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Take any group of Israeli adults at random and give them a good look. Some will be in good shape, exercise regularly, eat low-fat, nutritious meals rather than junk food and regard tobacco like the plague. Others overdose on fatty meats and gooey desserts in restaurants, hotel dining rooms and fast-food joints, are overweight or even obese, get little exercise beyond pressing their TV remote control and smoke like chimneys.
It's no longer a secret that the first group are likely to enjoy more years and a higher quality of life than the second, who will unnecessarily cost the health system a great deal of money to treat them before their premature deaths. But how does one get the message across to men and women, boys and girls, that it is worth investing energy in beneficial behaviors?
Perhaps one should first try to reach decisionmakers in the health system - Health Ministry officials, health fund managers, hospital directors, academics from the medical schools and others - such as the 80 who in mid-June attended the two-day annual conference of the National Institute for Health Policy and Health Services Research (NIHP). This institute, established 11 years ago by the National Health Insurance Law and funded by health taxes, is located at the Gertner Institute at Tel Hashomer. Its main objective is to follow and assess the effect of the National Health Insurance Law on the quality, efficiency and cost of health services here, and - on the basis of research - to propose changes and improvements.
MORE THAN a handful of guests observed in the dining room of the lovely Mt. Canaan Spa Hotel - owned by Kupat Holim Meuhedet and run with healthy habits in mind - were very overweight and spent more time at the gooey-cake end of the buffet than on the salad side. And only a dozen or so were willing at 7:30 a.m. to go on a brisk pre-breakfast walk, led by a hotel fitness trainer, among the hills surrounding Safed.
Is changing Israelis' lifestyles as futile as talking about the weather, or can it be done - with hard work? That was the focus of this year's seventh NIHP conference, which in past years has been devoted to more esoteric subjects such as health fund competition and regulation.
The discussion of "Healthy Behavior as a National Target" - health promotion and disease prevention - was long overdue for a health system that spends about 97% of its budget on treating disease and the meager remainder on prevention and health promotion. The NIHP prepared an excellent 100-page background paper for discussion and mailed it to the participants in advance, but clearly not everyone had read it, so the discussions (especially in the three committees) tended to drift from practical solutions. Participants in the plenum broke up four times during the 30-hour conference to discuss incentives and other economic tools to promote healthy lifestyles; the role of the health system in health promotion and disease prevention; and the contribution of other national systems in achieving these targets.
HEALTH MINISTRY associate director-general Dr. Boaz Lev, who practices what he preaches by running kilometers every day and heaping his plate with greens, said the aim of the conference was to change behavior. For too long, he said, patients have been passive, waiting for their doctors to treat them rather than taking an active part in their own health. Many chronic diseases, he added, are due to individual lifestyle.
"Disease is drama, but prevention is not." Lev said. He added that even though the public benefit is clear, there is some controversy about health promotion: "There are tens of thousands of Web sites claiming that state intervention in the public's lifestyle is 'health fascism,' that if the state is responsible for everybody's health like a parent in control of his child, it can lead to tyranny."
But he noted that he recently gave an order to bar all smoking - and optional smoking rooms - in the Rehov Rivka ministry building where he works.
"We have received no complaints, only words of thanks," he said.
Although it may not seem so at first glance, health promotion and disease prevention can be explosive subjects, continued Lev, as they involve smoking (a major economic and legal issue) and overeatng, which involves a lot of emotions. "We have to turn healthful behavior into something natural like breathing. But should you punish people for smoking in their own home, or for being obese? Do you turn healthy living into a kind of religion? Do you make people feel guilty for not behaving properly? Poverty is a greater risk factor for disease than even obesity or smoking. Trying to change people can be regarded as arrogance, and there is a thin line between paternalism and genuine concern."
Dr. Eli Rosenberg, a senior ministry adviser working with Healthy Israel 2020 project coordinator Dr. Leah Rosen, said life expectancy figures of Israeli men and women are better than the European average, but their ranking is lower when the numbers of healthy years are
compared. Obesity rates here have not reached the frightening levels in the US, but they are going up, and Israeli youngsters' consumption of sweet soft drinks and the number of hours they spend opposite TV and computer screens is the highest in the world. Rosenberg quoted foreign health experts as saying that the steady increase in life expectancy in the developed world over the past two centuries "may soon come to an end" because of obesity.
