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Photo by: AVI HAYOUN
*Putting their heads together*
By JUDY SIEGEL-ITZKOVICH
08/31/2014
Despite the financial difficulties of the past year, the Hadassah Medical Organization managed to hold its eighth annual medical conference.
 
It had been held during the previous seven summers at Jerusalem’s International Convention Center with over a thousand people attending each time.

But many were not sure it would convene again this year, given the managerial upheavals, dismissals, resignations, strikes, bad blood, depressing headlines and painful budget cuts that hit the Hadassah Medical Organization in the past year.

Yet HMO’s Israel Medical Conference convened, filling Teddy Hall with members of the general public, who listened to more than eight hours of greetings and lectures, as well as a stand-up routine about doctors for some relief. It was organized almost without a hitch by Hadassah trauma surgery expert Prof. Avi Rivkind.

In addition to sponsorship by Haifa’s Bnai Zion Medical Center, the International Fellowship of Christians and Jews and others, this time there was a first – Hadassah’s longtime competitor, Jerusalem’s Shaare Zedek Medical Center, was invited to be a sponsor as well.

When HMO was in the throes of strikes over late wage payments and salary cuts, sleep-starved SZMC staffers had come to the rescue and for weeks treated most of Jerusalem’s sick and delivered even more of its babies.

Institutional competition over patients and leading doctors was forgotten as acting HMO director-general Prof. Tamar Peretz – a breast cancer oncologist with a international reputation – posed for photos with SZMC’s accomplished top administrator, director-general Prof. Jonathan Halevy. At least for that hot day in August, idyllic peace seemed to have alighted on the capital’s hospitals (except for the absence of any Health Ministry officials, from Minister Yael German on down, for unexplained reasons).

Yet one theme from all the previous sessions repeated itself: there is not enough money in the public health system. With the economic fallout of the war against Hamas in Gaza continuing and the national economy overburdened by defense costs, it didn’t seem there would be any good news in that sector in the coming year.

‘I’m glad the conference is being held again despite Hadassah’s crisis of the past,” said Knesset Speaker MK Yuli Edelstein. “I want to salute the country’s health system and the Israel Defense Forces. I visited some hospitals with wounded, and I saw miracles. But at the same time, disease and accidents and deliveries and the regular hospital workload continued.”

“As a wounded soldier in Lebanon in 1980, I remember how long it took to be evacuated to the hospital,” said Jerusalem Mayor Nir Barkat, who has greeted participants at the event almost since its inception. “Now it is very different. I have great respect for the potential of healthcare and biotech in the capital. We will be able to bring back many doctors and scientists who left the country and raise Jerusalem’s attractiveness for them even beyond what it is today.”

The mayor noted that the city’s hospitals are an oasis of coexistence and cooperation, with doctors, nurses, patients and families of all religions getting along, with only illness as their enemy. With the planned construction of hotels and other major facilities at the western entrance to the city and the speedy train from Tel Aviv, there will be a major upgrade for medical conventions, he added.

“There has never been a lack of money for healthcare [such] as [there is] today,” said Dr. Amnon Rofeh, Bnai Zion’s director-general. “Health is not a top priority for the government.”

“A strong nation consists of people who get good medical care,” added Israel Medical Association chairman Dr. Leonid Eidelman.

“We don’t have enough resources. A strong nation is built from people who get good medicine. Patients, doctors and nurses feel this every day.”

“Just as we wondered whether the new generation of IDF fighters would be as brave and bold as their predecessor, we wonder if the new generation of doctors will be up to the challenges,” said Halevy. “But we have seen that they are both dedicated and no less so than the previous generation. The rules have changed; medicine has changed. Devotion to patients and empathy must continue. It won’t be private medical care in the public hospitals that will dictate equity in care but the lack of financial resources.”

The SZMC director-general, who was for two years chairman of the public committee for expanding the basket of health services and has been asked by the health minister to do it again for the 2015 basket, noted that it will again be increased by NIS 300 million worth of new drugs and technologies.

“With a NIS 35b. basket for the population, that sum is only 0.8 percent more, despite the aging of the population and the advance of medicine. If we received a 2% increase, we could add so much.”

With the inclusion of public representatives, health fund administrators and health economists, the “basket committee” meets intensively for a month to choose among hundreds of technologies to select what to add. A new drug not yet in the basket that virtually cures hepatitis C costs $90,000 per patient – and there are many tens of thousands of such patients. One Druse child in the Galilee with a life-threatening enzyme deficiency needed a drug costing NIS 1 million; it was approved.

The committee constantly has to make Solomonic decisions in the face of a very limited budget, Halevy said. “We also care about prevention and try to include a new vaccine every year. We don’t vote; we always reach a consensus.”

‘Cancer, which is actually many diseases, not one, is more common here than the OECD average,” said Peretz. Lung cancer is much more frequent in Arab than Jewish men, even though male mortality from cancer is generally lower than the OECD average.

