Healthy soldiers are better soldiers

The Israel Defense Forces spares no expense in guarding the health of its recruits, the IDF's chief of medical services tells Judy Siegel-Itzkovich.

IDF soldier lebanon 224 (photo credit: Ariel Jerozolimski [file])
IDF soldier lebanon 224
(photo credit: Ariel Jerozolimski [file])
Getting seriously ill is no picnic, but many Israelis are unaware that the IDF goes all out when it comes to its soldiers' health. If a lifesaving transplant is needed and no organs are available here, the soldier (accompanied by a relative) is sent abroad; expensive medications not included in the Health Ministry's official basket are provided as needed; women soldiers can now get the expensive HPV (human papilloma vaccine) to protect them from cervical cancer at a subsidized price; and all hospitalized soldiers are assigned an IDF representative to look out for their needs. If a sick or wounded soldier is hospitalized far from home, the IDF will pay for a nearby hotel room for his immediate family. In an extremely rare initiative, the IDF Spokesman's office invited The Jerusalem Postfor a personal briefing by Aluf-Mishne (Colonel) Dr. Kobi Haviv, the officer in charge of the IDF's medical services. Haviv, whose Tel Hashomer office is in what used to be a British army camp during the Mandate period, is considered equivalent in responsibilities to the director-general of one of the four public health funds. Born in Bat Yam, Haviv earned his MD degree at Tel Aviv University's Sackler Faculty of Medicine as part of the IDF's Atuda (academically trained service) program, and then served as a military physician, where he has remained. He worked in the field, in the paratroops and elsewhere, received his master's of public health and completed a specialty in occupational medicine inside the IDF, leading to his previous post as the first chief of the occupational medicine branch. Few civilians - and even physicians - are aware that the IDF offers training in certain medical specialties outside of public hospitals. "I was the first to study occupational medicine in 2001, but since then, specialty training has been offered in public health, family medicine, mental health and health management. This was an historic IDF decision," he recalled. "Academization is a very important trend in the military. It was realized that without academic degrees, the level of knowledge would not be high enough. We are teaching medical management to 40 of our doctors," said the medical services chief. ATUDA SERVICE has not been very attractive to would-be doctors in the past decade or more - even though medical school tuition is paid by the IDF (unlike when Haviv was a medical student and had to pay his own way). The IDF Medical Corps needs 70 to 75 new physicians a year, but in 2006, only 45 joined the Atuda to study medicine and then serve as an IDF doctor. Only last week, IDF Chief Medical Officer Brig-Gen. Dr. Nachman Ash aroused some controversy when he announced plans to issue a tender for an existing academic medical school to open a branch that would admit candidates with slightly lower psychometric and matriculation scores who had failed to be accepted to one of the four university-affiliated medical faculties. But while coming with slightly lower grades, the IDF intends to select "women and men whose personalities and leadership traits are more suited to serving as military physicians." The announcement was criticized by Rambam Medical Center director-general Prof. Rafael Beyar, a leading cardiologist and past dean of the Technion-Israel Institute of Technology's Rappaport Faculty of Medicine in Haifa. Beyar maintained that establishing a "separate" military medical school was a waste of resources. But the idea of a military medicine school as part of a civilian medical school was defended by Ash, who argued that if today he were applying to one of the university-affiliated medical schools - with their almost unachievable grade demands - he would not be accepted. PROF. SHAUL SOFER, a veteran pediatrician at Soroka University Medical Center in Beersheba and currently the dean of the Health Services Faculty at Ben-Gurion University of the Negev, reacted to Beyar's criticism. It will not be a separate medical school but a program in an existing medical school, wrote Sofer, whose medical school is competing in the IDF tender. "It will not be managed by the IDF... but its curriculum will be set and run by the [academic] medical school." Acceptance of students will be in accordance with today's criteria for admission by the academic Atuda, Sofer stated. The curriculum will be identical to those in medical schools, and in most classes, the IDF students and medical students will attend together. There will also be seminars and additional studies of military medicine and special military courses during medical school vacations, Sofer concluded. "We want military doctors who will be very good in the field," said Haviv. "Not every graduate of a regular medical school is suitable for the IDF. It won't be easy to establish a special school, and it will require considerable money and need enough clinicians who can teach in the hospitals. But the IDF has allocated money for this, as we believe it will succeed. We will put applicants through special tests to see whether they will be not only excellent doctors but also excellent officers in units. We now take doctors that medical schools produce, but that doesn't mean they are all suited to be the best military physicians and officers," Haviv said. "My dream is that all soldiers will receive absolutely the best medicine available in Israel." PLANS ARE to launch such a medical school in the fall of 2009 after an academic medical school wins the tender. There might even be the need, Haviv added, to set up a separate school for nurses in the military, given the national shortage of civilian nurses. But there is no reason, he asserted, to go back to the situation during the early days of the State and have separate military hospitals. Despite the lack of IDF general practitioners, Haviv said it has enough high-level medical specialists. "We buy services from hospitals for consultations with specialists, or we send them to our own specialist clinics; some are IDF officers, while others are civilian specialists who work on a voluntary basis as their reserve duty." But in primary care for non-combat soldiers, the IDF is aware that a lot more has to be done. It has issued a public tender for the supply of such health services in civilian health fund clinics. It will begin soon as a pilot program to replace primary care clinics at the Tel Hashomer base and in Tel Aviv's Kirya base so that more military doctors can be shifted to bases in the north, south and other outlying areas where combat soldiers serve. "We want to continue to be responsible for such care, but through outsourcing and careful supervision of the services provided to the IDF," Haviv said. "Under the pilot project, selected primary-care physicians working at health fund clinics