FORTUNATELY, THERE is a rich compendium of imported and some Israeli scientific evidence about what can be done to fight these trends: For example, doctors, health promoters or nurses can give patients individual counselling about their lifestyles; workplaces can offer financial and other incentives to employees who exercise regularly; ads for unhealthful products can be barred; phone lines can be set up by support groups; and cities can install bike and walking pathways. Taxes can be levied on high-sugar, high-calorie and other unhealthful foods, but this is problematic; the poor will be forced to pay more for what they eat, yet a tax could induce them to change their diets.
But there are other ways: A 680,000-member health maintenance organization in Minnesota called HealthPartners managed to improve their health dramatically through exercise programs, smoking cessation and diet counseling, Rosenberg said.
The committee on economic tools to promote healthy lifestyles heard a very interesting proposal for financing medical treatment for smokers from Amos Hausner, a leading lawyer and head of the Israel Council for the Prevention of Smoking. He suggested legislation that would force all tobacco manufacturers and importers to pay a large amount of money in advance to cover the medical costs of consumers of its products. "As tobacco is the only product on the market that kills when used in the way it is intended, companies that sell it should be required to transfer such a deposit in the Treasury, which would allocate the money for health care."
Although this specific idea has never been applied, the principle is being used as a result of the US government's massive lawsuit against the tobacco companies, which are paying $245 billion to the states for their health expenditures on smokers. Tobacco companies that were defendants in the case are now demanding that tobacco companies established since the settlement should be required to make a deposit in advance to pay for damage to customers' health, Hausner said.
Other suggested measures to reduce smoking were to levy a tax on hookah (nargila) tobacco and paraphernalia and to raise cigarette taxes, with the aim of discouraging young people from smoking. Healthful lifestyles could also be promoted by reducing taxes on fitness equipment, barring the sale of sugary soft drinks and junk food in schools, distributing free nicotine patches, and lowering health taxes for those who don't smoke and are not overweight.
The committee on health system intervention heard evidence from foreign studies that patients want to talk to their doctors about improving lifestyles, but in Israel's reality, most doctors have too little time during consultations about medical complaints, and are often embarrassed or untrained to do so. The National Health Insurance Law, which went into effect in 1995, almost totally ignored disease prevention and health promotion, and few of these services are included in the basket of health services. The committee recommended that the law be amended to correct this.
THE EDUCATIONAL system, the four public medical schools, National Insurance Institute, Israel Defense Forces, Israel Police, local authorities, the media and other institutions outside the health system can do a lot more to promote health, the third committee said in its recommendations. More schools should educate with the health of their pupils (and their families) in mind. With the cancellation of the Employers Tax about a decade ago, workplaces are not required to contribute toward their employees' health, but it is in their best interests to do so by improving work environments, offering exercise facilities and giving dietary and smoking cessation advice, the committee said.
Although some participants urged the establishment of a separate authority or even a new ministry to promote health and prevent disease - because the Health Ministry is seemingly too busy with supplying and supervising medical care to do this - this initiative was fought tooth-and-claw by senior ministry officials, who admitted that they are not doing enough but claimed that a new authority "would not solve the problem." Associate director-general Lev said: "I don't think I am complacent.
There is a lot we still have to do, and priorities have to change, but when you compare Israel to other developed countries, we are not so bad! There must be enough political will."
Dr. Rami Ditzian of Clalit Health Services commented: "Too often, our health promotion programs, such as free mammograms, are taken advantage of by higher socioeconomic groups. We can improve averages yet miss whole populations.
Perhaps doctors in the haredi and Arab communities should get more of a bonus for persuading patients to get a mammogram than a doctor working in Ramat Aviv. And the public are confused about health issues. If you ask what is the biggest public health problem, most would say cellular phone antennas and not overweight.
They'd say their grandmother was overweight but she still survived."
Perhaps the best gauge of the success of this year's annual NIHP conference would be to measure the waist size of the participants when they attend next year; if the overweight are slimmer and if their bodies are more muscular, they have internalized the message and will be ready to spread it among the rest of us.