewithdrawalofanyspecificrecommendation,forfurtherdebate.
Thereportwasforthefirsttimepresentedasaconsentcalendar,whichmeantthatallrecommendationsthatwerenotchallenged(extracted)werethenvotedforenblocandapproved.
Dr.
Plestedsuggestedtheextractionofpara2.
2.
1,theProposedStatementonReducingtheGlobalimpactofAlcohol.
ThisenabledhimtospeakinfavourofthedocumentemphasisingthepointmadewithinitofthenecessityforaStrategicFrameworksimilartotheoneonTobacco,followingthisthestatementwasagreedunanimously(theAlcoholStatementwillappearinthenextissueofWMJ).
SkillsDrainTheBMAhadpreparedtwobackgroundpapersontheHealthcareSkillsDrainfromDevelopingCountries.
Thesewillbedistrib-utedtoNMA'sforinformation.
FinanceandPlanningCommitteeDr.
JohnNelsonpresentedhisreportofthemeetingofthecommittee.
Alltherecom-mendationswereadoptedwithoutfurtherdebateincludingtherevisedduesstructure.
(seealsoDuesabove)OtherBusinessRecommendationsonBusinessDevelop-mentandonNon-duesincomewereagreed(seeabove!
).
DisasterPlanningItwasAGREEDthataWorkGroupbeestablishedtoconsiderthepreventivemea-suresandcontingenciesnecessaryforDisasterPlanningincludingthepossibleAsianFlupandemic.
TheCanadian,SouthAfrican,GermanandAmericanMA'swillcontributetothis.
PreventingChronicDiseasesDr.
Appleyard(IPP)referredtohisreporttoCouncilinMayconcerningtheWHOinitia-tiveonPreventingChronicDiseasesandstressedtheimportanceofthemajorfinan-cialburdenthiswouldplaceondevelopingcountries.
WHOwaslaunchingtheinitia-tiveattheendofOctoberanditwouldbeappropriatefortheWMAtoidentifyitselfwiththisimportantpreventiveventure.
InviewofthetimeconstraintshesuggestedaspecialCouncilResolution:TheWMA(Council)welcomestheWHOReporton"PreventingChronicDiseases,avitalinvestment,andrecom-mendsthatallNMA'sworkwithhealthprofessionalorganisations,interestedstakeholdersandtheirGovernments,topreventandrelievetheincreasingburdenofchronicdisease.
ThiswasformallyproposedbyDr.
HaddadandsecondedbyDr.
Wu.
Dr.
Kloiberraisedconcernsaboutthefinan-cialimpactsayingthathehadnocapacitytoattendthelaunchlaterinthemonth.
AfterfurtherdebatetowhichDr.
Appleyardreplied,readingoutfortranslationpurposesabriefbackgroundpaperhehadprepared,theCouncilResolutionwasAGREEDnemcon,withthecaveatthattherewouldbenoadditionalcostincurred.
(fullWHOreportisaccessibleatwww.
who.
int/chp/chronic_disease_report/overview_en.
pdf)ExecutiveCommitteeDr.
JohnNelsonraisedaquestionaboutthecompositionoftheExecutiveCommittee,expressingconcernattheexclusionofthethreePresidentsasnon-votingmembers.
PresidentswereelectedfromtheGeneralAssemblyrepresentingalltheNMAs,notjustthoselargerNMA'swhohad'bought'seatsontheCouncilwiththeirlargerdeclaredmembership.
Dr.
KloibersaidthathewasboundbythelastdecisionofCouncilthatonlythevotingmembersofCouncilwouldbeincludedontheexecutive.
ThesehadbeenspecifiedastheChairofCouncil,DeputyChair,andtheChairofthethreeCommittees.
TheExecutivecommitteehadalreadydecidedtorevisittheissueagain.
TheWorldMedicalAssociationrecog-nizesthepotentialglobalmorbidityandmortalityasaresultoftheH5N1strainofavianflu.
Thispossibilityincreaseswitheverypassingdayasmorecountriesfindinfectedbirdsintheirterritories.
TheWMAwillworkwithmemberNMAs,theWHOandotherstakeholderstotracktheprogressofthediseaseandproposethenecessarymeasurestominimizeitsimpactontheglobalhumanpopulation.
TheWMAalsourgesgovernmentstoengagewithNMAstoprepareforthepos-sibilityofapandemic.
TheWorldMedicalAssociationResolutiononAvianInfluenzaAdoptedbytheWMAGeneralAssembly,Santiago2005WMA98Preamble1.
Inrecentyears,thefieldofgeneticshasundergonerapidchangeanddevelopment.
Theareasofgenetherapyandgeneticengineeringandthedevelopmentofnewtechnologyhavepresentedpossibilitiesinconceivableonlydecadesago.
2.
TheHumanGenomeProjectopenednewspheresofresearch.
Itsapplicationsalsoprovedusefultoclinicalcarebyallowingphysicianstoutilizeknowledgeofthehumangenomeinordertodiagnosefuturedisease,aswellastoindividualizedrugtherapy(pharmacogenomics).
3.
Becauseofthis,geneticshasbecomeanintegralpartofprimarycaremedicine.
Whereasatonetime,medicalgeneticswasdevotedtothestudyofrelativelyraregeneticdisorders,theHumanGenomeProjecthasestablishedageneticcontribu-tiontoavarietyofcommondiseases.
Itisthereforeincumbentuponallphysicianstohaveaworkingknowledgeofthefield.
4.
Geneticsisanareaofmedicinewithenor-mousmedical,social,ethicalandlegalimplications.
TheWMAhasdevelopedthisstatementinordertoaddresssomeoftheseconcernsandprovideguidancetophysicians.
Theseguidelinesshouldbeupdatedinaccordancewithdevelopmentsinthefieldofgenetics.
MajorIssues:GeneticTesting5.
Theidentificationofdisease-relatedgeneshasledtoanincreaseinthenumberofavailablegeneticteststhatdetectdiseaseoranindividual'sriskofdisease.
Asthenumberandtypesofsuchtestsandthediseasestheydetectincreases,thereisconcernaboutthereliabilityandlimita-tionsofsuchtests,aswellastheimplica-tionsoftestinganddisclosure.
Theabilityofphysicianstointerprettestresultsandcounseltheirpatientshasalsobeenchal-lengedbytheproliferationofknowledge.
6.
Genetictestingmaybeundergonepriortomarriageorchildbearingtodetectthepresenceofcarriergenesthatmightaffectthehealthoffutureoffspring.
Physiciansshouldactivelyinformthosefrompopula-tionswithhighincidenceofcertaingenet-icdiseasesaboutthepossibilityofpre-maritalandpre-pregnancytesting,andgeneticcounselingshouldbemadeavail-abletothoseindividualsorcoupleswhoareconsideringsuchtesting.
7.
Geneticcounselingandtestingduringpregnancyshouldbeofferedasanoption.
Incaseswherenomedicalinterventionispossiblefollowingdiagnosis,thisshouldbeexplainedtothecouplepriortotheirdecisiontotest.
8.
Inrecentyears,withtheadventofIVF,genetictestinghasbeenextendedtopre-implantationgeneticdiagnosisofembryos(PGD).
Thiscanbeausefultoolincaseswhereacouplehasahighchanceofcon-ceivingachildwithgeneticdisease.
9.
Sincethepurposeofmedicineistotreat,incaseswherenosicknessordisabilityisinvolvedgeneticscreeningshouldnotbeemployedasameansofproducingchil-drenwithpre-determinedcharacteristics.
Forexample,geneticscreeningshouldnotbeusedtoenablesexselectionunlessthereisagender-basedillnessinvolved.
Similarly,physiciansshouldnotcounte-nancetheuseofsuchscreeningtopro-motenon-healthrelatedpersonalattribut-es.
10.
Genetictestingshouldbedoneonlywithinformedconsentoftheindividualorhis/herlegalguardian.
Genetictestingforpredispositiontodiseaseshouldbeper-formedonlyonconsentingadults,unlessthereistreatmentavailableforthecondi-tionandthetestresultswouldfacilitateearlierinstigationofthistreatment.
11.
Validconsenttogenetictestingshouldincludethefollowingfactors:a.
Thelimitationsofgenetictesting,includingthefactthatthepresenceofaspecificgenemaydenotepredisposi-tiontodiseaseratherthanthediseaseitselfanddoesnotdefinitivelypredictthelikelihoodofdevelopingacertaindisease,particularlyinmulti-factorialdisorders.
b.
Thefactthatadiseasemaymanifestitselfinoneofseveralformsandinvaryingdegreesc.
Informationaboutthenatureandpre-dictabilityofinformationreceivedfromthetests.
d.
Thebenefitsoftestingincludingthereliefofuncertaintyandtheabilitytomakeinformedchoices,includingthepossibleneedtoincreaseorreducereg-ularscreeningsandcheckups,andtoimplementriskreductionmeasurese.
Theimplicationsofapositiveresultandtheprevention,screeningand/ortreatmentpossibilities.
f.
Thepossibleimplicationsforthefami-lymembersofthepatientinvolved.
12.
Inthecaseofapositivetestresultthatmayhaveimplicationsforthirdpartiessuchascloserelatives,theindividualtest-edshouldbeencouragedtodiscusstheresultsofthetestwithsuchthirdparties.
Incaseswherenotdisclosingtheresultsinvolvesadirectandimminentthreattothelifeorhealthofanindividual,thephysicianmayrevealtheresultstosuchthirdparties,butshouldusuallydiscussthiswiththepatientfirst.
Ifthephysicianhasaccesstoanethicscommittee,itisTheWorldMedicalAssociationStatementonGeneticsandMedicineAdoptedbytheWMAGeneralAssembly,Santiago2005WMA99preferabletoconsultsuchacommitteepriortorevealingresultstothirdparties.
GeneticCounseling13.
Geneticcounselingisgenerallyofferedpriortomarriageorconception,inordertopredictthelikelihoodofconceivinganaffectedchild,duringpregnancy,inordertodeterminetheconditionofthefetus,ortoanadult,inordertodeterminesuscepti-bilitytoacertaindisease.
14.
Individualsathigherriskforconceivingachildwithaspecificdiseaseshouldbeofferedgeneticcounselingpriortocon-ceptionorduringpregnancy.
Inaddition,adultsathigherriskforvariousdiseasessuchascancer,mentalillnessorneuro-degenerativediseasesinwhichtheriskcanbetestedfor,shouldbemadeawareoftheavailabilityofgeneticcounseling.
15.
Becauseofthescientificcomplexityinvolvedingenetictestingaswellasthepracticalandemotionalimplicationsoftheresults,theWMAseesgreatimpor-tanceineducatingandtrainingmedicalstudentsandphysiciansingeneticcoun-seling,particularlycounselingrelatedtopre-symptomaticdiagnosisofdisease.
