America has quite a lot to learn from Israel on how to provide high-level medical care to all citizens equitably, but Israel can only envy the US for its massive funding for biomedical research - which in turn leads to better health care for its people.
Some of the leading experts in obtaining and allocating money for basic science - which leads to benefits at the bedside - came to Israel recently to advise the Israel Academy of Science and the Humanities, and participated in real and online consultations to alleviate the problems that cause many leading Israeli researchers to emigrate. The experts from the US National Institutes of Health (NIH), the UK Medical Research Council (MRC), the French Academy of Sciences, the German Robert Koch and Paul Ehrlich Institutes and the Swedish Medical Research Council came to Jerusalem to discuss the subject with their Israeli counterparts.
The two days of consultations were also the occasion for the Israel academy to celebrate the jubilee year of its establishment, and to publicize the hefty report of the Committee for the Assessment of the State of Biomedical Research in Israel. Two years in the making, it was a work of love by Israel academy vice president and leading Weizmann Institute immunologist Prof. Ruth Arnon and colleagues.
Arnon, a co-developer of the multiple sclerosis drug Copaxone, which significantly reduces the frequency and severity of attacks of the as-yet-incurable neurological disease, told the audience that while Israel excels in computer sciences - it's actually number one in citations per capita - and is tops in mathematics, theoretical physics and chemistry, it lags behind in clinical medical research.
"I think the level of medicine - in healthcare and research - is one of the aspects in a country that really increases the quality of life; purchasing medical knowhow and technology abroad does not replace producing your own," said Arnon.
Knesset Science and Technology Committee chairman MK Meir Sheetrit urged that state expenditures on merit-based scientific research increase from the current $65 million to a least $100 million, and that biomedical research funds come at the expense of Industry and Trade Ministry chief scientist grants for R&D at startup companies. Sheetrit promised to discuss the issues in his committee, and called for changing the nation's priorities for allocations.
This country "doesn't have to reinvent the wheel" in finding ways to increase investment in biomedical research, he added. "It can learn from others' experience. Israel should aim at setting up the equivalent of the NIH to objectively set policies and allocate enough funds to preserve and expand Israel's reputation for top scientific research in various fields."
ANOTHER POLITICIAN, Deputy Health Minister Ya'acov Litzman, promised to try to increase the amount of money received by the Treasury for allocation to medical researchers, but added that it was "not easy." His ministry's own Chief Scientist Office distributes a minuscule NIS 8 million a year for biomedical research.
It was rather depressing to hear Israel academy president and theoretical economist Prof. Menahem Yaari say the US has a gross domestic product 50 times that of Israel but spends 1,000 times (relative to GDP) as much on merit-based competitive research.
"That indicates the position of basic research in the priority lists of the two countries. The comparative rate involving only biomedical research makes us look much worse," he said.
Prof. Manuel Trajtenberg, chairman of the Council of Higher Education's powerful Planning and Budgeting Committee, called on the government to take action immediately. "Israel has a very good scientific base in the life sciences. There are young, eager scientists who have contacts with colleagues abroad. They have hutpza and believe they can solve even difficult problems. We have a very good healthcare system compared to many other countries, plus a diverse population that can serve as an interesting, compact laboratory for medical research. The health funds have in two decades developed computerized medical records that are the envy of other developed countries."
But he added that there are serious deficiencies in regulatory systems, and who owns the intellectual property produced by people working in state institutions is a big issue. They don't have enough incentive to spend their time in research, and there is also not enough management talent; "that can't be learned from the very successful hi-tech sector," said Trajtenberg.
Prof. Harvey Fineberg, a physician and president of the US Institute of Medicine at the NIH, credited the late Mary Lasker - an influential American health activist who worked to raise funds for the development of the NIH, which was established in the 1930s. Not only the US federal government (including the Department of Defense, which even spends money on breast-cancer research) invests in biomedical research but also state governments, universities, private foundations, donors and non-profit organizations.
When the administration wanted more money last year for economic recovery and investment, Senator Arlen Specter, who had the deciding vote,, demanded $10 billion more for the NIH - and it got it. The US voter really values investing in health, said Fineberg, and most want to spend more.
