When your mayor worries about health

A holistic approach to creating healthy communities, once unfashionable, has ignited the imagination of everyone involved.

By JUDY SIEGEL-ITZKOVICH
DR. MILKA DONCHIN and Amram Mitzna 311 (photo credit: Judy Siegel-Itzkovich)
DR. MILKA DONCHIN and Amram Mitzna 311
(photo credit: Judy Siegel-Itzkovich)
During modern Israel’s early years, most people had no riches, so there was nothing to covet or steal. As time progressed, mayors used to worry about filling potholes, collecting trash, fixing traffic lights, making sure children went to school and collecting property taxes – giving hardly a thought to the health and wellbeing of the people. But in the second decade of the 21st century, the gaps between rich and poor, newcomer and veteran, healthy and sick are widening.
Fortunately, heads of municipalities and local authorities are investing more of their time than ever to improve the physical, mental and holistic health of residents – not only to win the next election but out of the realization that this will make their city a better, more livable and attractive place.
An initiative formulated 27 years ago in Canada and developed into an experimental project by the World Health Organization (WHO) was adopted here in 1990 as the Israel Network of Healthy Cities. The network’s first four members were Jerusalem, Tel Aviv, Netanya and Ramat Hasharon, but it has since expanded to 50 cities, towns, local authorities and regional councils – most of them actively involved. They vary from the big cities of Jerusalem, Tel Aviv and Haifa to Arab localities such as Um El Fahm and Kafr Kara.
THE NETWORK, headed by Dr. Milka Donchin since its founding 21 years ago, promotes better health among each locality’s residents via a wide variety of projects, including the boosting of physical activity, dental health and smoking cessation; the construction of biking and pedestrian paths, recycling, reduction of teen vandalism; and battles against pollution and dog excrement on sidewalks. It also provides information on successful projects around the country and helps municipalities amass “health profiles” so they can assess what is working and what needs to be improved. It is a cooperative effort with the health funds and a variety of voluntary organizations.
Donchin, who is head of the health-promotion track of the Hebrew University-Hadassah Braun School of Public Health and Community Medicine, recently presided over an all-day conference at the Hadassah University Medical Center in Ein Kerem on “Healthy Cities and Academia Work to Reduce Gaps.” The gathering – the 20th Healthy Cities Network conference sponsored by the four public health funds and Mifal Hapayis – was attended by over 150 people from a variety of professions and was addressed by number of dignitaries.
Donchin said “every city that adopts our principles is bound to be involved in promoting health and reducing gaps in health among the various sectors.” Every municipality and local or regional council has to pass a decision in the city council to join the network and set up a steering committee. It must prepare a “city health profile” based on objective data such as that from the Central Bureau of Statistics. Municipal health coordinators, with help from the national network, must determine the causes of inequality and pinpoint who suffers from it, she said.
THE DATA include not only pure health statistics but also what percentage of 12th graders matriculate, how many elderly get income supplements, and how many immigrants live there. “How many residents smoke? How many live in their own apartments? How many exercise? How many women over 50 undergo mammography? Is there trust among residents, or are neighborhood disputes common? Are there mosquito infestations? “How much juvenile crime is there? How many break-ins? What are the conditions of sidewalks, and how much dog excrement is there?” she said, just to name a few issues.
Health Ministry director-general Prof. Ronni Gamzu, who appeared briefly at the conference before rushing off to participate in more negotiations of the Israel Medical Association-Treasury labor dispute, said: “Social and economic gaps in Israel are among the worst in the OECD countries of which Israel is now a full member. This is because of the structure of our diverse population and the social, economic and geographic gaps. All these affect the health of a population. But you can’t do it alone; one has to get help from the local authorities. The big health problems today are no longer acute diseases but chronic diseases from obesity to cancer that put a terrible burden on the West.”
Gamzu promised that by August, his ministry’s Healthy Israel 2020 plan will reach the cabinet; in preparation for several years, this plan is aimed at health promotion and disease prevention.
Like Donchin’s Healthy Cities Network, the Healthy Israel 2020 plan also requires the cooperation of a wide variety of government ministries, local authorities and non-profit organizations.
MK Rachel Adatto, a gynecologist and a strong supporter of Healthy Cities, said it was unfortunate that the Ministerial Committee on Legislation just turned down the private member’s bill she and MK Dov Khenin presented that would require all proposed infrastructure projects to undergo assessments of how they would affect health. “It is so elementary. How can it be that the ministerial committee rejected it? Health is connected to everything else.”