who are found suitable will treat soldiers. If it succeeds, we will expand it. We hope all four health funds eventually will be part of the program. This will free up IDF doctors to treat soldiers in the field. It will not be aimed at saving money but to improve medical care for soldiers and avoid duplication of services." KOLBOTEK, CHANNEL 2 TV's investigative program, voiced harsh criticism earlier this year of outsourced urgent medical care for IDF soldiers when military clinics are closed at night, on weekends and on holidays. A year ago, the IDF chose the Bikur Rofeh chain of clinics in a public tender to provide such care. The show presented hundreds of fevered, coughing or mildly injured soldiers packed into clinics, waiting in line for hours until they were seen by allegedly unsuitable and overworked physicians. The show was viewed in the IDF as being unfair and misleading, as it was filmed only during the running in of the service, before it was officially launched. The Medical Corps' now-closed seven primary-care clinics had only one physician on duty in each, and the queue was long. Now there are eight Bikur Rofeh clinics designated for soldiers only, employing 24 civilian physicians, and two more will be opened soon. Haviv said he and his colleagues "supervise these closely, and are very satisfied with the level of care. Our contract with the company stipulates that soldiers have to be attended to within an hour of arrival, and this occurs in 95 percent of cases," he continued. "Complaints have been halved. If a soldier has a complicated problem that can't be dealt with in the clinic, he can always go to a hospital emergency room. Almost all the clinics have a 'personal physician' that the soldier knows and who knows him, instead of going to any doctor who is free. Bikur Rofeh clinics in the larger cities have an orthopedist on duty; we never had such a specialist in our own." Although violence against doctors and nurses in civilian clinics and hospitals has been widespread, the IDF Medical Corps has shown "zero tolerance" for such a phenomenon in its own facilities. "We are not different from the rest of society," maintained the IDF medical services commander. "Soldiers and their families are tense and anxious. Even verbal violence by a soldier leads to a hearing. Soldiers have been jailed for months by military courts for harming medical staffers. In the past, there were cases dismissed 'for lack of public interest' but today the military police must deal with it. If it is a non-IDF relative or friend who is violent, we automatically file a criminal complaint with the police. A violent soldier becomes a violent civilian. It is the 'handwriting on the wall' and must be dealt with." In addition, IDF physicians undergo special training to learn how to defuse violent situations, he said. As for dental care, the IDF runs several clinics. "Some dentists are from the Atuda, and others are on reserve duty. We give the most attention to younger soldiers doing their compulsory service. We want soldiers to have better teeth when they leave the army than when they enter - and many come to us with a lot of dental problems because their families could not afford dental care and their teeth were neglected. Every draftee undergoes a basic dental checkup, and the most urgent cases are treated first," Haviv said. Haviv is not responsible for health promotion and disease prevention, but others in the Medical Corps work to prevent smoking and enforce no-smoking laws; promote healthful lifestyles and decrease overweight by improving the military diet and encouraging physical activity; and minimize occupational injuries and environmental harm. Although smoking is no longer allowed in IDF rooms, clubs and other indoor areas, there is a continuing trend of young people starting to smoke during service. The latest figures for 2007 show that 33% of men smoke at induction, compared to 40% upon completion of service; for women the figures are 32% and 38% respectively. Since a private member's bill initiated by Kadima MK Yoel Hasson was passed into law by the Knesset last February, rules that governed smoking on military bases were often not enforced properly. It was very difficult for soldiers to demand that their commanding officers observe the no-smoking rules. Under the new law, military police and others in charge of discipline in the security forces enforce the anti-smoking rules; violators face a disciplinary board and can be rebuked, fined and even jailed. Dr. Omer Ankol, head of IDF Medical Corps army health branch (in charge of health promotion and disease prevention) - who has had a career path similar to Haviv's in medicine, public health and occupational health - told The Post that even though cigarettes are still sold at bases, great efforts are made to encourage soldiers to kick the habit through smoking-cessation courses and lectures on adopting healthy lifestyles. Ankol, who never smoked and managed to persuade his wife to quit, said such courses are now available for young draftees in addition to professional soldiers; 65% are induced to stop smoking after the course, with 50% smokefree a year later. The IDF has trained 14 soldiers to run such courses after initially depending on civilian personnel, and this number will increase, said Ankol. While he did not have the latest data on the rate of overweight (Body Mass Index between 25 and 29) among inductees, Ankol did say that 4.8% of men and 2.3% of women inductees are obese (over 30 BMI) - 4.5% and 2.3% respectively when discharged. Obesity and overweight rates are lower in officers, thanks partly to the fact that they have an incentive to be physically fit and undergo more lifestyle counselling. In addition, the military kitchens - increasingly privatized and using civilian caterers - have minimized the availability of high-fat burekas and calorie-laden cakes and increased that of salads, fruit and low-fat foods. Although eating disorders are relatively common in civilian society, the IDF, noted Ankol, is careful not to describe anorexia or bulimia because doing so is known to increase the number of sufferers; instead, stress is put on healthful lifestyles. As for drug use, a new survey will soon be conducted with the help of the national Anti-Drug Authority. The risk of AIDS and other sexually transmitted diseases, as well as contraception, are taught draftees, and proper diet and health promotion of pregnant women in the professional army are taught in a variety of booklets. As for environmental and occupational health risks to soldiers, anyone can call the Medical Corps to file complaints. The days of the Nahal Kishon affair (in which IDF divers were exposed to toxic chemicals in the Haifa body of water while training), and dangerous asbestos map boards (finally removed a few years ago) are gone. The IDF's awareness of the world's increasing interest in health is high, Ankol concluded, and it is more active than ever in fulfilling its obligation to return the soldiers entrusted to it in a healthy state.