DUE TO globalization, the NIH is spending more on research projects outside the US, but even so, it is difficult to get an NIH grant - and he congratulated an Israeli participant who said he has never been turned down. "Research," said Fineberg, "is today more interdisciplinary and problem oriented. It is targeted to translational research that turns it from basic knowledge to things that can be used at the bedside."
While the US system offers excellent research universities, a high level of funding, a review system based on merit and plenty of entrepreneurship, its weaknesses include earmarking by legislators on behalf of projects in their own state and the reduction of basic research by industry. Israel can still benefit by learning from it, he said. Thanks to the Bayh-Dole act, scientists who get funding from the government can still benefit financially and share the profits with their universities.
The United Kingdom's MRC was first set up in 1911, when every working person gave one penny to support a tuberculosis sanatorium and conduct research into the disease, said Prof. Christopher Kennard of the University of Oxford. Later, the council had its own royal charter, and was able to make decisions independent of government. Today it has 700 million pounds Sterling at its disposal and 4,000 employees, has established its own units around the country and funds much outside research. All hospitals have full-time doctor/researchers who work without having to treat patients; this is almost unknown in Israel, where physicians generally prefer to receive patients privately after hours.
The French give tenure to biomedical researchers in their mid-30s, said Prof. Jean-Francois Bach, permanent secretary of the Academy of Science in Paris. "They have a salary for the rest of their lives. They don't have to compete all the time and can invest all their energies in scientific work. That's good, but in some cases it's terrible," because even those who are not good any longer continue to get paid. Two French institutions, INSERM and the CNRS, are autonomous, raise their own funds but spend most of their income on salaries. Hospital centers of clinical research excellence are devoted to specific themes such as organ transplantation, said Bach, who noted both the strengths and weaknesses of the French system.
After World War II, German government institutions were naturally decentralized, so there are research jobs in universities and colleges of all sizes and large research institutes like Koch and Ehrlich, said Prof. Reinard Kurth, who was president of both of them, as well as the Max Planck and Fraunhofer Societies, some of which do basic science while others do translational and clinical work.
The Karolinska Institute is number three in Europe and fifteenth in the world in research - but, said Prof. Olle Stendhal, former secretary-general of the Swedish Medical Research Council, it has lost impact in biomedical research in the past 15 years. Instead, Denmark has spent 11 billion euros on research, about a quarter to a fifth on biomedical research. Israel, similar in size to these Scandinavia countries, said Stendhal, can learn from their mistakes and achievements.
Arnon's report stated that "in many Western countries, the government supports biomedical research through agencies created solely for that purpose, such as INSERM in France, MRC in England and NIH in the US. Israel, in contrast, has no organization or agency that exclusively supports biomedical research, and the government does not allocate significant resources to such research."
The current state of affairs, the report continued, does not allow Israeli biomedical investigators to reach their full potential due to the limited amount of funds available; outdated research infrastructure; the inability of young researchers to secure position; and the large amount of time wasted in chasing after many small research grants. Also, the level of research done in Israeli hospitals (where most clinical research is conducted) is much lower than in Israeli universities. One indicator of this disparity is the citation index, where research papers originating from hospitals receive, on the average, much lower scores than research papers originating in the universities.
The authors recommended the establishment of a new national fund - financed by the Israel academy, the Israel Science Foundation and the Health Ministry - devoted exclusively to the support of biomedical research, adequately capitalized and run by appropriate experts. Such a fund, they wrote, would help Israel achieve its full potential in biomedical research.
As the hospitals are owned and run by many different bodies without a centralized mechanism for establishing uniform clinical research policy, the committee recommended creating a special unit within the new National Fund for Biomedical Research to promote clinical research and physician/researcher careers through research grants and stipends. In addition, incentives should be provided to universities interested in developing biomedical and biotechnological research, the report said.
The authors recommended that Israel adopt the provisions of the Bayh-Dole Act as a model for intellectual property rights and protecting discoveries made by government employees.
Those, and the report's other numerous recommendations, certainly sound good. The question is whether it will go in the footsteps of other committee reports aimed at promoting Israeli scientific development that were consigned to the dust heap or will arouse enough support to actually be implemented.