Academia cannot be removed from daily life, said Prof. Eran Leitersdorf, dean of the Hebrew University Medical Faculty in Jerusalem. “We can’t lock ourselves up in an ivory tower. When we saw that the Israel Defense Forces couldn’t get enough young doctors to work in the military, we established a military medicine program to teach them, and have begun to produce 62 for our first graduating class. Now that the National Health Indicators program was established to look at healthfund equity and services to the public, our School of Public Health became responsible for assessing them. As a medical faculty, we must be involved. Academia can donate tools for research and followup, and even help set policy. We have excellent students. We can’t just have them study without expressing themselves on important issues. Once a year, we give a School for Public Health student a prize for carrying out the best project in the community, whether in the fight against smoking or promoting a ‘green campus.’ We do the same in our nursing, pharmacy and occupational therapy schools.”
TWENTY YEARS ago, it wasn’t fashionable to be involved in the Healthy Cities program, added outgoing Hadassah Medical Organization directorgeneral Prof. Shlomo Mor-Yosef. “But in recent years, the matter has become very relevant to the general public. Institutions have to be relevant, not just to increase knowledge in the world but to influence public health. Hospitals must cooperate with the community.” Mor-Yosef noted that the Hadassah University Medical Center in Ein Kerem invites all seniors in Jerusalem high schools who get their driver’s licenses to spend three days seeing with their own eyes the result of careless driving .
Prof. Orly Manor, dean of the Braun School of Public Health, said there are major health gaps depending on what community people belong to, how much education and income they have, and how healthy they already are. Life expectancy is much higher among Jewish men in Israel than among Israeli Arabs, who have a significantly higher rate of disability and type II diabetes. Infant mortality is 2.3 times higher in the Arab than the Jewish sector. Uneducated women have five times the risk of cardiovascular disease than highly educated women.
The less education one has, the more likely one is to smoke. The more educated one is, the more likely one is to exercise. If one has gone to college and has a car, this is almost an automatic sign that one’s health will be better and one’s life expectancy longer. Manor said. But there are health gaps within single communities. Some in the Israeli Arab community, for example, are much better off than others, she said.
Arnon Mantver, veteran director of Joint-Israel, said “populations is what we most focus on in Israel.” The Joint, established by US Jews in 1914 even before the British Mandate took over from the Turks and later invested heavily in North African and Soviet Jewry, has devoted much effort in recent decades in Israeli society. “The main problem here is the great difficulty in implementing policy,” said Mantver. “It’s easy to announce new ones, but producing change is slow and frustrating. A country like Poland is homogeneous, with people of one religion and culture. But Israel has such variety in one very small space.”
Improving target communities is very difficult, said the Joint Israel director. “The various sides often agree on policy, but get stuck in the community. You have to do a lot of visiting people and talking to them. But there are points of light in which we have succeeded. We developed a model that has worked quite well.”
The Joint used to actually provide institutional services, but it is gradually reducing this aspect because of the lack of money. Instead of putting the focus on institutions, it is now stressing services on the community level. “People in the community are very smart; they know what they need.”
Today, the Joint focuses on programs for the elderly, unemployed, the disabled, immigrants and children at risk. “We don’t give direct services, but develop services so they will be successful,” he explained. It has established eight centers to help haredi men and women find employment, centers for haredim and others for Arabs, 35 centers for youth, 250 programs for helping the elderly remain in their neighborhoods, six centers for helping the disabled live independently, and more. The culture of each group has to be taken into consideration. “If we can close the economic gaps, we automatically reduce gaps in their health situation.”
Joint projects have helped Ethiopian women get jobs; today, 53% of those of working age are employed.”
The Joint-Israel’s strategy, Mantver said, is to identify social problems, then plan a model to cope with them, build partnerships that can be financed and finally, it scales down or phases out its involvement when it is sure worthwhile projects can continue on their own.
Also at the conference were numerous municipal and academic leaders who have cooperated to promote health and better lives for residents of localities in the Healthy Cities Network. They lectured on everything from encouraging adults to walk regularly on Fridays to redesigning streets and sidewalks.
Amram Mitzna, the former (and maybe future) Labor Party leader who completed a decade as mayor of Haifa and then devoted himself for five more years as an appointed mayor to improving the long-neglected southern development town of Yeroham, was clearly welcomed for his successful and pioneering work there.
Before he returned to Haifa, Mitzva was determined that Yeroham’s Healthy City participation would continue in his absence. “It was a central project when I was mayor and improved residents’ quality of life by cooperation. Residents are now aware of health, and that they have a responsibility to prevent disease and work together. The town is like a mini-laboratory. Its social fabric has improved.”
Mitzna is optimistic. “The children are the best ambassadors to bring change in the future.”