The workdays of senior officials in the Health Ministry and the medical establishment are often like that of firefighters, rushing to put out conflagrations. Rarely do they have the time or presence of mind to plan years or even decades ahead and deal with the promotion of health and disease prevention. But since (according to Benjamin Franklin) a "stitch in time saves nine," the ministry has decided to invest considerable manpower, thought and energy in a new project called "Healthy Israel 2020" - an effort aimed at formulating a comprehensive program for health promotion and disease prevention by the end of the year. "One of the biggest problems in the ministry is our daily routine," admitted director-general Prof. Avi Yisraeli. "We have to deal with urgent problems every day. Our work on long-term solutions has always had to be postponed, as people try to change our agenda to deal with burning issues." The health promotion and disease prevention initiative will not be easy to implement, he added, as Israel is complex and not every issue is measurable. We cannot do everything ourselves, as implementation depends on cooperation from the Treasury and other ministries, such as Education and Industry, Trade and Employment. Many actors, within the government and outside, have to work together." INITIATED BY the ministry's associate director-general Dr. Boaz Lev, Israel's proposed health agenda is due to be brought to the cabinet for approval before the end of this year in the hope that the government will make it a top priority and invest in long-term plans. The Healthy Israel 2020 project, where Yisraeli spoke, was formally launched last week at a day-long conference at the Kibbutz Ramat Rahel convention center, attended by 150 professionals, many of whom are volunteering their services. The audience of doctors, nurses, health system administrators and others were hopeful but cautious, well aware that a previous effort died two decades ago because of a lack of political will and stability, and minimal public demand. Promoting good health and preventing disease were not national priorities in the mid-Eighties, but times have changed. People realize that the threats of war and infectious disease are no longer their biggest worries. With a much-extended lifespan, "lifestyle" diseases such as heart attack, stroke and Type II diabetes threaten not only life, but the quality of life. Thus many people are exercising and reading food labels, the smoking rate in the general population has dropped to 24%, and how to achieve good health is a major topic in the media. But at the same time, an astounding 46% of newly discharged male soldiers smoke; obesity in children is a greater threat than ever; the health gaps between Israeli Jews and Arabs, rich and poor have not been wiped out; road injuries kill more people than terror attacks; and home and school accidents and parental abuse victimize children. Lev appointed Dr. Leah Rosen as national coordinator of the project, and Dr. Eli Rosenberg as a senior adviser on disease prevention; both are Anglo immigrants and ministry staffers with extensive experience in the field. A TOTAL of 21 working groups involved in sub-topics such as prevention of accidents and violence, the elderly and tobacco have already been set up; these are comprised of volunteers who will meet on a regular basis, but will also depend on data from professionals in the ministry and help from experts abroad who have carried out such projects in the US, the UK and other countries. "Many people," said Lev, "are eager to jump on the wagon and participate. We don't want to bite off more than we can chew, and maybe the project is too ambitious. We know it won't be easy, but we'll do our best." Gabi Bin-Nun, the ministry's deputy director-general for economics, told participants at Ramat Rahel that nearly 20 years ago the ministry declared the year 2000 as a target for health promotion and disease prevention. Health is not merely the absence of disease, but also a feeling of wellbeing, Bin-Nun said. "The aim is to give more life to one's years, and not merely more years to one's life." In 1985, Israel joined the European region of the World Health Organization; previously, Israel was officially a member of the Asian region, but because of political problems received little cooperation from other members. "But in the European region, we became partners in Health for All 2000 - a WHO project with such aims. We decided to adopt the European model, set up steering committees, examine the status quo in a long list of health subjects and set priorities and 36 long-term targets." But it got nowhere, Bin-Nun lamented. The organizing team lacked reliable data and experience, public attention was elsewhere, and the rest of the government was preoccupied with "more pressing" matters. "There had been a lot of activity in the field, but the frequent turnover of health ministers and the lack of government support made it wane. A major lesson of that effort was that you have to have a complete data infrastructure and have to suit your plans to the Israeli reality of budgetary problems and political instability." Rosen hopes the Israeli public is ready for such a project today, even though it wasn't in the mid-Eighties. She especially worries about the impact of smoking on young men and women, calling it "a national catastrophe." Half of discharged male soldiers, many of whom learned to smoke during military service, will die prematurely if they don't quit, Rosen said. Last month she invited Mitch Zeller to Israel. Ziller is a leading American anti-smoking activist and former director of the US Food and Drug Administration's tobacco control office, and he lectured at the ministry on ways to fight this plague. Her partner Eli Rosenberg noted that Healthy Israel 2020 will succeed if it has evidence-based targets, if they can be applied, if there is a social need for proposed changes, and if the public demands it. One of the 30 foreign advisers to Healthy Israel 2020 is Prof. Martin McKee of the European Observatory on Health Systems - a physician and expert in public health. Born in Northern Ireland, McKee told the audience that in the early Eighties, he was a Belfast nephrologist who received kidney disease patients in his clinic. He knew nothing about operational research and organization, but was upset by the fact that the dozens of patients waiting every Friday evening always prevented him from going away for the weekend. "I thought that if we started earlier, we could end earlier. We made the arrangements, and all the patients had been seen by 4 p.m.. It was a matter of setting targets." TARGETS ARE for everybody. In 430 BCE, a plague hit ancient Athens, and the people blamed it on the gods. In medieval times, he added, influenza was referred to as della stella, meaning it was caused by the stars. But Irish pubs, which have always been notorious for their tobacco smoke, are now smoke free, and the House of Commons has barred smoking in public places. "Who would have believed it? Health promotion works!" Some people argue that if you leave health promotion to the people, without government intervention, it will happen naturally, said McKee. "But it doesn't work that way. Even if health care is free, not all needs will be met. Even if services are available, it doesn't necessarily mean that people will use them." Even when overall health levels and longevity rise, there may be many sectors left behind. There are parts of Glasgow in Scotland,for example, where average male life expectancy is 56 years, like that of Gabon [in Africa]." Mammography is recognized as an important way to reduce deaths from breast cancer, and while the machines can be found everywhere, it doesn't mean that they are properly used. "They must be integrated into a strategy, especially for reaching certain ethnic or language groups," McKee said. Even if they are screened, it doesn't mean that those found to be positive undergo treatment. People must be empowered." The UK expert advised his Israeli counterparts to set health promotion and disease prevention targets that are specific, measurable, acute, realistic and timebound. As many countries have been through the process before, Israel can learn from their experiences and avoid a lot of trial and error. Some targets, like the enforcement of speed limits on the roads or seatbelt use, can bring immediate results in the form of lower death rates. Other targets, such as cancer prevention, said McKee, take years - even decades - before the results become clear. Who pays for health promotion? McKee noted that taxes can always be raised, but finance ministries have to be educated to understand that health promotion saves money, even paying for itself over a few years. In addition, the improvement of a population's health and productivity can greatly spur economic growth. Health promotion and disease prevention, he concluded, can save Britain 50 billion euros by 2020 - two-thirds of what the country is spending on health now. Dr. Edward Sondik, a leading data expert at the US National Center for Health Statistics, advised Israeli health professionals to set targets with the aim of increasing the quality of life and eliminating heath disparities among groups. For the US Healthy People 2010 program, 28 professional areas were mapped out, with 467 specific objectives. "Targets have to be bold, but not so bold as to be laughable and lose credibility. Data upon which decisions are made must be absolutely reliable," he concluded, but you have to watch the trends and adapt strategies, as they may change several times before 2020 rolls around." Tune in in about 14 years to find out whether the Israeli politicians, bureaucracy and public will have achieved the health targets being earnestly set today.