A shot in the arm for the Health Ministry?

The new director of public health services wants to boost health promotion, disease prevention and environmental health.

itamar grotto 224.88 (photo credit: Judy Siegel-Itzkovich)
itamar grotto 224.88
(photo credit: Judy Siegel-Itzkovich)
Many Israel Defense Forces officers who move on to government positions learn that in the military you give an order and it is usually carried out; in civilian life, it can take a lot of persuasion. Dr. Itamar Grotto - previously in charge of public health in the IDF and hired by the Health Ministry last December to become its director of public health services - has already learned this lesson. "When I came here, I found the ministry hierarchical, with people working according to the guidelines they know. It is a bureaucracy. But I arrived optimistic, and I want to be here for a long time," he said in an interview with The Jerusalem Post in his office on Jerusalem's King David Street. Grotto, a man of few words, studied medicine at Tel Aviv University's Sackler Medical Faculty immediately after high school as part of the IDF's atuda (academic training) program. Upon graduation, he joined the military's health branch, and got a master's degree in public health at the Hebrew University-Hadassah Braun School of Public Health and Community Medicine. Then he was appointed IDF chief of epidemiology, trained in a district health office and became head of the IDF's health branch - the military counterpart of his current job in the ministry. Three years ago, he taught epidemiology and public health at Ben-Gurion University, with which he is still affiliated. But then the ministry asked him to replace its long-time director of public health services, Dr. Alex Leventhal (who became its international liaison). Grotto felt he couldn't turn the offer down because "the job is an important one." The ministry knew of him because he served as an adviser for possible emergencies such as a pandemic influenza The Hod Hasharon resident is now in charge of some 2,000 ministry employees in the Food Service, epidemiology department, tuberculosis and AIDS department, environmental health, mother-and-child health department, nutrition, public health nursing, health promotion and district health offices. HE IS WELL aware that health education and disease prevention get short shrift in the state budget, attracting less than 5% of health expenditures, with most devoted to the treatment of disease in clinics and hospitals. But Grotto is determined to change that. One of the more urgent matters he has had to deal with is a recent outbreak of measles. About 1,000 cases have been registered, and there is no end in sight. It began in August 2007, after a 22-year-old Satmar hassid from London attended a Jerusalem wedding along with 2,000 others and went to the TEREM urgent care clinic with a rash - one of the usual symptoms. Dr. Brendon Stewart, director of TEREM's Talpiot branch, said the hassid didn't show the oral sores and eye infections that also characterize measles. Stewart remembered reading about a measles outbreak in London a few weeks earlier and realized the hassid was infected. He learned that the man had never been vaccinated against measles and immediately called Dr. Nitza Abramson, the deputy chief district health officer in Jerusalem, who gave him advice. But the ministry did not act immediately to contact Satmar rabbis and synagogues, even though numerous parents in this community refuse to have their children vaccinated against numerous diseases, which they regard as "not serious." Although the ministry's epidemiology department thought the chain of infections would be halted when haredi children went on their Succot vacation, it continued nevertheless. Months later, a vaccination campaign in the haredi community was launched, but the chain of infection continues, reaching a secular Hebrew University student, hospital personnel, people outside Jerusalem and even airline and bus passengers. GROTTO SAYS he was not aware of what happened before he took his post and couldn't say whether the continuing spread of measles is partly the ministry's fault. The vaccine was developed abroad in 1957 but used in Israel only since 1967. "Then, only one dose was given, but in 1977 it was realized that two doses were preferable, and this became policy. There is still a problem with some haredim. Bnei Brak has a 99% vaccination rate, but in Jerusalem, there are some whole streets where parents have refused vaccination. We tried to use pashkevilim [printed messages hung on walls - the major form of communication in haredi communities] to inform residents of the urgency of vaccinating those who have not received shots. The outbreak will end, but I don't want to predict when." Asked whether the ministry might offer material incentives, such as a bag of disposable diapers, for bringing children in, Grotto said this was "a good idea that we might consider, even though the Treasury might oppose it." The ministry must also keep its eye out for West Nile virus, which in recent years has been part-and-parcel of the summer months due to infected mosquitoes who serve as vectors for the pathogen carried by birds. But because of more awareness of the danger of standing water as breeding grounds and action by the authorities, there have been fewer cases and no deaths in recent years. In 2000, there were nearly 500 cases here, and over a dozen deaths. MANAGING THE Israel Food Service, which supervises food production and marketing, is a year-round major function of Grotto's staff. But there is a severe shortage of inspectors because of Treasury limitations. "We recently received some more, and now there is a total of 21, but we still need more. We can't supervise every food manufacturing plant. All over the world, the health authorities trust those that have met GMP (Good Manufacturing Practices) standards. Nevertheless, we try to make inspections, including surprise visits." Grotto said he had not seen the recent Second TV Channel's Kolbotek program that uncovered the fact that one importer regularly erased last-date-of-sale markings on products and stamped them with later dates. In one film clip, a ministry inspector was shown visiting the storeroom, where workers stopped their illegal erasing and stamping until the inspector left. "If there are criminals, we can't do much. We do sampling." In 2003, the ministry was caught failing to properly supervise the Remedia baby formula company that had sold a shipment of soy-based powder which had failed to include a vital B vitamin and killed three infants, causing serious neurological damage to others. After the scandal, baby foods were classified by the ministry as "special," which means they need more rigorous supervision - almost like that of pharmaceuticals. One problem, says Grotto, is that food supervision requires cooperation among a large variety of authorities, including the Agriculture and Environmental Protection Ministries. "But now I am glad to say there is much better coordination." Grotto, a former smoker who has not lit up "for years," says he is for strict enforcement of laws barring smoking in public places. "We have to do something to bar automatic vending machines for cigarettes," he said, when asked about this part of the World Health Organization's Framework Convention on Tobacco Control, passed unanimously by a majority of WHO members in May 2003 and formally ratified by Israel in 2005. In addition, he favors barring smoking in vehicles carrying children, but said this would require agreement by the Transport Ministry. Still, he thinks the ministry may be well advised to allow people to smoke at open-air tables outside restaurants and cafés, even though this is prohibited today. Grotto said he is keeping a close watch on the Association for Public Health - a non-governmental body to which responsibility for the National School Health Service was transferred under Treasury pressure last year despite opposition by all public health experts. He concedes that not all schoolchildren have received their vaccinations in time, and that little or no health education or monitoring is going on. A Hebrew University-Hadassah Braun School of Public Health proposal for health education in the schools is being examined by ministry officials, he said. Grotto also wants to improve the services of the much-depleted Tipat Halav (well-baby) clinics, which have been threatened with privatization for years by the Treasury. Since Prime Minister Ehud Olmert announced that this service would remain in the Health Ministry's hands, the threat seems to have receded. "It is true that for years, Tipat Halav nurses have not visited the homes of new mothers to see conditions there, but we hope to go back to the standard service." But, he added, there are some things that don't depend only on money. "It is policy and cooperation among authorities, such as the Education Ministry, which is needed. We are working on it, such as getting junk food out of the schools. There are basic things I want to change, including more preventive services for children. I want to work more on environmental health and environmental epidemiology. I may set up a ministry unit on environmental health that would be involved with planning agencies. We need more bicycle paths to improve health, and more health information to the public."