A lot of health, for little money [pg. 15]

The controversy surrounding the basic basket of services provided by Israel's health funds focused mostly on medications and imaging devices. While these are worthy issues, the larger topic of public health - which impacts on all Israelis, even those in good health - seldom makes the news. In reality, low-cost public health and health promotion efforts can save lives and improve our national state of health. We'd like to draw attention to these. Israel has achieved a great deal in public health, with life expectancy among the highest in the world, especially for men. Historically our immunization program was also among the best, but it has gradually lost speed as new and effective vaccines become available but are not part of the routine system. Israel has added important vaccines in the past decade, such as hepatitis B, then hemophilus influenza b and hepatitis A. Yet we have failed to add varicella, pneumococcal pneumonia and influenza vaccines, recommended for routine child health by the American Academy of Pediatrics and the Centers for Disease Control in the United States and used widely in other countries. These would help to reduce morbidity and mortality among our populations, especially those in the poor and minority population groups. WIDESPREAD POVERTY, especially among children, is occupying much current political discussion. Yet the Ministry of Health has failed to implement basic food fortification, as recommended in 1996 by the ministry's Berry Committee. Failure to fortify salt with iodine in Israel leaves people in some parts of the country susceptible to fetal damage and intellectual impairment. The World Health Organization has recommended mandatory fortification of salt for the past two decades, yet Israel remains one of the few countries on earth which has not yet complied. Fortification of flour with B vitamins and iron, present in almost all breakfast cereals, could prevent common deficiency conditions in our population, again especially among the poor, who depend on basic breads as a key part of their diets. The discovery in the 1990s that folic acid prevents birth defects adds a major new reason to proceed with mandatory fortification of flour, providing important health benefits at minimal cost. DESPITE THE total absence of vitamin D in raw milk, the milk industry has avoided adding vitamin D to 3% milk, as it is legally required to in 1% milk and margarine. Once again the cost is negligible, while the benefit to children and women would be enormous. Canada and the United Sates have implemented mandatory fortification of salt, flour and milk for many decades, with great benefit to the population and no harmful effects. In 1998 folic acid was added to the mandatory list. The cost of fortification is very low and the benefits reach not only children and women in the age of fertility, but also the elderly. The Israeli national nutrition survey has revealed vitamin and mineral deficiencies to be present in many groups in our population; they could be prevented by currently practiced methods in leading countries in this field. The American Academy of Pediatrics has since 2003 recommended vitamin D supplements for all children up to and including adolescence because of widespread findings of low vitamin D levels even in sunny parts of the country. Low vitamin D levels have been shown in our elderly population, in adolescents and the middle-aged, leaving many in our population vulnerable to osteoporosis and its complications. THESE ARE but a few of many examples where relatively minor investments in health can produce very large benefits not only in preventing important infections among children, birth defects and brain damage to newborns, but also in giving many groups in the population healthier lives. There are many other examples of needed public health interventions, such as working to reduce road crash deaths and injuries with speed cameras and aggressive policing. These too require some investment. Indeed, there is a whole range of things society can do to promote health with fitness. But first we must put the issue more squarely on the public agenda. Those now debating the basket of services need to widen their focus. If we want to improve the health of the Israeli population and prevent disease or injury, public health should be a prominent part of the discussion about the allocation of government resources. The key is prevention. It makes sense to build fences around roofs to prevent people from falling off. It's better than paying for ambulances to pick them up after they've been hurt. This op-ed was jointly written by Theodore Tulchinsky MD MPH, Yehuda Neumark Ph.D, Jeremy Kark MD Ph.D, Elliott Berry MA, MD, MRCP, Nihaya Daoud RN BA, MPH. All are affiliated with the Braun School of Public Health of the Hebrew University-Hadassah, Jerusalem.