The Nobel Prize is like a rear-view mirror: The world's most prestigious award usually honors achievements attained many years - even decades - before. It's no different in Israel, where researchers at the Technion - Profs. Avram Hershko and Aaron Ciechanover - were in 2004 the first Israelis in biomedicine to become Nobel laureates. For years it was axiomatic that Israeli physicians are world leaders in medical research - an elite, well-educated group who spent sabbaticals at top labs abroad, were guest lecturers at international conferences and published in the most prominent journals. But there are worrisome signs that this reputation is becoming tarnished - that Israeli advances, while still numerous, are the result of decades of hard work by researchers who are now nearing retirement. Medical ethicists have noted with much concern that the vacuum caused by the dearth of public research funds has encouraged vested commercial interests such as the pharmaceutical, tobacco and food industries to sponsor biomedical research. Is the State of Israel still cultivating future Nobel winners? Hershko and Ciechanover shared the Nobel in Chemistry for their discovery of the ubiquitin system of regulated protein degradation. This led to the development of a drug used to treat bone marrow cancer, and has sparked worldwide study of the ubiquitin system and potential treatments for a wide variety of diseases. Both have said they are worried about the future, and warn that Israel isn't adequately funding biomedical research and education. Without this, they stressed, Israeli scientists and technologists will not be able to make significant contributions, and the country's reputation will be resting mostly on its laurels. But governments over the decades have not gotten the message. Back in 2002, Health Ministry chief scientist Prof. Rami Rahamimof stated that per capita Israeli investment in medical research was already among the lowest in the world. Rahamimof, a 1998 Israel Prize winner for medicine, former dean of The Hebrew University-Hadassah School of Medicine and a leading physiologist at the school, told a Knesset committee that the annual per capita expenditure on medical research here totalled only 40 US cents, compared to $47 in the US. Israel, he said four years ago, is also near the bottom compared to Western European countries, where 6.7% of the civilian research and development budget went to medical research, compared to 0.4% in Israel. Rahamimof knows his figures, because in 1989 he was appointed chairman of a state committee to recommend ways of advancing Israeli medical research. The nine-member committee presented a serious report but new ministers came in, and nothing came of it. Even then, the Rahamimof committee noted a drop in the number of citations of Israeli articles by foreign researchers, and bemoaned the reduction in foreign-funded clinical research. Rahamimof's predecessor at the ministry, Prof. Bracha Rager, complained in 1999 that she had only NIS 8 million a year to invest in medical research. Still, the current chief scientist can only envy that 1999 budget. A veteran scientist in brain research, Rahamimof says his office's budget is currently a measly NIS 4.2 million. Only NIS 32 million in public money - via the Health Ministry, the Ministry of Industry and Trade and the Israel Academy of Sciences and Humanities - went to medical research last year. The US National Institutes of Health (NIH), by comparison, spends nearly $30 billion annually on biomedical research. In the OECD countries, the average investment in civilian R&D is 8.2% of GDP, but in Israel it's little more than 0.4%. "The situation is clear," he told The Jerusalem Post in an interview. "The Israeli impact on the world's biomedical research is declining. The Treasury cuts the Health Ministry's budget, much of which is tied up in salaries and other fixed costs; medical research via the chief scientist's office is considered a luxury." David Ben-Gurion, who cared so much about investment in science and the frontier, "would turn over in his grave," Rahamimof laments. RAGER, A prize-winning Ben-Gurion University researcher in immunology and microbiology who is, like Rahamimof, past retirement age, told The Post: "The Treasury has not internalized the fact that you have to protect and preserve the infrastructure of medical knowhow. Clinicians need a basic understanding of research to understand what drugs can do for patients. Treasury bureaucrats claim Israel can import such knowhow by consulting the Internet! But people, diseases and health systems are different. Treasury officials keep changing, and there is a high turnover in health ministers as well. The National Institute for Health Policy Research - established a decade ago to study the effects of the national Health Insurance law and get a fixed amount of National Insurance Institute-collected health taxes - suffered cuts as well. The academy has a fund for basic science, but it is dependent on the Council of Higher Education's planning and budgets committee." Rager, who is president of the Israel Microbiology Society and still serves as an adviser to the Health Ministry's chief scientist, noted that the academy is able to finance only three physician-researcher positions through Keren Batsheva de Rothschild. "It hurts to see young doctors do great work but have no money for research and thus can't advance." The chief scientist's office received about 300 formal applications for grants in 2005, but only about three dozen were approved, and the grants are small, just NIS 80,000 annually for two years. "Since biomedical researchers are aware of the meager budget, many don't even bother to make applications because they think they have little chance of winning," Rager added. Prof. Mordechai Shani, former Health Ministry and Sheba Medical Center director-general and now head of Sheba's Gertner Institute for Epidemiological Research and Health Policy, estimates that there has been a 