Independentgeneticcounselorsalsohaveanimportantroletoplay.
TheWMAacknowledgesthattherecanbeverycom-plexsituationsrequiringtheinvolvementofmedicalgeneticsspecialists.
16.
Inallcaseswheregeneticcounselingisoffered,itshouldbenon-directiveandprotecttheindividual'srightnottobetest-ed.
17.
Incasesofcounselingpriortoorduringpregnancy,theprospectiveparentsshouldbegiveninformationtoprovidethebasisforaninformeddecisionregardingchild-bearing,butshouldnotbeinfluencedbythephysicians'personalviewsinthismat-terandphysiciansshouldbecarefulnottosubstitutetheirownmoraljudgmentforthatoftheprospectiveparents.
Incaseswhereaphysicianismorallyopposedtocontraceptionorabortion,he/shemaychoosenottoprovidetheseservicesbutshouldalertprospectiveparentsthatapotentialgeneticproblemexistsandmakenoteoftheoptionofcontraceptionorabortionaswellastreatmentalternatives,relevantgenetictests,andtheavailabili-tyofgeneticcounseling.
Confidentialityofresults18.
Likeallmedicalrecords,theresultsofgenetictestingshouldbekeptstrictlycon-fidential,andshouldnotberevealedtooutsidepartieswithouttheconsentoftheindividualtested.
Thirdpartiestowhomresultsmayincertaincircumstancesbereleasedareidentifiedinparagraph12.
19.
Physiciansshouldsupportthepassageoflawsguaranteeingthatnoindividualshallbediscriminatedagainstonthebasisofgeneticmakeupinthefieldsofhumanrights,employmentandinsurance.
Genetherapyandgeneticresearch20.
Genetherapyrepresentsacombinationoftechniquesusedtocorrectdefectivegenesthatcausedisease,especiallyinthefieldsofoncology,hematologyandimmunedisorders.
Genetherapyisnotyetanactivecurrenttherapybutisstillinastageofclinicalinvestigation.
However,withthecontinueddevelop-mentofthisfield,itshouldproceedaccordingtothefollowingguidelines:a.
Genetherapyperformedinaresearchcontextshouldconformtotherequire-mentsoftheDeclarationofHelsinkiwhiletherapyperformedinatreatmentcontextshouldconformtostandardsofmedicalpracticeandprofessionalresponsibility.
b.
Informedconsentshouldalwaysbeobtainedfromthepatientundergoingthetherapy.
Thisinformedconsentshouldincludedisclosureoftherisksofgenetherapy,includingthefactthatthepatientmayhavetoundergomultipleroundsofgenetherapy,theriskofanimmuneresponse,andthepotentialproblemsarisingfromtheuseofviralvectors.
c.
Genetherapyshouldonlybeundertak-enafteracarefulanalysisoftherisksandbenefitsinvolvedandanevaluationoftheperceivedeffectivenessofthetherapy,ascomparedtotherisks,sideeffects,availabilityandeffectivenessofothertreatments.
21.
Itiscurrentlypossibletoundertakescreeningofanembryoinordertopro-videstemcellorothertherapiesforanexistingsiblingwithageneticdisorder.
Thismaybeconsideredacceptablemed-icalpracticewherenoevidenceexiststhattheembryoisbeingcreatedexclusivelyforthispurpose.
22.
Geneticdiscoveriesshouldbesharedasmuchaspossiblebetweencountries,soastobenefithumankindandreduceduplica-tionofresearchandtheriskinherentinresearchinthisarea.
23.
Inthecaseofgeneticresearchperformedonlarge,definedpopulationgroups,effortsshouldbemadetoavoidpotentialstigmatization.
Cloning24.
Recentdevelopmentsinsciencehaveledtothecloningofamammalandraisethepossibilityofsuchcloningtechniquesbeingusedinhumans.
25.
Cloningincludesboththerapeuticclon-ing,namelythecloningofindividualstemcellsinordertoproduceahealthycopyofadiseasedtissueororganfortransplant,andreproductivecloning,namelythecloningofanexistingmammaltoproduceaduplicateofsuchmammal.
TheWMAcurrentlyopposesreproductivecloning,andinmanycountriesitisconsideredtoposemoreofanethicalproblemthanther-apeuticcloning.
26.
Physiciansshouldactinaccordancewiththecodesofmedicalethicsintheircoun-triesregardingtheuseofcloningandbemindfulofthelawgoverningthisactivity.
WMA100Introduction1.
Theprescriptionofadrugrepresentstheculminationofacarefuldelibera-tiveprocessbetweenphysicianandpatientaimedattheprevention,amelio-rationorcureofadiseaseorproblem.
Thisdeliberativeprocessrequiresthatthephysicianevaluateavarietyofsci-entificandotherdataincludingcostsandmakeanindividualizedchoiceoftherapyforthepatient.
Sometimes,however,apharmacistisrequiredtosubstituteadifferentdrugfortheoneprescribedbythephysician.
TheWorldMedicalAssociationhasseriouscon-cernsaboutthispractice.
2.
Drugsubstitutioncantaketwoforms:genericsubstitutionandtherapeuticsubstitution.
3.
Ingenericsubstitution,agenericdrugissubstitutedforabrandnamedrug.
However,bothdrugshavethesameactivechemicalingredient,samedosagestrength,andsamedosageform.
4.
Therapeuticsubstitutionoccurswhenapharmacistsubstitutesachemicallydif-ferentdrugforthedrugthatthephysi-cianprescribed.
Thedrugsubstitutedbythepharmacistbelongstothesamepharmacologicclassand/ortothesametherapeuticclass.
Howeversincethetwodrugshavedifferentchemicalstructures,adverseoutcomesforthepatientcanoccur.
5.
Therespectiverolesofphysiciansandpharmacistsinservingthepatient'sneedforoptimaldrugtherapyareout-linedintheWMAStatementontheWorkingRelationshipbetweenPhysiciansandPharmacistsinMedicinalTherapy.
6.
Thephysicianshouldbeassuredbynationalregulatoryauthoritiesofthebioequivalenceandthechemicalandtherapeuticequivalenceofprescriptiondrugproductsfrombothmultipleandsinglesources.
Qualityassurancepro-ceduresshouldbeinplacetoensuretheirlot-to-lotbioequivalenceandtheirchemicalandtherapeuticequivalence.
7.
Manyconsiderationsshouldbeaddressedbeforeprescribingthedrugofchoiceforaparticularindicationinanygivenpatient.
Drugtherapyshouldbeindividualizedbasedonacompleteclinicalpatienthistory,currentphysicalfindings,allrelevantlaboratorydata,andpsychosocialfactors.
Oncetheseprimaryconsiderationsaremet,thephysicianshouldthenconsidercom-parativecostsofsimilardrugproductsavailabletobestservethepatient'sneeds.
Thephysicianshouldselectthetypeandquantityofdrugproductthatheorsheconsiderstobeinthebestmedicalandfinancialinterestofthepatient.
8.
Oncethepatientgiveshisorhercon-senttothedrugselected,thatdrugshouldnotbechangedwithoutthecon-sentofthepatientandhisorherphysi-cian.
Failuretofollowthisprinciplecanresultinharmtopatients.
Onbehalfofpatientsandphysiciansalike,NationalMedicalAssociationsshoulddoeverythingpossibletoensuretheimplementationofthefollowingrec-ommendations:Recommendations9.
Physiciansshouldbecomefamiliarwithspecificlawsand/orregulationsgoverningdrugsubstitutionwheretheypractise.
10.
Pharmacistsshouldberequiredtodis-pensetheexactchemical,dose,anddosageformprescribedbythephysi-cian.
Oncemedicationhasbeenpre-scribedandbegun,nodrugsubstitutionshouldbemadewithouttheprescribingphysician'spermission.
11.
Ifsubstitutionofadrugproductoccurs,thephysicianshouldcarefullymonitorandadjustthedosetoensuretherapeu-ticequivalenceofthedrugproducts.
12.
Ifdrugsubstitutionleadstoseriousadversedrugreactionortherapeuticfailure,thephysicianshoulddocumentthisfindingandreportittoappropriatedrugregulatoryauthorities.
13.
NationalMedicalAssociationsshouldregularlymonitordrugsubstitutionissuesandkeeptheirmembersadvisedondevelopmentsthathavespecialrele-vanceforpatientcare.
Collectionandevaluationofinformationreportsonsignificantdevelopmentsinthisareaisencouraged.
14.
Appropriatedrugregulatorybodiesshouldevaluateandensurethebioe-quivalenceandthechemicalandthera-peuticequivalenceofallsimilardrugproducts,whethergenericorbrand-name,inordertoensuresafeandeffec-tivetreatment.
15.
NationalMedicalAssociationsshouldopposeanyactiontorestrictthefree-domandtheresponsibilityofthephysi-ciantoprescribeinthebestmedicalandfinancialinterestofthepatient.
16.
NationalMedicalAssociationsshouldurgenationalregulatoryauthoritiestodeclaretherapeuticsubstitutionillegal,unlesssuchsubstitutionhastheimme-diatepriorconsentoftheprescribingphysician.
TheWorldMedicalAssociationStatementonDrugSubstitutionAdoptedbytheWMAGeneralAssembly,Santiago2005WMA1011.
Acultureoflitigationisgrowingaroundtheworldthatisadverselyaffectingthepracticeofmedicineanderodingtheavailabilityandqualityofhealthcareservices.
SomeNationalMedicalAssociationsreportamedicalliabilitycrisiswherebythelawsuitcultureisincreasinghealthcarecosts,restrainingaccesstohealthcareservices,andhin-deringeffortstoimprovepatientsafetyandquality.
Inothercountries,medicalliabilityclaimsarelessrampant,butNationalMedicalAssociationsinthosecountriesshouldbealerttotheissuesandcircumstancesthatcouldresultinanincreaseinthefrequencyandseveri-tyofmedicalliabilityclaimsbroughtagainstphysicians.
2.
Medicalliabilityclaimshavegreatlyincreasedhealthcarecosts,divertingscarcehealthcareresourcestothelegalsystemandawayfromdirectpatientcare,research,andphysiciantraining.
Thelawsuitculturehasalsoblurredthedistinctionbetweennegligenceandunavoidableadverseoutcomes,oftenresultinginarandomdeterminationofthestandardofcare.
Thishasledtothebroadperceptionthatanyonecansueforalmostanything,bettingonachancetowinabigaward.
Suchaculturebreedscynicismanddistrustinboththemedicalandlegalsystemswithdamag-ingconsequencestothepatient-physi-cianrelationship.
3.
InadoptingthisStatement,theWorldMedicalAssociationmakesanurgentcalltoallNationalMedicalAssociationstodemandtheestablish-mentofareliablesystemofmedicaljusticeintheirrespectivecountries.
