How does one go about changing government policy, getting laws passed, modifying public behavior and having an impact? It's a Sisyphean task, often thwarted by vested interests, politics, lack of funds and chronic inertia, but it can be done - even in a field like health education and promotion, which is not considered "sexy" or urgent.
Most health conferences are just talk. The 13th annual conference on health education and promotion - organized by the Health Ministry at the Kibbutz Ma'aleh Hahamisha Hotel earlier this month - focused on practicalities. Its theme was "Mutual Influences of Policy on Health Realities, and Vice Versa," and it was attended by hundreds of health educators (most of them female government workers), the health funds and the municipalities. Lectures in three rooms on new initiatives included teaching the disabled how to relate to the opposite sex, reducing accidents in the Arab sector, finding ways to reduce HIV infection among homosexuals, reducing obesity among residents of mental-health hostels and getting middle-aged women to exercise.
"This is one of our most important conferences," said Health Ministry director-general Prof. Avi Yisraeli, who delivered greetings. "Too often, we have to give priority to acute problems of illness and disease; it seems they are most attractive. But prevention and education are also very important, because they affect many more people. We must change our priorities - not to spend less on acute problems and the hospitals, but to spend more for prevention. It's more difficult to encourage people to exercise, avoid sun exposure, discourage smoking and brush their teeth properly. This problem is not unique to Israel. It's very hard work," said Yisraeli, an infectious disease specialist, "and it sounds and looks much less attractive than dealing with disease, but it's more important. Only a rare health reporter is interested in writing about these subjects. It's vital to identify what new interventions are effective, and it's important to persuade decision makers like me to invest more money in promotion and prevention."
THE DIRECTOR-GENERAL said he hoped the no-smoking law presented by Likud MK Gilad Erdan that went into effect November 1 would have a significant impact. "I hope the new law will bring about a dramatic reduction in the smoking rate, as other laws have in places like Ireland."
Ruth Weinstein, head of the ministry's health education and promotion department, added that according to the latest ministry survey, the percentage of smokers in the adult population has reached its lowest-ever figure at 23.2 percent. But there is still a way to go, as the smoking rates among men remains far too high. Still, she is encouraged by the fact that 80% of those surveyed (including smokers) favored the prohibition of smoking in clubs, pubs and discotheques, and 78% are for barring smoking in cafes and restaurants. Even though the new law has empowered nonsmokers, 44% of them still say they are uncomfortable about asking a lawbreaking smoker to butt out.
Health policy changes can be carried out if those fighting for them take the opposition into consideration, amass a coalition of organizations to help push them through, and explain them to the public. This was the message of Amalia Waxman, head of the international affairs and public relations division of the Weizmann Institute of Science and formerly a project manager for noncommunicable diseases and mental health at the World Health Organization's headquarters in Geneva.
BETWEEN 2000 and 2003, Waxman worked at the WHO on a world strategy for nutrition, physical activity and the prevention of non-infectious diseases that was finally approved by the UN organization in 2004.
"It was a fascinating process, which also involved conflict between the WHO and other groups." She noted that 3.5 million people died from chronic diseases in 2005 - 60% of world deaths. The largest growth is in developing countries. While 850 million people suffer from malnutrition, a billion people are overweight or obese. Some 5.3 million deaths a year result from an unhealthy diet, and 1.9 million more from physical inactivity.
"We worked to persuade governments that many cases of heart disease, obesity, stroke, type-2 diabetes and cancer can be prevented. Healthful choices have to become easy choices," she told the conference. "We advocated the inclusion of more fruits, vegetables and whole grains in the diet, and this stepped on toes. So we decided on a consultation process with member states, the private sector, non-profit organizations and UN agencies. Still, there was much criticism, as some member nations argued that it was wrong to discuss overweight when there was still so much malnutrition. There was also intense pressure from manufacturers of processed foods and the sugar industry," said Waxman.