25% quantitative decline in Israel medical research over the past three years. "The quality of research that is still carried out is high, but the government provides much less funding," he told the Post. "The Treasury has weakened and all but destroyed the chief scientist's office. Health Ministry director-general Prof. Avi Yisraeli, who is very research minded, has tried. He begs for money, but he hasn't succeeded in getting more." Shani added that Treasury officials and other government bureaucrats fail to realize that if adequate public money is not made available to biomedical researchers, not only will research continue to decline quantitatively, but the vacuum will be filled by vested interests such as commercial firms. Politicians who set priorities are not interested in or aware of the desperate need for research, Shani said. Besides the dearth of funds, Rahamimof explains the decline in research in part by the fact that the Treasury refuses to give government hospital doctors any rights to their discoveries. "Intellectual property of state employees belongs to the Treasury accountant-general's office, so hospitals and their staff can't share in the profits. This is not true at Hadassah University Medical Center, The Hebrew University or the Weizmann Institute of Science, for example, which have R&D arms that share intellectual property with their researchers. We set up a committee years ago that recommended establishing research centers for government hospitals that would share profits and patent rights, but this was never implemented because of Justice and Finance Ministry opposition." The third major reason for the decline, according to Rahamimof, is the temptation of private practice. Senior doctors can open private clinics and earn hundreds of shekels for a few minutes of consultation per patient; this is a lot easier than working round the clock in research labs. Prof. Jonathan Halevy, director-general of Jerusalem's Shaare Zedek Medical Center and an internal medicine specialist, agrees that there is a problem. "I have the definite feeling there is less medical research. We at Shaare Zedek feel it less because we have been affiliated for six years with Ben-Gurion University's Health Sciences Faculty, so our research is on the upswing. Our technique is to encourage centers of excellence. But I do see a decline in the amount of Israeli biomedical research compared to when I was a young doctor at Beilinson. There is less motivation to do it." THE NEW dean of The Hebrew University's Medical Faculty, Prof. Ehud Razin, said there are still "islands of excellence in universities' basic biomedical research. But equipment costs hundreds of thousands of dollars, and the planning and budgets committee has in recent years given much more money to colleges, which don't do much research, at the expense of the universities. The quantity of research is less crucial than the quality, but you can't have quality either without investing in infrastructure," said Razin, an internationally known researcher in cell biology. "If I want to attract a promising young researcher who has done post-doctoral work at Harvard, I have to invest $700,000 on equipment. In a few years, if there is no massive investment, the medical and science infrastructure will collapse." "There is a decline in willingness of young doctors to go into research, and an increase in private clinics," commented Prof. Shlomo Mor-Yosef, director-general of the Hadassah Medical Organization (HMO). "It's not new, but today there is a culture of private medicine and people willing to pay." HMO is fortunate to have the Hadassah Women's Zionist Organization of America as a source of $1.5 million in annual medical research funds, and its doctors also apply for other grants. Hadassah funds five physician-researcher positions, which is more than the Israel academy does. "We haven't seen a significant reduction in funding. Our researchers still publish in prestigious journals. I can't give statistics about how many articles and how often they are quoted, but I agree that much more must be done to sponsor biomedical research by young people. The Treasury doesn't understand - or want to understand - that medical research boosts the infrastructure of knowledge and education and the level of medical treatment. It can also bring money into Israel in the form of donations and research foundations. For every dollar we at Hadassah invest, we receive six from foundations and other sources." Halevy and Rager endorse the idea of legislation that would set aside a fixed amount of health taxes for biomedical research. Mor-Yosef is in favor as well, but stresses that such an arrangement "must not siphon off money from the health system. It must be in addition, not at the expense of it." Rahamimof agrees, saying that NIS 300 million a year would be a very good start. With the election campaign gearing up and a new budget and government to follow, now is clearly the time to launch a campaign for it. Prof. Alexander Levitzki, an Israel Prize laureate in biochemistry who has done much cancer research, and who is chairman of the academy's natural sciences division, sounds angry and pessimistic. "Officially, we are the government's adviser on science policy, but we have no power. The prime minister has no time; the last prime minister who paid us some attention was Yitzhak Rabin, who boosted education and research funds. Governments look only to the riffraff and are not interested in our advice," Levitzki charged. "MKs don't come to academy conferences. We feel the media and the public are interested in science and education, but it's not an issue you demonstrate for in the street. In cultured nations such as the US and Europe, promotion of scientific research is initiated by the government from above, but not here. Our leaders are stupid and shortsighted, because scientific research brings in lots of added value. Countries from Sweden to Taiwan have realized this, but in Israel, we haven't."