Legalsystemsshouldensurethatpatientsareprotectedagainstharmfulpractices,physiciansareprotectedagainstunmeritoriouslawsuits,and"standardofcare"determinationsareconsistentandreliable,sothatallpar-tiesknowwheretheystand.
4.
InthisStatementtheWorldMedicalAssociationwishestoinformNationalMedicalAssociationsofsomeofthefactsandissuesrelatedtomedicallia-bilityclaims.
Thelawsandlegalsys-temsineachcountry,aswellasthesocialtraditionsandtheeconomiccon-ditionsofthecountry,willaffecttherel-evanceofsomeportionsofthisStatementtoeachNationalMedicalAssociationbutdonotdetractfromthefundamentalimportanceofsuchaStatement.
5.
Anincreaseinthefrequencyandsever-ityofmedicalliabilityclaimsmayresult,inpart,fromoneormoreofthefollowingcircumstances:a.
Increasesinmedicalknowledgeandmedicaltechnologythathaveenabledphysicianstoaccomplishmedicalfeatsthatwerenotpossibleinthepast,butthatinvolveconsider-ablerisksinmanyinstances.
b.
Pressuresonphysiciansbyprivatemanagedcareorganizationsorgov-ernment-managedhealthcaresys-temstolimitthecostsofmedicalcare.
c.
Confusingtherighttoaccesstohealthcare,whichisattainable,withtherighttoachieveandmaintainhealth,whichcannotbeguaranteed.
d.
Theroleofthemediainfosteringmistrustofphysiciansbyquestioningtheirability,knowledge,behaviour,andmanagementofpatients,andbypromptingpatientstosubmitcom-plaintsagainstphysicians.
6.
Adistinctionmustbemadebetweenharmcausedbymedicalnegligenceandanuntowardresultoccurringinthecourseofmedicalcareandtreatmentthatisnotthefaultofthephysician.
a.
Injurycausedbynegligenceisthedirectresultofthephysician'sfailuretoconformtothestandardofcarefortreatmentofthepatient'scondition,orthephysician'slackofskillinpro-vidingcaretothepatient.
b.
Anuntowardresultisaninjuryoccurringinthecourseofmedicaltreatmentthatwasnottheresultofanylackofskillorknowledgeonthepartofthetreatingphysician,andforwhichthephysicianshouldnotbearanyliability.
7.
Compensationforpatientssufferingamedicalinjuryshouldbedetermineddifferentlyformedicalliabilityclaimsthanfortheuntowardresultsthatoccurduringmedicalcareandtreatment,unlessthereisanalternativesysteminplacesuchasano-faultsystemoralter-nateresolutionsystem.
a.
Whereanuntowardresultoccurswithoutfaultonthepartofthephysi-cian,eachcountrymustdetermineifthepatientshouldbecompensatedfortheinjuriessuffered,andifso,thesourcefromwhichthefundswillbepaid.
Theeconomicconditionsofthecountrywilldetermineifsuchsoli-darityfundsareavailabletocompen-satethepatientwithoutbeingattheexpenseofthephysician.
b.
ThelawsofeachjurisdictionshouldprovidetheproceduresfordecidingTheWorldMedicalAssociationStatementonMedicalLiabilityReformAdoptedbytheWMAGeneralAssembly,Santiago2005WMA102liabilityformedicalliabilityclaimsandfordeterminingtheamountofcompensationowedtothepatientinthosecaseswherenegligenceisproven.
8.
NationalMedicalAssociationsshouldconsidersomeorallofthefollowingactivitiesinanefforttoprovidefairandequitabletreatmentforbothphysiciansandpatients:a.
Establishpubliceducationprogramsontherisksinherentinsomeofthenewadvancesintreatmentmodali-tiesandsurgery,andprofessionaleducationprogramsontheneedforobtainingthepatient'sinformedcon-senttosuchtreatmentandsurgery.
b.
Implementpublicadvocacypro-gramstodemonstratetheproblemsinmedicineandhealthcaredeliveryresultingfromstrictcostcontain-mentlimitations.
c.
Enhancethelevelandqualityofmedicaleducationforallphysicians,includingimprovedclinicaltrainingexperiences.
d.
Developandparticipateinprogramsforphysicianstoimprovethequalityofmedicalcareandtreatment.
e.
Developappropriatepolicypositionsonremedialtrainingforphysiciansfoundtobedeficientinknowledgeorskills,includingpolicypositionsonlimitingthephysician'smedicalpracticeuntilthedeficienciesarecorrected.
f.
Informthepublicandgovernmentofthedangersthatvariousmanifesta-tionsofdefensivemedicinemaypose(themultiplicationofmedicalactsor,onthecontrary,theabsten-tionofthephysicians,thedisaffec-tionofyoungphysiciansforcertainhigherriskspecialtiesorthereluc-tancebyphysiciansorhospitalstotreathigher-riskpatients).
g.
Educatethepubliconthepossibleoccurrenceofinjuriesduringmed-icaltreatmentthatarenottheresultofphysiciannegligence,andestab-lishsimpleprocedurestoallowpatientstoreceiveexplanationsinthecaseofadverseeventsandtobeinformedofthestepsthatmustbetakentoobtaincompensation,ifavailable.
h.
Advocateforlegalprotectionforphysicianswhenpatientsareinjuredbyuntowardresultsnotcausedbyanynegligence,andparticipateindecisionsrelatingtotheadvisabilityofprovidingcompensationforpatientsinjuredduringmedicaltreat-mentwithoutanynegligence.
i.
Participateinthedevelopmentofthelawsandproceduresapplicabletomedicalliabilityclaims.
j.
Developactiveoppositiontomerit-lessorfrivolousclaimsandtocon-tingencybillingbylawyers.
k.
Exploreinnovativealternativedis-puteresolutionproceduresforhan-dlingmedicalliabilityclaims,suchasarbitration,ratherthancourtpro-ceedings.
l.
Encourageself-insurancebyphysi-ciansagainstmedicalliabilityclaims,paidbythepractitionersthemselvesorbytheemployerifthephysicianisemployed.
m.
Encouragethedevelopmentofvol-untary,confidential,andlegallypro-tectedsystemsforreportingunto-wardoutcomesormedicalerrorsforthepurposeofanalysisandformak-ingrecommendationsonreducinguntowardoutcomesandimprovingpatientsafetyandhealthcarequality.
n.
Advocateagainsttheincreasingcriminalizationorpenalliabilityofmedicalactsbythecourts.
Dr.
GDumontwasre-electedChairandtheminutesofthemeetinginTokyo2004wereapproved.
Arisingfromtheminutes,Dr.
Kloiber,theSecretaryGeneral,reportedthat,followinglastyear'sresolutioninconnectionwithforcedsterilisationofwomenintheSlovakRepublic,hehadwrittentotheSlovakMedicalAssociation.
TheSlovakMinistryofHealthhadinvestigatedtheallegationwiththeMedicalAssociation.
Theallega-tionswerefoundtohavenofoundation.
TheSlovakMedicalAssociationhadwrit-tentoWMAstatingthatnomemberoftheSMAhadbeeninvolvedinthispracticewhichwasillegalintheSlovakRepublic.
GeneralAssemblyAssociates'Meeting,Santiago2005TheSecretaryGeneral,reportingonthetotalnumbersofAssociateMemberscommentedthathewasreviewingtheroleofAssociateMembersinthefuture,pointingoutthattheInternationalDentalFederation'sassociatemembersplayedamoreproactiverole.
RespondingtoaproposalbyDr.
Mont-gomery,thelongestservingmemberpresentatthemeeting,thatthemeetingbedisband-ed,Dr.
Appleyardopposingthis,saidthattheAssociate'smeetinghadproducedsomehelpfulstatements,citingthetwowhichwereontheagendaasexamples.
Juniordoc-torswerekeentoformagroupwithinWMAWMA103andhereferredtoIFMSAmembersbeingeligibleforfreeassociatemembershipofWMAforthreeyearsaftergraduation.
Dr.
Kloiberconfirmingthis,pointedoutthatres-olutionsoftheAssociates'meetingweresenttotheGeneralAssembly,althoughCounciltendedtoconsiderthemfirst.
AfteranextensivedebateitwasagreedthattheSecretaryGeneralwouldreportbackonhisdeliberation.
Dr.
Montgomeryproposed,secondedbyDr.
Nelson,thatAssemblybusinessbeconsid-erednextontheagenda.
AlthoughthiswasopposedbyDr.
Fransblau,themotionwasadoptedbyalargemajority.
ThemeetingthenelectedDrs.
MontgomeryandSmoakasrepresentativesattheGeneralAssembly.
ThemeetingthenconsideredaresolutiononMedicalAssistanceinAirTravelsubmittedbythelateDr.
Odenbach,presentedonhisbehalfbyDr.
Kloiber.
ThiswassupportedbyDr.
Montgomery.
Dr.
Appleyardfeltthattheissueofliabilityincircumstanceswherehumanitarianhelpwasofferedwasimpor-tantandproposedthatthemotionbereferredtoCouncilinthefirstinstance.
TheproposalwassecondedbyDr.
MontgomeryandtheResolutionwasadopted.
AsecondproposedResolutiononChildSafetyinAirtravel,wasintroducedbyDr.
Kloiber,expressingconcernthatadequatesafetysystemsforbabiesandsmallchil-drenhadnotbeenimplemented.
AftersomediscussiontheResolutionwaspassedunan-imously.
TheauthorofthefollowingnotespentthreemonthsintheWMAOfficethisyearandwritesabouttheexperienceandwhatitoffers.
ThevoiceoftheWorldMedicalAssociationisconsideredastheopinionofmillionsofphysiciansfromeveryregionoftheworld.
Itsfunctionhasalwaysbeentoconstituteafree,openforumforthefrankdiscussionofmattersrelatedtomedicalethics,medicaleducation,andsocio-medicalaffairs.
Withitsdeclarationsandstatementsithascon-tributedsignificantlytonationalandinter-nationaldebates.
ApprovedbyitsGeneralAssembly,WMAdocumentsguidenationalmedicalassociations,healthcare,govern-ments,non-governmentalorganisationsandUnitedNationsagencies.
TheWorldMedicalAssociationhasalso,however,alwaysbeeninvolvedinmanyotheractivitiesbeyondstatementsandreso-lutions.
Anumberofglobalprojectsandprogrammesarecontinuouslyinitiated,supportedorconductedbytheWMA.
Theseactivitiesmightnotbeasvisibleandwellknowntothehealthcarecommunityandthegeneralpublic.
WhoisdoingalltheworkPeoplemightassumethatafewtensofhighlyspecializedstaffmembersworkinexorablyinthehigh-techofficesofalargeWMAheadquarters.
TheWMAmustsurelyworkwithheavyadministrationandstaffbudgetsIntruth,forreasonsofeconomy,andinordertooperatewithinthevicinityofGeneva-basedinternationalorganizationsliketheWHOandotherUNagencies,theInternationalRedCrossandinternationalassociations,theWMASecretariatwastransferredin1975fromNewYorktoitspresentlocationinFerney-Voltaire,FranceclosetoGeneva.