"We prepared reports on marketing food to children, nutrition labels and health claims. We also worked a lot with leading publications in the international arena, and issued press releases, held press briefings and met opinion leaders. We worked a lot with national governments, both those in favor and those against. Initially, we encountered a total lack of faith within the food industry, which was afraid of developing the same bad reputation as the tobacco industry. Some threatened us. But gradually we built feelings of trust, and some food companies even asked us to help them plan more healthful products. Private industry adopted promotion of healthful diets, physical activity, product reformulation with more nutritional value, improved food labelling and responsible marketing, especially for children. Many governments prepared programs for physical activity, nutrition and fighting chronic diseases. I learned how to promote policy change in a transparent way.
The WHO's final report, calledDiet, Nutrition and the Prevention of Chronic Diseases, which Waxman worked on, attracted a lot of attention and was the basis for actual policy changes.
THE EFFORT by Beterem, the National Center for Child Safety and Health, to pass a law requiring children and addults to wear helmets when riding bicycles, skates, skateboards, rollerblades and anything else on wheels except for a tricycle, was described by the non-profit organization's Liri Andy-Findling. Some 185,000 Israeli children are involved in a variety of accidents each year and taken to emergency rooms; of these, 24,000 are hospitalized and 170 die. Of the total, 660 are hospitalized after bicycle and other wheeled-vehicle injuries, and 10 of them die. Studies, said Andy-Findling, show that helmets reduce harm to the head by 88%
After succeeding in getting laws passed that limit heating levels of new water boilers to reduce the risk of burns, mandatory seatbelts in schoolbuses and labelling changes to protect children from dangerous chemicals, Beterem launched its campaign for mandatory helmets. It enlisted Likud MK Gilad Erdan, who has been at the forefront of fighting against smoking in public places, to present the bill.
Finally, the bill passed with a large majority, despite opposition by bike-riders' groups. Dr. Shaul Katzir, an enthusiastic biker and historian at Tel Aviv University, lectured after Andy-Findling and aroused protests from some members of the audience, who rejected his claim that the Helmet Law Is harmful.
"Even if helmets gave 100% protection to the whole body - which they don't - forcing people to wear them will cause a decrease in use by 10% and thus harm public health," he argued. Helmets are uncomfortable, especially during Israeli summers, and riders don't like the inconvenience of carrying them along, said Katzir, who claimed they may reduce injuries when a rider falls and the impact to his or her head comes at no more than 20 kilometers per hour, but have little protective effect if he is hit by a vehicle. Thus the law, he maintained, was more suited for Holland or Denmark, where bikers fall but rarely collide with vehicles. He concluded that it should be "left to riders, especially adults, whether to wear helmets in the city. In rural areas, they should be worn because they will help riders."
Baruch Remes, a Jerusalem Post reader, reacted in anger to Katzir's claims: "As one who biked daily for many years and always wore a helmet, I know that it takes only a short time to get used to wearing a helmet, and its cost is also not great - certainly less than the cost of a head injury."
Katzir's claims have been strongly denied by Beterem. Andy-Findling explained in her lecture the lessons she learned about how to get health-promotion legislation passed. "One should not ignore those who oppose you. Always dialogue with others. The Justice Ministry, for example, was cold to the idea but became enthusiastic after officials read about support for mandatory helmets abroad. We found that the strategy itself can be effective, as it affects public attitudes and behavior, even without formal enforcement by the authorities. We got wall-to-wall support from government ministries, the Israel Police, Metuna, hospitals, medical societies and others. We lobbied MKs and even used a professional lobbying company. Even before the Helmet Law went into effect, 75% knew of it and 92% were in favor. Signs have gone up in bicycle and toy stores. The police already tell us they see a change in the streets, with more riders wearing helmets, even though they are giving warnings and haven't yet begun to hand out fines."
She noted that those who want to get health promotion bills passed have to be patient, as it takes an average of two year for laws to be approved.
"Evidence-based data are important. You must do surveys and research, write position papers and build an ad hoc coalition of experts," the Beterem official said. "But even when the legislation is passed, your work isn't done. You have to continue with educational efforts."