In the Jewish sector, there is a decline in the prevalence of cancer, while among Arabs, especially the men, there is a rise. More men survive prostate cancer, while fewer survive lung cancer, which is almost always due to smoking. The best ways to win the war against cancer, said the acting HMO director-general, “is to prevent it and to detect it early.”

There is more innovation in the field, and new technologies enter the market relatively quickly, said Peretz, “but this can be problematic, because it takes time to learn the drugs’ limitations. There’s a learning curve, so often it takes time to refine treatment and a reduction in success. We may lose some surgical expertise, and the drug industry likes to push us – and sometimes misleads us.”

Many soldiers’ lives were saved and suffering reduced by new technologies used on the battlefield – from freeze-dried plasma reconstituted with water to self-applied tourniquets and pain-relieving lollipops, said IDF surgeon-general Brig.- Gen. Prof. Yitzhak Kreiss. The IDF chief physician, who is due to leave the IDF next year, said that three years ago his office introduced a program called “Shomer Ahi” (My Brother’s Keeper) to reduce deaths on the battlefield and which was fully implemented in Operation Protective Edge.

A major difference between the current military operation and previous ones in Gaza and other battlefields, he said, was that IDF doctors and paramedics were on the scene within seconds or minutes to treat the wounded, instead of lesser-trained medics. In addition, all soldiers on the front were provided with special tourniquets that can be applied by a wounded-but-conscious soldier immediately after an incident, to reduce or halt the bleeding.

In Operation Protective Edge, the IDF was the first army in the world to use freeze-dried plasma to improve the chances of survival of soldiers wounded in battle. In Israel’s previous wars, most of those that died did so within minutes, up to an hour, but reconstituted plasma makes it possible to infuse immediately.

Labor and Social Welfare Minister Meir Cohen noted the unfairness of residents in the periphery having to travel as much as 40 kilometers to get twice-weekly dialysis. The former mayor of Dimona said the average person living in the center was only three kilometers away.

“It has been shown in studies that people far from the center have a life expectancy shorter by a few years, and poorer health. Many don’t take prescribed drugs because they can’t afford the copayments.” When he noted as mayor that there was no late-night medical service in his city, he found a donor to finance Dimona’s outpatient emergency room, and many lives were saved.

“The main problem – but not the only one – is that there is not enough money in the public health system,” said Prof. Yehushua Shemer, a former Health Ministry and Maccabi Health Services director-general and now chairman of the private Assuta Medical Centers chain.

“I am part and parcel of public health services, even though I am now in private healthcare,” he said. “No country in the world can give all the medical services and drugs that are available,” he continued. “There’s rise in the standard of living; people expect more. Our healthcare is among the best in the world, but there are negative incentives to do more. Hospitals are not fully compensated,” said Shemer.

“There is no complete equity, although we must try to achieve it. There are waiting lists for operations and treatments, so there must be private alternatives, but they will not overcome public care, as we constitute only NIS 2b. out of NIS 74b. in annual health expenditures,” he added.

Private care shortens the queues in public health facilities, Shemer argued, because those with private insurance are siphoned off by private facilities.

Prof. Yosef Caraco, head of the clinical pharmacology unit at Hadassah University Medical center, noted the danger of polypharmacy, in which older patients take even many – even dozens – of different pills for chronic illness daily. Some of them are the same medication with different commercial names, while others may cause harmful interactions.

“Almost every specialist adds another medication, and more side effects result. Polypharmacy can lead even to undertreatment, because patients may not take prescribed medications they can’t afford, and doctors think they are taking them. Too many patients have minimal knowledge about disease and what the drugs are for.”

As a result, Caraco said, Hadassah and ESHEL established a pilot program for a center for drug information for people over age 70; they call in to hear about side effects and interactions and how to divide up the pills during the day.

Prof. Ephrat Levy-Lahad, head of SZMC’s medical genetics unit, said that thanks to molecular biology, “everything can be measured and quantified. The future of medicine will be to build 3-D maps of the human genome and individual microbiomes. We can’t yet do this, but we can make a map of a person’s individual 25,000 genes. For years, geneticists have been able to check embryos of a few cells for genetic disease and place the healthy ones in the womb. If a parent is a carrier, we can check if the embryo is at risk and give suitable drugs without side effects. We can test biopsies of people who died to help family members avoid disease,” said Levy-Lahad.

“We can test the blood of pregnant women to find defects in the embryo. But there is a huge amount of data and a gap between what we learn and what we can do with it.”

Bnai Zion senior orthopedist Dr. Neta Raz discussed the use of robots and cyberknife radiosurgery systems to improve patient treatment.

In addition to the famous Da Vinci surgical robot used in everything from gynecology to urology, there is the Mazor Renaissance system – developed on the basis of research at the Technion-Israel Institute of Technology.

“It is comfortable for orthopedic surgeons to use, and we can even plan the operation at home or in the office on a personal computer.

In a few years,” Raz concluded, “surgeons who don’t use robots will have to defensively explain why they don’t.”
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