MembershipoftheWorldMedicalAssociationisvoluntaryanditsbudgetisfundedfrommembershipfeesfromnation-almedicalassociations.
Hence,fundsarelimitedandvarysignificantly.
TheWMAhasbeenamarvelinmanagingprojects,programmesanditsmeetingsandassem-blieswithextremelysmallbudgets.
ItsSecretariatoperateswithasmallpermanentstaffonly,butmanagestoaccomplishanimpressiveamountofwork.
TheWMAwouldcertainlybeinterestedtocommititselftoevenmoreprojectsandactivities.
However,moremanpowerwouldbenecessary.
OnewaytoincreasecapacitiesatWMAisitsprogrammeforhealthcareprofessionalstospendthreetosixmonthsattheWMASecretariatinFerney-Voltaire.
Nationalmedicalassocia-tionsmayusethisopportunitytosendastaff-memberforashort-term"training"attheWMASecretariat.
ThereiscertainlynobetterwaytogettoknowtheworkoftheWMAandexperi-encethejobenvironmentofatrulyinterna-tionalorganization.
Itisawin-win-situationFellowsareabletodiveintohandson"workfromtheveryfirstday.
Apartfromsomeroutineworkwhichclearlyhelpstounderstandtheevery-dayworkofaninter-nationalorganization,Fellowshavethechancetotakeonthemanagementofindi-vidualprojects.
Fellowsroutinelyinteractwithseniorhealthcareexpertsfromthevarioushealthcareorganisationsandworkself-responsiblyandindependently.
Forexample,thissummertheWMAstart-edaprojecttodevelopanonlinecourseforphysiciansonmulti-drug-resistanttubercu-Beyondstatementsandresolutions–WorkingattheWMASecretariatinFerney-VoltaireDr.
RaminParsa-Parsi,MD,MPH,GermanMedicalAssociationWMA104losis(MDR-TB).
TheWMAhadprevious-lydevelopedasimilarprogrammeforphysiciansinprisons.
Thistrainingcourseisbeingdevelopedtotrainphysicianstomoreeffectivelydiagnose,preventandtreatMDR-TB.
TheWMAiscollaboratingwiththeSouthAfricanMedicalAssociationanditsFoundationforProfessionalDevelopmentonthisproject.
TheWMAisalsocollaboratingwiththeWHOandseveralnationalmedicalassoci-ationsinordertoproduceastate-of-theartanduniversallyaccessibleproduct.
TheNorwegianMedicalAssociationistrans-formingthematerialintotheonlineformatandtheGermanMedicalAssociationishelpingwithlogisticsupport.
Themanage-mentandthecoordinationoftheentirepro-jectisperformedbyWMAstaff.
Althoughthecoordinationofallstakeholdersandinternationalexpertscanbechallenging,helpingtomakethisprojecthappenisatrulyexcitingandrewardingtask.
ThefinalproductwillbeanimportantcontributiontotheglobalfightagainstMDR-TB.
ForanotherprojecttheWMAcollaborateswiththeInternationalRehabilitationCouncilforTortureVictims(IRCT)onaEuropeanUnionsponsoredproject.
Usingthe"IstanbulProtocol"asamanual,physi-ciansaretrainedineffectiveinvestigationanddocumentationoftortureandothercruel,inhumanordegradingtreatmentorpunishment.
Thetrainingseminarswerecompletedinfivepilotcountries:Morocco,Mexico,Uganda,SriLankaandGeorgia.
WMAexpertsparticipatedincoordinationandevaluationmeetingsandattendedpreparatorymissionsandtrainingsemi-nars.
TheWMAparticularlyfosteredtheidentificationprocesswithnationalmed-icalassociationsanduseditsspecialexper-tiseinmedicalethicsduringseminars.
Also,thecollaborationwithotherorganiza-tions,localauthoritiesandconsultantshasbeenhelpfulandimportantintheprocess.
Thecontinuationoftheprojectwithanewphaseisprojectedtorunoverathree-yearperiodandwillmostprobablystartbyJanuary2006.
Thenewprojectwillincludeaconsolidationofactivitiesinthefivecur-rentprojectcountriesandinitiateactivitiesinfivenewcountries.
Furthermoreitwillsupportcapacity-buildingactivitiesforrehabilitationcentresandstrengthenthecollaborationbetweencentresandlocalhumanrightsorganizations.
TheIRCTandtheWMAhaveaformalpartnershipinthisprojectwithsharedresponsibilities.
Thecollaborationhasbeenextremelygood.
Regularcontactanddiscussionsonkeyissueshelpedensuringacoordinatedandefficientprocess.
ApplicationsarewelcomeBeinginvolvedintheworkofvariousdif-ferentprojects,fellowswillexperiencetheentirespectrumofhealthcareservicesandsystems.
Furthermore,regularcommunica-tionwithrepresentativesofnationalmed-icalassociations,includingnewandfutureWMAmembers,helpsunderstandingthedifferencesandsimilaritiesofphysicianorganizationsworldwide.
AlsohelpingtoprepareCouncilmeetingsandtheAnnualGeneralAssemblyisindeedrewarding.
Inshort:WorkingattheWMASecretariatisauniqueexperience.
NationalMedicalAssociationswhoareinterestedinthefellowshipprogrammemaycontacttheWMASecretariatinFerney-Voltaire.
Interestedpartiesmayalsocontactpreviousfellowsformoredetailedinformation.
Pleasecontact:Dr.
RaminParsa-ParsiPhone:030/400456-366TheWorldMedicalAssociation13,ch.
duLevantCIB-BtimentA01210Ferney-VoltaireFrancePhone:+33450407575Fax:+33450405937e-mail:wma@wma.
netWhilecurrentlythewholeworldseemstoworryabouttheprisonersinGuantánamoBaythoseincarceratedintheotherprisonsofCubaseemtobeforgotten.
Menandwomenaskingfornothingbutfreedom,whoarenotinvolvedinterrorism,waroroppression,arebeingheldasprisonersofconsciencepermanentlyorrepeatedly,somefordecades.
ManyofthemhavenotsurvivedthespecialtreatmentbytheCubangovernmentandotherspossiblywilldie.
WhileformanyofusCubamaybeseenasacheapCaribbeanholidayresort,forthoselivingtheretheparadisemayhavesomedarkspots.
FormorethanfortyyearsCubahasbeenundercommunistdictatorship.
Whathasbeenovercomeinmostofthefor-mercommunistcountriesinEurope,terror,intimidation,oppression,andprosecutionofthosewhowantfreedom,stilllivesinCuba.
The"CubanSpring2003"standsforanaggressive"cleaning-up"campaignwhichthecommunistscarriedoutinCuba:Asfarasitisknowninthefreeworld,75personsweresentencedtolongprisontermsofupto28years.
Thewaytheyaretreatedissim-ilarfortotalitarianregimes.
Methodsincludeimprisonmentfarawayfromtheirfamilies,placmenttogetherwithviolentcriminals,intimidationoffamilymembersandreducedallowancesforvisits.
Leftwithoutsufficientfoodsomelooseweightrapidly,andfoodandmedicinebroughtbyrelativeshasbeentakenaway.
TheWorldMedicalAssociationhasrepeat-edlyrememberedthefateofCubanPhysicians.
Theyareoutstandingcol-FromtheSecretaryGeneral'sdesk"Don'tforgettheothers"WHO105leaguesfightingforthefreedomoftheCubanPeopleandforthefreedomofmed-icineintheircountry.
Whattheycurrentlygetishellonearth.
Sixofthemareknowntous,theyandtheirfamiliesandfriendsdeserveourattentionasexamplesofallthosewhopayahighpriceinthestruggleforfreedom.
Thefollowinginformationhasbeencompiledfromvarioussources:Dr.
OSCARELASBISCET,44yearsold,aspecialistininternalmedicine,isthepres-identoftheunofficialLawtonHumanRightsFoundation.
Hehasbeendetainedmorethantwodozentimes,chargedwith'insulttothesymbolsofthehomeland,''publicdisorder,'and'incitementtocom-mitanoffence'.
Dr.
Biscethasbeenkeptinspecialpunishmentcellsforrefusingtocarryoutdisciplinarymeasures.
BeforeSpring2003whenDr.
Biscetwasarrestedlast,hehadalreadybeeninprisonfor3years.
NowinDecember2005itaddsupto6years.
TodiscouragevisitsbyhisfamilyhewastemporarilyimprisonedinPrisonKilo8intheprovinceofPinardelRio,sharingacellwithtwelveotherprisoners.
Hehasbeensentencedto25yearsinprison.
DR.
MARCELOCANORODRGUEZ,41yearsold,isNationalCoordinatoroftheunofficialCubanIndependentMedicalAssociation,anassociationofmedicalpro-fessionalsaroundtheisland.
FornotrespectingtheprisonrulesforcriminalsDr.
Canohasnotbeenallowedtoseethesunfor10month.
Dr.
Canohasbeensentencedto18yearsinprison.
DR.
JOSLUISGARCAPANEQUE,aged39,isaplasticsurgeonandamemberoftheCubanIndependentMedicalAssociation.
Hehasworkedasajournalist,asdirectoroftheindependentnewsagencyLibertadandmemberoftheindependentJournalists'Society.
Dr.
Paneque'sweighthasdroppedfrom86to48kgandheispresentlyintheinfirmaryof"LasMangas"PrisoninBayamo.
Hishealthcontinuestobecritical.
HiswifeiscurrentlybeingthreatenedwithimminentmobattacksagainsttheirhomeDr.
Panequewassen-tencedto24yearsinprison.
DR.
LUISMILNFERNNDEZ,36yearold,isamemberoftheCubanMedicalAssociation.
InJune2001heandhiswife,LisandraLafitta,alsoadoctor,signedadocumentcalled'Manifiesto2001,'callingamongothermeasuresforrecognitionoffundamentalfreedomsinCuba.
Togetherwithotherhealthprofessionalstheycarriedoutaone-dayhungerstriketocallattentiontothemedicalsituationofdetaineesandotherissues.
Althoughwithoutemotionalormentalproblems,heisnowconfinedwithmentalpatientsinthepsychiatricwardofthePrisonofBoniato,intheprovinceofSantiagodeCuba.
Dr.
MilánFernández,hadbeensentencedto13yearsinprison.
ALFREDOMANUELPULIDOLPEZ,aged45,graduatedin1983inthespecialtyofStomatology,andDentistry.
Hepracticeduntil1998,whenhewasfiredfromhisjobforjoiningtheChristianLiberationMovement.
In2001hejoinedtheunofficialnewsagencyElMayorinCamagüeyforwhichheworkedasjournalist.
