The aviation medicine section is responsible for all aspects of health of aviation personnel, including health promotion, medical certification, providing support and developing guidance to promote flight safety. In this Skytalk, the ICAO aviation medicine section will discuss the elements of decision-making for medical fitness to fly in accordance with the ICAO Standards and Recommended Practices (SARPs). It will include a visualization of the integration of various ICAO Annexes, several ICAO Manuals, latest scientific developments State best practices and industry initiatives concerning medical fitness. The process of developing SARPs and associated guidance material will be briefly outlined. Current and future activities will be discussed, highlighting concerns to be addressed as a matter of priority.