In many countries, including Israel, people who want to join a health club must get written permission from a doctor or even undergo an exercise-tolerance test. Now an Israeli team has shown that such screening does not reduce the risk of sudden death in low-risk persons, and could discourage them from exercising. The study by Dr. Dror Lahav (of Tel Aviv Sourasky Medical Center), Dr. Moshe Leshno (of Tel Aviv University) and Prof. Mayer Brezis (of the Hadassah University Medical Center) was published in the August issue of the Journal of General Internal Medicine.
Brezis, a nephrologist and public health expert who is responsible for preventing medical errors at Hadassah, has tried for years to get the Health Ministry to cancel the screening requirement, and it was one of 10 recommendations of a Health Ministry-appointed committee - of which Brezis was a member - on how to promote exercise by Israelis. But Brezis charged that all the recommendations were ignored. A senior ministry official told The Jerusalem Post that "everybody in the ministry agrees about eliminating the requirement, but such a decision must be taken by another ministry."
The study used a technique called a "Monte Carlo simulation" (a formula in which samples are taken randomly over and over) to determine what would result if people at low to high risk of heart disease underwent an exercise-tolerance test. The researchers said such screening would prevent some sudden deaths only in people at moderate to high risk from unaccustomed exercise. A low-risk person could get false-positive results and be discouraged from exercise, they argued, noting that sudden death from working out is very rare, "far less common than the mortality resulting from a sedentary lifestyle."
Brezis called the existing law "ridiculous, since it doesn't require a physician to see me before I run in the street, where I can get hurt even more easily."
In any case, nobody needs a license or a doctor's note to get out on the sidewalk and jog, argues Brezis, who stresses that "couch potatoes" should always start exercising gradually, and stop immediately if they suffer from symptoms such as dizziness or chest pain. Anyone who knows he has heart disease should of course consult his doctor before exercising anywhere. They also urge that sports facilities install semi-automatic defibrillators to resuscitate anyone whose heart suddenly stops.
EQUITY THROUGH TELEMEDICINE
Although the national basket of health services is officially the same for all residents, many Israelis in the periphery and in the lower socioeconomic groups have less opportunity to access the best treatment and health-promotion activities. Thus, Maccabi Health Services - the second largest health fund - has launched a unique program to promote equity in health services.
Maccabi director-general Dr. Ehud Kokia has announced that videoconference facilities are being set up among health fund branches to allow doctors working in the periphery to consult with leading specialists in the center of the country. In addition, Maccabi is training its staffers in "cultural competency" to understand the cultural norms and practices among various ethnic groups, hiring translators to communicate with those who do not speak the country's official languages. In addition, mobile facilities will bring advanced technology to the periphery so that members will not often be required to travel to the center of the country to get it.
Kokia said the health fund has identified a number of ethnic groups that receive fewer services than those to which they are entitled; the problem for many was that they did not speak Hebrew but only Russian. A team of Russian-speaking Maccabi nurses was sent to the new-immigrant health fund members in their hostel and explained their rights and where to get the health services they needed.
Maccabi also noted that certain low socioeconomic groups did not go for early detection of colon cancer; information efforts were carried out among them to encourage them to get tested. The health fund produced its first-ever "social map" of members that showed where the disadvantaged and those receiving fewer health services live. They were rated on a scale of 1 to 20. Although Maccabi is known for insuring the wealthier and better-educated populations -- with 26 percent included in the highest levels (16 to 20), it has a substantial number in the lowest rungs. There are some 40,000 relatively young Arab Maccabi members, for example, who are in the lowest levels of the scale. While rates of mammography are increasing in the whole population, there are still social and ethnic groups where too few women go for testing. The health fund has targeted these to promote equity.