IncarceratedintheMaximumSecurityPrisonKilo7hishealthisrapidlydeteriorating.
Heisnotonlysufferingfromseveremigraine,buthasalsoexperiencedseveralhypoglycemicepisodes.
Insteadofprovidingtreatmenthehasbeenthreatenedthathegetsapsychi-atricevaluationtofindoutthesourcesofhisheadaches.
Dr.
PulidoLópezhasbeensentencedto14yearsinprison.
RICARDOENRIQUESILVAGUAL,32,physicianandmemberoftheChristianLiberationMovementlikeDr.
PulidoLópez.
Dr.
SivaGualsufferingfromglau-coma.
Dr.
SilvaGuallhasbeensentencedto10yearsinprison.
Sources:CoalitionofCuban-AmericanWomen/LAIDACARRO.
Joseito76@aol.
com.
Humanrightsfirsthttp://action.
humanrightsfirst.
org/cam-paign/BiscetAmnestyInternationalhttp://web.
amnesty.
org/library/Index/ENGAMR250022005InternationaleGesellschaftfürMenschenrechtehttp://www.
igfm.
deMedicinaCubanahttp://medicinacubana.
blogspot.
com/2005_09_01_medicinacubana_archive.
htmlForfurtherinformationmonitorourweb-site:www.
wma.
netGeneva,Switzerland,9November2005.
"Thankyouformakingthisaremarkableandproductivemeeting.
Theworldhasbeenwatchingandlisteningas,overthesethreedays,thescaleofthechallengeshasemerged.
Theinternationalsolidaritytoconfrontthesethreatsisclear.
Theurgencyofactingnowisfeltbyusall.
Preciserec-ommendationsforactionhaveemerged.
Equally,preciseoffersofhelpandsupporthavebeenputforward,bybothdevelopingandindustrializedcountries.
Iwillnowreviewthecentralpointsthathavecomeoutofthemeeting.
NextIwilloutlineanintegratedprogrammeofactionwhichrespondstotheissuesraised.
1.
MinimizingthethreatatsourcetobothanimalandhumanpopulationsthroughrapidreductionoftheviralburdenofWHOFAO/OIE/WB/WHOMeetingonAvianInfluenzaandHumanPandemicInfluenzaClosingremarksofDr.
LEEJongWook,D.
G.
,WHOWHO106H5N1isessential.
Thisentailstimelynotificationofoutbreaksinbirds,poul-trycullingandvaccinationasindicated,includingbackyard"flocks,andprovi-sionofappropriatecompensationforfarmers.
2.
"Earlywarning"andsurveillancesys-temsforanimalandhumaninfluenzaarecriticaltoeffectiveresponse.
Thecurrentwindowofopportunitytointerveneismeasuredindays.
Transparentandimmediatereportingisessential.
3.
TheintroductionofavianinfectionwithH5N1toothercountriesispredicted,followingthepatternsofmigratorybirds,andasaresultofproductionsys-temsandmarketpractices.
Otherstrainsofavianfluarealsoanongoingandemergingthreatandmustbemonitored.
Strengthenedveterinaryservicesareacrucialaspectofdetectionandresponse.
Opensharingofvirussamplesisessen-tial.
Qualityassuredanimalvaccinesproducedtointernationalstandardsshouldbeusedinhealthypoultrywhenappropriate.
4.
Atpresentmanygovernmentsarenotreadytocopewithoutbreaks,stilllessapandemic.
Preparednessisvitalineverycountry,ineveryRegion.
Integratedcountryplanswillbuildonandstrength-enexistingsystemsandmechanisms.
Theywillbecomprehensive,costed,andevaluated.
Responsemechanismsshouldberehearsedthroughsimulationexercis-es.
Theseplanswillincludeprotectionofvulnerablegroupssuchaschildren,refugeesanddisplacedpopulations.
5.
Resourcesneededtoslowdownorcon-taintheemergenceofapandemicareinsufficient.
Suppliesofantiviraldrugscurrentlydonotmeetpotentialdemand.
Issuesremainofequitableaccesstomedicinesanddeploymentofstockpiles.
6.
Auniversalnon-specificpandemicvac-cinemaybetheultimateprotectivesolu-tionforhumaninfluenza.
Smart"solu-tionsarebeinginvestigated.
Issuesoftechnologytransfer,resolutionoflicens-ingandregulatoryobstacles,sustaineduseofgoodmanufacturingpracticesandpre-qualificationareunderdiscussion.
Predictable,increasedordersforseason-alfluvaccinewillsupportgreatermanu-facturingcapacity,includingindevelop-ingcountries.
7.
Communications.
Therecentseriesofhigh-levelmeetingsonavianinfluenzaandhumanpandemicinfluenzahavesuccessfullycreatedasharedagenda.
Thepublicneedsclear,regular,reliableinformation.
Civilsociety,nongovern-mentalorganizationsandothercommu-nitygroupsmustbeinvolved.
8.
Aricharrayofresourcesispotentiallyavailabletosupportgovernmentandinstitutionalefforts.
Countriesthathavesuccessfullycontrolledoutbreaksofavianinfluenzaarepreparedtohelpoth-ers.
9.
Mechanismsfordonorsupportareinplace.
Thereisbroadcommitmenttominimizetransactioncostsofinterna-tionalsupportthroughalignmentandharmonization.
Internationalsupporttocountryplansshouldsupplementnation-alresources,aswellasexistingdonorresources,andshouldtargetresource-poorcountries.
10.
Investmentsareurgentlyneededatnationallevel–potentiallyreaching1billiondollarsoverthenextthreeyears.
Anadditional35milliondollarsisneed-edimmediatelytosupporthighpriorityactionsbytechnicalagenciesattheglob-alleveloverthenextsixmonths.
The10pointsIhaveoutlinedneeddetailedandconcreteactions.
Thismeetinghasidentifiedaseriesofintegratedactionsthatwillstartstraightaway.
1.
Supportthedevelopmentofintegratednationalplansforavianinfluenzacon-trolandhumanpandemicinfluenzapre-parednessandresponse.
2.
Assistcountriesinaggressivecontrolofavianinfluenzainbirds,anddeepentheunderstandingoftheroleofwildbirdsinvirustransmission.
3.
Nominaterapidresponse"teamsofexpertstosupportepidemiologicalfieldinvestigations.
4.
Strengthencountryandregionalcapacityinsurveillance,laboratorydiagnosis,andalertandresponsesystems.
5.
Expandthenetworkofinfluenzalabora-tories,withregionalcollaborativesys-temsforaccesstoreferencelaboratories.
6.
Establishandintegratemulti-countrynetworksforthecontrolorpreventionofanimaltrans-boundarydiseases,andregionalsupportunitsasestablishedintheGlobalFrameworkfortheProgressiveControlofTrans-boundaryAnimalDiseases.
7.
Expandtheglobalantiviralstockpile,andpreparestandardoperatingpracticesforitsrapiddeploymenttoachieveearlycontainment.
8.
Assesstheneedsandstrengthenveteri-naryinfrastructureinlinewithOIEstan-dards.
9.
Mapoutaglobalstrategyandworkplanforcoordinatingantiviralandinfluenzavaccineresearchanddevelopment,andforincreasingproductioncapacityandequitableaccess.
10.
PutforwardproposalstotheWHOExecutiveBoardatits117thmeetingforimmediatevoluntarycompliancewithrelevantarticlesoftheInternationalHealthRegulations2005.
11.
Finalizedetailedcostingofcountryplansandtheregionalandglobalrequirementstosupportthem,inprepa-rationfortheJanuarypledgingmeetingtobehostedbytheGovernmentofChina.
12.
Finalizeacoordinationframeworkbuildingonexistingmechanismsatthecountrylevel,andatthegloballevel,buildingoninternationalbestpractices.
Thisisachallengingagendawhichwillrequireallourbestefforts.
"WHO107PublichealthexpertshaveconfirmedthatapolioepidemicintencountriesinwestandcentralAfrica–Benin,BurkinaFaso,Cameroon,CentralAfricanRepublic,Chad,Cted'Ivoire,Ghana,Guinea,MaliandTogo–hasbeensuccessfullystopped.
Theepidemichasparalysednearly200childrenforlifesincemid-2003,butnonewcaseshavebeenreportedinthesecountriessinceearlyJune.
Atthesametime,polioeradica-tioneffortsareintensifyinginNigeria,whereextensivediseasetransmissioncon-tinues,aspartofamasspoliocampaignacross28Africancountriesbeginningtoday.
EmergencyeffortstostoptheepidemichadbeenlaunchedundertheauspicesoftheAfricanUnion(AU),andlargelyunderwrit-tenthroughUS$135millioninemergencyfundingfromtheEuropeanCommission(EC),CanadaandSweden.
Thetencoun-tries,whichhadpreviouslybeenpolio-free,participatedinaseriesofmassimmunisationdrivesacross23countries,reachingasmanyas100millionchildrenwithmultipledosesofpoliovaccineoverthelast18months.
Speakingonbehalfofdonors,EuropeanCommissionerforDevelopmentandHumanitarianAid,MrLouisMichel,said:Thereversaloftheseepidemicsisprecise-lywhatECdevelopmentobjectivesareallabout.
SucharapidreturnondevelopmentinvestmentisgoodforAfrica,goodfordonors,andmostimportantly,goodforthechildrenofAfrica.
"Expertscautioned,however,thatongoingdiseasetransmissioninremainingendemicareascontinuestoposeariskofmoreout-breaksacrosstheregion.
Tominimisethisrisk,28Africancountries–includingthetencountrieswhichhavestoppedtheirepi-demics–todaylaunchedthefirstelementofa'maintenance'programmetosustainthisprogress,withanadditionalseriesofsynchronizedimmunisationactivitiestoreachmorethan100millionchildrenwithpoliovaccineinNovemberandDecember.
The'maintenance'programmeispartofafour-prongedstrategytoprotecttheUS$4billioninvestedgloballysincethe1988launchoftheGlobalPolioEradicationInitiative.
Theotherelementsofthestrate-gyinclude:strengtheningroutineimmuni-sationatcountrylevelinclosecollabora-tionwiththeGlobalAllianceforVaccinesandImmunisation(GAVI)andthroughthenewGlobalImmunisationVisionandStrategy(GIVS);increasingsurveillancesensitivityandoutbreakresponsecapacity,andincreasingboththenumberandqualityofpoliocampaignsintheremainingendemicareas,particularlyinNigeria.
TheNigeriangovernmenthassignalledstrongcommitmentstofurtherstrengthen-ingitspolioeradicationprogramme.
Withvirusnowbeatenbacktothenorthofthecountry,effortsarefocusingonre-deploy-ingsupportstafftothenorthernstatesdur-ingtheupcomingimmunisationcampaigns.
Tosucceed,however,Nigerianeedstheongoingsupportoftheinternationalcom-munitytoensureeverychildisreachedthroughoutthecountrywithpoliovaccine.
Keytosuccessisensuringthenecessaryfundscontinuetobemadeavailable.
AUS$200millionfundinggapfor2006musturgentlybefilled,US$75millionofwhichisneededbyDecember,toensureactivitiesinthefirstquarterofnextyearcanproceed.
Underliningtheurgencyofclosingthefundinggap,latearrivaloffundsmaycom-promisethequalityoftheimmunisationcampaignsinsomecountries.
TosupportNigeriaandwestandcentralAfricainpolioeradicationefforts,RotaryInternationalisalsogearingupitssupporttotheregion.
RotaryclubmembersfromacrossNorthAmerica,EuropeandAsiaarejoiningfellowRotariansinAfricatopartic-ipateinthepoliocampaigns,"commentedCarl-WilhelmStenhammar,PresidentofRotaryInternational.
AtRotary,wearecommittedtodoingeverythingwecantosupportAfricaintheirpolioeradicationefforts".
RotaryInternationalandits1.
2millionvolunteersworldwidehavebeenintegraltotheglobaleradicateofpolio.
Collectively,RotarianshavecommittedwelloverUS$600milliontotheeffort,andcontributedcountlessvolunteerhoursdur-ingimmunizationcampaigns.
Thepolioeradicationcoalitionincludesgovernmentsofcountriesaffectedbypolio;privatesectorfoundations(e.
g.
UnitedNationsFoundation,Bill&MelindaGatesFoundation);developmentbanks(e.
g.
theWorldBank);donorgovernments(e.
g.
Australia,Austria,Belgium,Canada,Den-mark,Finland,France,Germany,Ireland,Italy,Japan,Luxembourg,Malaysia,Monaco,theNetherlands,NewZealand,Norway,Oman,Portugal,Qatar,theRus-sianFederation,Spain,Sweden,UnitedArabEmirates,theUnitedKingdomandtheUnitedStatesofAmerica);theEuropeanCommission;humanitarianandnongovernmentalorganizations(e.
g.
theInternationalRedCrossandRedCrescentsocieties)andcorporatepartners(e.
g.
SanofiPasteur,DeBeers,Wyeth).
Volunteersindevelopingcountriesalsoplayakeyrole;20millionhaveparticipat-edinmassimmunizationcampaigns.
Since1988,globaleradicationeffortshavereducedthenumberofpoliocasesbymorethan99%,from350,000annuallyto1,469casesin2005(asof1November).
Sixcoun-triesremainpolioendemic(Nigeria,India,Pakistan,Afghanistan,NigerandEgypt),howeverpolioviruscontinuestospreadtopreviouslypolio-freecountries.
Intotal,11previouslypolio-freecountrieshavebeenre-infectedinlate2004and2005(Somalia,Indonesia,Yemen,Angola,Ethiopia,Chad,Sudan,Mali,Eritrea,CameroonandNepal).
Formoreinformationcontact:SonaBariOliverRosenbauerTelephone:+41227911476Telephone:+4122791383Email:baris@who.
intintEmail:rosenbauero@who.
int1Benin,BurkinaFaso,Cameroon,CapeVerde,CentralAfricanRepublic,Chad,Cted'Ivoire,theDemocraticRepublicoftheCongo,Djibouti,EquatorialGuinea,Eritrea,Ethiopia,Gabon,Gambia,Ghana,Guinea,Guinea-Bissau,Kenya,Liberia,Mali,Mauritania,Niger,Nigeria,Senegal,SierraLeone,Somalia,SudanandTogo.
Massiveinternationaleffortstopspolioepidemicacross10WestandCentralAfricancountriesRegionalandNMANews108TheseprojectswillbeimplementedbyESAwiththetechnicalassistanceofWHO.
Nowadays,theuseofsatellite-basedInfor-mationandCommunicationsTechnologies(ICT)fortelemedicineisprogressingfromthescoutingphasetowardsamorestableandoperationalprofile,whereintegrationintoexistinghealthcaresystemsandtheattain-mentofself-sustainabilityisincreasinglybecominganessentialconditionforsuccess.
Inthisframe,theEuropeanSpaceAgencyinlinewiththerecommendationsoftheTelemedicineWorkingGroup(ref.
'OpportunitiesandChallengesofeHealthandTelemedicineviaSatellite',EuropeanJournalofMedicalResearch,vol.
10,2005,http://telecom.
esa.
int/telecom/media/docu-ment/Scientific%5FPublication%5FESA%5FTelemed.
041222.
final.
pdf)isissuingthreeinvitationstotendertodemonstratetheexploitationofSatcominTelemedicineandvalidatetheassociatedsustainabilitythroughauserdrivenapproach.
TheultimategoalofthisactionistopavethewayforaEuropeanTelemedicineviaSatelliteProgrammeofdirectbenefitfortheHealthcommunityandwhichwillbedevelopedincloseconsultationwithWHO.
Thethreeinvitationstotenderarefocusedonthefollowingthematicareas:HealthEarlyWarningTheactivityonHealthEarlyWarningwillbeaimedattheintegration,deploymentandvalidationofaSatcombasedsystemdevot-edtogatheringdatafromthefieldtopredictcommunicablediseasediffusionpatternsandassociatedrisksofoutbreak.
Thesys-temwillalsoprovideafastandresilientwaytodistribute,overgeographicalareasearlywarningandinformationtothepopu-lationtofacilitatetheestablishmentofade-quateprotectivemeasurestosafeguardthepopulation'shealth.
Thesystemwillbecon-ceived,inparticular,tofacehealthcarecon-sequencesofcatastrophicevents.
InterconnectivityforHealth-careServicesandProfessionalMedicalEducationbridgingCommunitiesinEasternandWesternEuropeTheactivityofInterconnectivityforHealthcareServicesandProfessionalMedicalEducationbridgingCommunitiesinEasternandWesternEuropewillestab-lishapilotexploitationperiodandvalidatetheassociatedsustainabilityofthedevel-opedsatellitebasedservicesupportingremotemedicalconsultationandhealthcareprofessionaleducationandcollaborationbetweentwomedicalsystems,oneinaremoteareasofEasternEurope,andtheotherinaWesternEuropeancountry.
ManagementofMedicalEmergencyforCommercialAviationTheactivityofManagementofMedicalEmergencyforCommercialAviationwillbeaimedtodevelop,integrateandvalidateinanoperationalenvironmentatelemedi-cineservicetosupportdiagnosisfromon-boardcivilaircrafts.
Thesystemwillpro-videinteractivemultimediadataexchangebetweenaircraftandgroundbasedmedicalcenterstosupportdecisions,incasesofmedicalemergency,onwhethertogoforaflightdiversionandwhichactionstotakeonboard.
ThedetailsofthesethreeinvitationstotenderareavailableatthefollowingURLaddress:ftp://ftp.
estec.
esa.
int/pub/telemediAnumberofmeetingsintheEuropeanre-gionrelatingtohealthissuesareofinterestatbothregionalandinternationallevels.
Inaninterestingdevelopmentin1994anini-tiativesupportedbytheCatalangovernmentandtheEuropeanUnioninaconferencesoughttoexplorehealthcareandhealthcareproblemsintheMediterraneanregion.
Enti-tledEuromedHealthForum(EuromedSalud)theoutcomewastheDeclarationofBarcelona(1994)urgingco-operationinthehealthcarefieldbetweenallthecountriesborderingontheMediterraneanSea,includ-ingthoseonthenorthcoastofAfrica,andattheeasternendoftheSea.
InNovemberofthisyearthetenthanniversaryofthiswascelebratedwithafurtherhighlysuccessfulForuminBarcelona.
Itexploredsuchareasashealthpolicydevelopment,theuseoftelemedicineandtheregulationandlicens-ingofhealthcarephysiciansandotherwork-ers.
Afurtherdeclarationwasissuedex-pressingtheviewoftheForumthatthesedi-aloguesshouldcontinueandthatafurthermeetingtakeplaceintwoyearstime.
Thisinitiativetodialogueandexplorepositivecollaborationrepresentsapotentiallyinter-estingdevelopmentincollaborationintheHealthsectorbetweenthenorthernsideoftheMediterranean(mostlyEuropeanUnioncountries),thoseattheeasternend,andonthenorthAfricancoast.
Formorethan20yearstherehasbeenanan-nualmeetingunderthetitleofEuropeBlancheundertheaegisoftheInstitutdesSciencesdelaSanté(Paris),todiscussaspecificmajorhealthorhealthprofessionalproblem.
ThesehaveincludedsuchtopicsasEuropeandMedicines,Continuingmedicaleducation,TheTherapeuticRevolutionetc.
Thesemeetinghaveprovidedanimportantforumatwhichleadingfigureswithanin-terestinhealthincludingresearchers,physi-cians,healthcareprovidersandorganisers,economists,ministersandotherpoliticiansTelemedicineviaSatellite:AnopportunitytodevelopSatcombasedsustainableservicesRegionalandNMANewsEuropeanRegionRegionalandNMANews109andotherrelevantpersonsinsocietyhavebeenabletomeetanddiscussissuesduringatwodaymeeting.
TheenlargementoftheEuropeanCommunityto25hasintroducednewconsiderationsintothediscussions.
ThisyearthemeetingwasheldintheBu-dapest,capitalofoneofthenewmembersoftheEU,thetopicfordiscussionwas"LivingLongerbutHealthierLives"exploringhowtoachievehealthgainsintheElderlyoftheEuropeanUnion.
AtthesemeetingstheSe-niorandJuniorEuropeandMedicinePrizesareawarded.
Finally,atameetingorganisedbyWMAandtheCaringPhysiciansoftheWorldNet-work,leadersofnationalmedicalassocia-tionsintheEuropeanRegionoftheWorldMedicalAssociationmetinPragueinNo-vembertodiscusstwomajorissues.
Presen-tationsweregivenbyWHOandotherex-pertsonthetwotopicsofdiscussion.
Thefirstwasonthe"SkillsDrain"amongphysi-ciansandwhatactionsNMAscantake.
ThesecondtopicwasHumanAvianInfluenzawhenthemeetingconsideredwhatactionscanbedonebyNMAsincollaborationwithotherinstitutionstoprepareforapotentialpandemic.
Thepresentationsanddiscus-sionswerebothlivelyandproductive.
UndertheaegisoftheCaringPhysiciansoftheWorldInitiative,membersoftheGeneralAssemblyofCONFERMELmetwithrepre-sentativesofWMAtodiscussissuesofim-portancetothemedicalprofession,HealthPolicyandreformoftheHealthSector,thenewroleofphysiciansinsocietyandhowNMAscanmeettheemergingneedsoftheirmembersatameetingheldon10thOctoberpriortotheWMAAssembly.
Amanifestowasissuedinthenameofthe12countriespresent,Argentina,Bolivia,Brasil,CostaRicaEcuador,Honduras,Mexico,Nicaragua,Panama,Peru,VenezuelaandUruguay.
Itre-ferredtothedifficultsituationinthesecoun-triessuchaspovertyandunfairnesswhichcontinue,despitesomeadvancesingrowthindices.
Inparticularreferencewasmadetotheconsequentnutritionaldeficiencies,lackofsanitation,drinkingwaterandthehighprevalenceofmalaria,dengueAIDSandtu-berculosis.
Concernwasexpressedthattheprocessesofreformandmodernisationofthehealthsectorinthesecountriespromotedpri-vatisationofthepublicsector,deepeningtheinequitieswithoutsubstantialimprovementinthequalityoflifeandexcludinglargeseg-mentsofthepopulationfromhealthcare.
PointingoutthatreformandmodernisationoftheHealthsectorneedstheparticipationofrepresentativeorganisationsofhealthprofessionalsattentionwasdrawntothe"The2ndKEMATteamarrivedinAbbot-tabadinthemorningofOctober22andtookoverallthetasksfrornthe1teamwithoutanyreservatinn.
Asmanyyophysi-cianshavejoinedthe2ndteam,mostlycomposedbystaffofAsianMedicalCenterinSeoul,thecampwasfullofenergyandvibrancy.
LawrnakerMr.
SeokHyunLee,theChairpersonofHealthandWelfareCommitteeofKoreanNationalAssembly,alsojoinedthisteamandsupportedallthecommitmentandhardworkofalltheKore-anmedicalteamsandrescueteamsdis-patchedtothequake-hit-areastakingafieldassessmentfromAbbottabadviaBal-akottoMuzaffarabad.
OvertenKoreanNGO`saretakingpartinvoluntarymedicalworkinPatika,Balakot,Muzaffarabad,BatagramandAbbottabad.
Casesofscabiesarecontinuouslyontheriseandmanypeople,especiallychildren,arestillinneedoflong-termmedicalatten-tionafterbeingamputated.
Dr.
IrfanKhat-tak,generalsurgeonofAyubMedicalCom-plexandcoordinatorofvoluntarymedicalworksaidthattheyneedmedicalequip-mentsuchasDERMATOSEorMESHERtotakecareofthesepatients.
Drugsforanesthesiaarealsoneeded.
Moreover,men-talshockstheyaregoingthroughalsoshouldbebroughtunderdelicatetreatment.
OperationRoomsofAyubMedicalCom-plex,onceshutdownofadditionalcollapsearenowfunctioninglittlebylittle.
The2ndKEMATconductionfivemajorsurgeriesincludingskingraftforopenfractures,K-WireReconstructionOperationandPROSTALACatoperationroomsincoop-erationofPakistanidoctors.
InBalakotmobileclinic,considerablenumbersofpatientsaresufferingfromdiar-rheaandde-hydration.
Scabiesisamajorconcernhere,too.
The2ndteamhastreatedtotal2,810patients(2,485atAyuhMedicalCenter,and325inBalakotmobileclinic).
LatinAmericaandtheCaribbeanlackofprioritygivenbygovernmentsinre-sourceallocationtothehealthcaresystemswhichamongothersaffectsqualityofcareandtherightsofphysiciansandotherhealthpersonnel.
Themanifestodenouncedtheindiscriminatecreationofmedicalschoolswithoutsocialnecessity,andthecreationofnon-medicalcareerspermittingtheillegalpracticeofmedicine.
Expressingconcernaboutinequitablecom-mercialagreementsrelatingtointellectualpropertyandpharmaceuticalswhichlimitac-cessofcitizenstodrugs,anddisregardingWTOagreements,themanifestoendsbyreit-eratingtheprofessionalorganisations'commit-menttothesupervisionofthequalityofmed-icalcareandtheautoregulationoftheprofes-sionthroughobligatorymembershipofacol-legeinaccordancewithnationallegislation.
KoreanMedicalAssociationActivityReportoftheKMAMedicalTeamintoquake-affectedareasinPakistan(Extractfromthisinterestingreport.
Ed.
)Letters110Replacingthetasksofthe2ndteam,the3rdKEMATteam,composedofsixdoctors,fivenurses,onepharmacist,onepolicemanandtwoadministrativestaff,arrivedinAb-bottabadonOctober29.
The3rdteamspe-ciallyiscomposedbythestaffofNationalPoliceHospital.
Duetothehugedifferenceoftemperaturesbetweendayandnight,thenumberofpa-tientscomingdownwiththeART(AcuteRespiratoryInfections)continuestoinerease.
AtAyubMedicalComplex,quake-relatedemergencypatientshavedecreasedpromi-nently,comparedtothesituationoftwoweeksagoandmoreandmorepatientswithchronicdiseasescometoseeadoctorandwanttogetmedicinesfortheirdiseases.
Howeverpatientsinneedofminorsurgerydressing,castandsuturingstillanaverage70–80peopleaday.
Moreequipmentandeffortsarenecessarytobeputpreventionofepidemics.
Al-thoughKEMATiscarryingoutsomepre-ventionstepsusingasmokedisinfector,moreorganizedprojectsshouldbeurgentlyarrangedandcarriedout.
InBalakotmobileclinic,casesofdiarrheaskindiseaseslikescabies,andARIarestilltoppingthelistandmanypatientsneedingtogettheirdressingrenewed,orneedtogetcareafterampulationkeepvisitingthemo-bileclinic.
The3rdteamhastreated3,395patientsallto-gether(2,353atAyubMedicalComplexand1,040atmobileclinicinBalakot),makingthetotalnumberofpatientsthroughtheac-tivitiesofKEMATis7,505approximately.
Endingitsvoluntarymedicalworks,theKEMATdonatedmedicines(anti-scabiesdrugs,antibiotics,fluids,etc.
)andmedicalsuppliesleftfromtheiractivitiestotheAyubMedicalComplexandsomemedi-cinestotheGoodSamaritanHospitalrunbyKoreanmissionariesinPakistan.
ContactinfoofKoreanMedicalAssocia-tionMedicalTeam(KEMAT;KMAEmer-gencyMedicalAssistanceTeam):MsYoonsunPark,ChiefofStrategiePlan-ningTeam,KMA:+8227942474(ext.
120)(oftice)/+82117926908(mobilephone)Sir,Firstletmeintroducemyself:IamaPaediatricSurgeon,formerHeadoftheDepartmentofSurgeryofthemainLisboa'sChildren'sHospitalandalsoafor-merPresidentoftheWMA(morethan20yearsago–1981/1983).
SecondlyIwouldliketocongratulateyouandyourco-workersfortheexcellentqual-ityofthe"WorldMedicalJournal",whichIreadalwayswithgreatinterest.
FinallyIhavetomakeashortcommentonyourarticle"SavingthelivesofSiameseTwins"[WMJ51(2)30-31,2005].
Myexperiencestartedin1978andstemsfrom7,fullyandpersonallyoperatedpairs,with9survivorsand5deaths(inonepaironechildwasalreadydeadonarrival,anotherdiedof"malignanthyperthermia"afterseparationhadalreadybeenper-formed,andtheremainingonepatientdying1monthpost-operatively,withperi-tonitisduetoaleakinanintestinalanasto-moses).
LisboaanditsHospitalD.
Estefania,arenotasfashionableandwell-knownworldwide,astheHospitalforSickChildren,(GOS),inLondon…!
Mylongestoperation,with"total"recon-structionofomphaloischiopagustwins(boys,ofwhichonehadtoremainagirl,duetoonlyoneexistingpenis)took13.
30hours,because,takingintoaccountthetrainingIreceivedinEngland(GOSandAlderHey),Iwasabletoconductthewholeoperation,inbothtwins,from"toptobot-tom"(andnothaving,atmyside,severalsub-specialist,workinginsuccession,intheAmericanStyle).
Alsoskinexpandersprovedunnecessary,afteradequateiliacosteotomies.
The7survivorsleadtotallynormallives,andthe2latestoneshaveonlyminorprob-lemsandleadalso,practically,normallives.
Theliverisusuallytheleastproblem,withnosignificanthaemorrhagicdanger,asnormallyareasonablenoticeabledemarca-tionexistsbetweenthe2individualseg-ments.
Themostdifficultproblem,foragoodfunctionalandaestheticoutcome,isassociatedwiththeurinarytract,followedbytheintestines.
Osteotomiesintheiliacbonesusuallydoawaywiththeneedtousepreviouslyinsertskinexpanders.
InmyopinionlivertransplantationisnotaprimaryfactorinthetreatmentofSiamesetwins,anditsprogress,nomatterhowdesirableitcertainlyis,willnotbenefitthesechildren(atleastdirectly).
Goodanaesthesiaandintensivecare(includingnurses),aretherealissues,apartfromsurgeryitself.
Nomatterhowwellasur-geonworks,ifanaesthesiaandintensivecarearenotalsoasgood,theresultmaybedisastrous.
Infact,theonlyreallyinopera-bleSiamesetwinsarethosewitha"com-monheart",andinwhich,theexistingheartandmajorvessels,cannotbeusefulforanyofthem(somalformedtheyare…).
AsHorsleyoncesaid,"Abeautifulopera-tionthatendswiththedeathofthepatientisnotsatisfactorysurgery".
FinallyIbelieveitiscompletelywrongandarealpity,toabortSiamesetwins,foundatroutineechographies(aswellassomeapparentlymajormalformations),asmod-ernPaediatricSurgeryisabletocorrectthem(allowingthosehumanbeings,toleadnormal,usefulandhappylives).
Thatshould,Ifeel,bethemainmessagetopro-mote!
Unfortunatelyabortioniswhatwefindinthe"so-called"developedcountries.
MostoperatedSiamesetwinscomefromdevel-opingcountries,whereechographyisnotcurrentlyavailableandthediagnosisismadeonlyafterbirth!
YourssincerelyProf.
Dr.
AntonioGentilMartinsRuadeCampolide166-GLisbon1070-096PORTUGALEmail:agentilmartins@netcabo.
ptLetterstotheEditorSavingtheLivesofSiameseTwinsReview111Sir,Withregardstoyourarticleabout'Spray-onSkinGrafts'.
Ithinkthistechniqueandothersimilartechniquesinvolvingthecul-tureofskinstemcellsstillhasalongwaytogobeforetheycanbeusedforburnsinvolvingthefullthicknessoftheskin.
IamnotfamiliarwiththetechnologyusedatEastGrinsteadbutIsuspectitmayhavebeenratheroverhyped.
JustthisweektherehasbeenanarticleintheLancetfromaFrenchgroupusingfoetalskincellswhichgrowrapidlyandareincorporatedintoacollagenmatrixwhichhavebeenusedsuc-cessfullyinasmallnumberofpatientsbutitisreallyabiologicaldressingwhichisreplacedbyhosttissue.
Theuseofculturedskincellsobviouslyisattractiveparticular-lynowthatthestemcellsoftheskincannowbeidentifiedandgrownquiterapidlybutthisstillprovidedaverythinlayerwhichwouldnotbeadequatetoreplaceafullthicknessburnfollowingexcisionofthescar.
However,thisisanimportantareaofdevel-opmentandmanygroupsaroundtheworldareworkingonthecultureofcellsoftheskinandparticularlythestemcellsoftheepider-misandwithoutquestioninduecoursesuc-cessfulclinicalapplicationswillbedevel-opedthatwouldallowpermanentreplace-mentwithoutscarring.
Thisthenwouldbeperhapssuitableinreconstructionoftheface.
YourssincerelySirPeterMorrisACFRSFRCSHead,CentreforEvidenceinTransplan-tation,EmeritusProfessor,UniversityofOxford,HonoraryProfessor,UniversityofLondonTheRoyalCollegeofSurgeonsofEngland35-43Lincoln'sInnFields,LondonWC2A3PEwww.
rcseng.
ac.
ukEthicsofResearchandTreatmentinDevelopingCountriesFranoisandEmmanuelHirsch,editorsCollectionEspaceéthiqueParis,LibrairieVuibert,200514.
50EuroISBN2711772780WhentheWorldMedicalAssociationundertookthelatestrevisionoftheDeclarationofHelsinkiin1997,itencoun-teredissuesintheapplicationofethicstomedicalresearchindevelopingcountriesthathadnotarisenpreviously.
Themostcontroversialarticlesinthe2000versionoftheDeclarationarepreciselythosethataddresstheseissues,namely,paragraph29thatdealswiththecomparatortobeusedinaclinicaltrial,andparagraphs19and30thatspecifytheobligationsofresearchersandresearchsponsorstothosewhoserveasresearchsubjects.
Thesesameissueshavebeenconsideredinotherinternationalstatementsonresearchethicssuchasthe2001NationalBioethicsAdvisoryCommission(U.
S.
A.
)report,EthicalandPolicyIssuesinInternationalResearch:ClinicalTrialsinDevelopingCountries,the2002CouncilforInternationalOrganizationsofMedicalSciences(CIOMS)InternationalEthicalGuidelinesforBiomedicalResearchInvolvingHumanSubjects,the2002NuffieldCouncil(U.
K.
)report,TheEthicsofResearchRelatedtoHealthcareinDevelopingCountriesandits2005follow-updiscussionpaperwiththesametitle,andthe2003EuropeanGrouponEthicsinScienceandNewTechnologiesOpinion#17ontheEthicalAspectsofClinicalResearchinDevelopingCountries.
Asthe2005NuffieldCouncildiscussionpaperexplains,thesedocumentsdonotagreeonmanyofthekeyissuesinresearchindevelopingcountries.
InOctober2002,aconferencewasheldinParistodiscusstheseissueswithparticularreferencetothefrancophonecountriesofAfrica.
Theproceedingsofthisconferencearethesubjectofthisreview.
ManyofthecontributorsareAfricanandtheydonothes-itatetocriticisethedominant'Western'par-adigmofmedicalresearchasitisappliedintheircountries.
Twosetsofessayssetoutthecontextforthepresentationsthatfollow.
Thefirstdealswiththeprinciplesofhumanrightsandmedicalresearch,andtheseconddescribesthemethodologyofclinicaltrialsandrelat-edethicalissues.
ThemajorpartofthebookconsistsofsevensubstantialessaysonAfricanapproachestobiomedicalresearch,eachofwhichpointsoutshortcomingsintheappli-cationof'Western'researchmethodologyinAfrica.
AccordingtoGodfreyB.
Tangwa,thismethodologyisbasedonaworldviewthatisquitealientoAfricans,forwhom"metaphysicalconcepts,ethics,customs,lawsandtaboosformauniqueensem-ble…"(p.
57).
WhereasWesternapproach-esdisplayanexcessofepistemologicalconfidence,borderingonarroganceandoftenresultinginimprudence,"theprinci-palvalueunderlyingAfricanworldvisionsandconceptsisitsepistemologicalhumilityandrespectfulprudence…"(p.
60).
CertainAdvancingSurgicalStandards–StemCellsReviewthiquedelarecherchéetdessoinsdanslespaysendéveloppementReview112ethicalprinciplesofgreatimportanceinWesternsociety,suchastheconfidentialityofpersonalinformation,mustbeapplieddifferentlyinAfricawherethefamilyandthecommunity,nottheautonomousindi-vidual,arethefundamentalsocialunits.
ThewidespreadsuspicionofWesternresearchersandtherevelationsofracistmedicalresearchinapartheid-eraSouthAfrica,haveprovidedfertilegroundforthespreadofconspiracytheoriesregardingtheoriginandtreatmentofdiseasessuchasHIV/AIDS.
Therationingofmedicaltreat-mentbyabilitytopayratherthanbyneediscontrarytotheAfricanviewofhealthcareasaservice,notacommodity.
ToillustratetheWesternattitudetoAfrica,Tangwapro-videsacasestudyofamedicalresearcherinCameroonwhodevelopedapromisingapproachtoavaccineforHIVbutwasunabletogetfundingfromanyoftheWesternresearchagenciesbecauseitdidnotfittheirparadigmofmedicalresearch.
Animportantconceptinbothmedicalresearchandmedicaltreatmentis'quality'.
Inhisarticle,Jean-GodefroyBidimaraisesmanyquestionsregardinghowthisconceptappliesinAfrica–qualityofwhat,qualityforwhom,andhowshoulditbemeasured(pp.
80-83).
HegoesontodiscusswhytheWesternconceptofinformedconsentisinapplicableinmuchofAfrica:"IncertainAfricanculturesonedoesnotexpressarefusaltosomeoneinauthority.
Oneexpressesarefusalbynotcarryingoutanorderthathasbeengiven,butformallyoneagreesinorderthattheauthoritydoesnotloseface.
Thecaregiverisanauthority,andwhenasickAfricangivesconsent,whatdoesthatsignifyAnagreementorsimplepoliteness"(p.
85)TheAfricanunderstandingofclinicaltrials('essaisthérapeutiques')isexploredbyAssétouIsmalaDermeinrelationtopro-posedtreatmentsformalaria.
Aswithotherailments,malariaisconsideredtobenotjustaphysicalafflictionbutaresultofupsettingtherelationshipsofnaturalandsupernaturalforces.
Healingthereforerequiresspiritualaswellasphysicalmea-sures.
Researchonthepreventionandtreat-mentofmalariaiscomplicatedbythemul-tiplelocaltermsusedforthedifferentphas-esofthisillness.
Researchersmusttakeallthesefactorsintoaccountwhenundertak-ingprojectsinAfrica.
IntheIvoryCoast,accordingtoLazareMarcelinPoame,theconceptoffreeandinformedconsenttomedicalresearchortreatmentislargelyunknown.
Physiciansaretheexpertsandthepatientisexpected,andexpects,tofollowtheirorders.
Moreover,busyphysicianssimplydonothavethetimerequiredtopresentalltheirpatientswiththeinformationnecessaryforinformedconsent.
Whereconsentissought,itisusuallyfromthefamilyratherthantheindividualpatient.
Despitealltheseobsta-cles,PoamebelievesthatthepracticeofinformedconsentisachievableintheIvoryCoastandoffersconcretesuggestionsformovinginthisdirection.
AFrenchsocialscientist,ChristophePerrey,reportsonaresearchprojectoninformedconsentconductedintheIvoryCoastinwhich57womenwereinterviewedabouttheirunderstandingofclinicaltrials,includingthemeaningofplacebo.
Despiteexplanations,itturnedoutthatnoneofthewomencouldexplainwhataplaceboisandtheyallwereconvincedthattheyhadreceivedtheexperimentaldrug.
Otherchal-lengestoinformedconsentweredifferentunderstandingsandterminologyforthesymptomsandcausesofdiseases,thediffi-cultyofgettingspousalconsentforawoman'sparticipationinthetrial,andrumoursabouttoxicityoftheproposedintervention.
Iftheprincipleofinformedconsentistobeimplementedinsuchset-tings,muchmoreworkisneededonitspedagogy.
InMay2002theFrenchNationalAgencyforAIDSResearchpublishedaCharterofEthicsforResearchinDevelopingCountriesthataddressesmanyoftheissuesraisedatthisconference.
InpresentingtheCharter,BrigitteBazinnotedsomeofthedifficultiesinitsimplementation,includingtheabsenceofethicsregulationsandcom-mitteesinmanydevelopingcountries,thelackofresourcesforthoseethicscommit-teesthatdoexist,andtheinabilityofnon-profitagenciestoprovidecontinuingcaretoparticipantsinresearchasrequiredbytheDeclarationofHelsinki.
InthefinalcontributionfromAfrica,PatriceEmmanuelMboAbenoyapprovidesaperspectiveontheseissuesfromAfricantheology.
Africanslivesimultaneouslyintwoworlds:thevisibleoneofhumansandfinitecreaturesandtheinvisibleoneofenergiesandpowers.
Intheformer,individ-ualsaresubordinatetothecommunity;inthelatter,theyaresubordinatetosupernat-uralforces.
BothrelationshipschallengetheWesternconceptofindividualautonomyandtherelatedprincipleofinformedcon-sent.
Moreover,thefactthatone'sfamilyisoftentheonlysourceoffundsforone'smedicaltreatmententailsthatthefamilyhasalegitimateroletoplayintheconsentprocess.
Tocompletethelistofissuesthatneedtobeconsideredinrelationtotheethicsofresearchindevelopingcountries,theedi-torsincludedasanannexasummaryofdis-cussionsthattookplaceinParisinJanuary2001andthatpresumablyinspiredthecon-ferencethatledtothisbook.
Theadditionalissuesmentionedincludethefollowing:therighttohealth,globaldisparities,lackofdemocracyinsomedevelopingcountries,theneedsofmigrants,corruption(atwo-wayprocess,involvingcorruptersaswellascorruptees),taboos,andlearningfromdevelopingcountries.
Noneoftheissues,problemsandchal-lengesraisedinthisbookadmitsofeasyanswers.
However,theymustfirstberecog-nized,andtheauthorshaveprovidedavaluableserviceinpointingoutboththeo-reticalandpracticaldifficultiesintheappli-cationofinternationalstandardsofresearchethicsindevelopingcountries.
Thesugges-tionstheymakeforimprovingthesituationareworthyoffurtherconsideration,butastheauthorswouldbethefirsttoadmit,muchmoreneedstobedone.
Allthoseresponsibleforinternationalresearchethicsshouldfollowtheexampleoftheeditorsofthisbookinseekingmeaningfulinvolve-mentofdevelopingcountryrepresentativesinboththereviewofpoliciesandinthedesignandimplementationofresearchstudies.
JohnR.
Williams,Ph.
D.
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