To Your Health - International Public Health Course

Medicine treats the health needs of the individual, while public health takes into account the needs of society as a whole, explained Prof. Leon Epstein, Head of the Department of Social Medicine at the Hebrew University - Hadassah Hospital Joseph and Belle Braun School of Public Health and Community Medicine in Ein Kerem, Jerusalem. These two needs often conflict, particularly in the developing world where

doctors must worry about the optimal use of scarce resources.

Consequently good public health decision making is imperative if nations are to best use the potential medical resources available to them. The International Masters of Public Health Program (MPH) held each year at Hebrew University - Hadassah has played a key role in helping medical professionals throughout the developing world tackle the enormous public health problems facing their countries for nearly three decades. Inaugurated in 1970 at Hadassah under the auspices of MASHAV, and with the 24^th such course now running, more than 500 graduates from some 70 countries have taken the degree.

The impact of these graduates is enormous, stressed Prof. Epstein. These are senior medical professionals and one or two graduates can have a great influence on their nations public health thinking. Last year I met 21 MPH alumni in Buenos Aires, Argentina. They came from throughout Latin America and this was the point that they made - that they have had a significant impact across their continent.

Prof. Epstein commented that the Schools approach to public health has been largely based on the Community-Oriented Primary Care (COPC) model introduced to Israel by the late Prof. S. L. Kark, who sadly passed away during 1998.

Prof. Epstein observed that even before the establishment of Israel in 1948 pioneering founders gave the setting up of community health care facilities the highest priority. The nationwide network of mother and child clinics and the General Sick Fund clinics were good examples of primary care community health programs, said Prof. Epstein.

Prof. Elisheva Simchen, a former Director of the School of Public Health and Community Medicine, reinforces this point. Israel as a small and relatively young country can share a lot of its development experience with professionals from other developing nations, she noted. In some areas like maternal and child health, we can show achievements and offer some solutions.

The School tries to convey a general approach, she added, for solving health problems. We train students in epidemiology as the basic science of public health and we study health care systems and the delivery of health care, in particular primary care and maternal and child care.

Having dealt successfully with such issues as communicable diseases, infant mortality and nutritional problems, continued Dr. Gofin, Israel decided to share its experience with other health workers around the world by training people to deal with their public health problems.

Among the graduates of the 1997/98 program was Fadiah Oweis from Ramallah north of Jerusalem, which has been a Palestinian autonomous zone since 1994. Ms. Oweis, a graduate of Bethlehem Universitys Nursing School, has been lecturing for the past four years in medical and surgical nursing and nursing administration at Ramallahs Iben Sina Nursing College and has also worked at St. Josephs Hospital in east Jerusalem.

The program has been a marvelous opportunity to broaden the scope of my knowledge, observed Ms. Oweis, to include public health issues and community care problems. I think these kinds of people-to-people contacts and professional exchanges of views between Palestinians and their Israeli counterparts are vital if there is to be peace in the region. After all, public health problems and illness knows no borders. Diseases and epidemics attack everybody regardless of whether they are Israeli or Palestinian, Jew, Muslim or Christian.

Ms. Oweis was one of 20 students from 16 different countries participating in the 1997/98 MPH program. According to Dr. Yehuda Neumark, Coordinator of the Program, within the framework of the peace process, Israel hopes to play a major role in promoting public health awareness in the Middle East.

In the past year the Palestinian Authority has opened two schools of public health, related Dr. Neumark. Some of our 20 Palestinian graduates were involved in the opening of these schools and are on their Faculties. For the first time in the 1998/99 course we have a Jordanian student.

We are proud that our graduates hold important positions worldwide, at local, national and international levels, added Dr. Neumark, himself a graduate of the Hebrew University - Hadassah MPH course, who has taught in the School of Public Health for 10 years and is a co-founder of the Alumni Association. Graduates of the program include some deputy ministers of health worldwide, leading hospital administrators, researchers and practitioners. Dr. Neumark added that above and beyond their individual positions and responsibilities upon returning home, our graduates share a common public health language and philosophy, thus enabling them to work together for the betterment of their communities and countries. Indeed, several local alumni chapters have been established in different parts of the world. This provides the framework for the graduates to meet and, when possible, members of the School Faculty run regional workshops and continuing education courses for our Alumni. Unfortunately, funding and time limitations make the events all too rare.

I am doing my project on the quality of care, explained Ms. Oweis. This is a subject that we in the Palestinian health system have very little data about, from handwashing procedures through to sterilization measures for wound infections.

The government provides health services for those who can pay, she said, while UNRWA looks after the refugees. And for the poor who cannot pay we have many charities. We are a family oriented, charitable society and I dont believe that there are those who go untreated.

I refused offers from other universities, he said, because for me it is an honor to come to Jerusalem and I consider Hadassah one of the best university hospitals in the world. In Jordan we are plagued by diseases which characterize the developing world - like malnutrition and polio - as well as illnesses of the developed world - cancer and heart disease.

Prof. Epstein noted that the teaching of Public Health had adjusted to new realities over the years. Firstly society both in the developed and developing world has more old people to look after, he explained. The other major change is the vast amount of technology involved in modern medicine. Of course this is a problem in the developing world where resources are so limi.

The MPH course intensively crams two years of study into 12 months with little vacation time and the students learn right through the summer. However, the course generates an intensive social atmosphere, bringing together students from all over the world who participate in a wide-range of cultural activities. These include trips throughout Jerusalem and Israel, meeting members of the Israeli Parliament, archeological excavations, and parties.

This has been a truly multi-cultural experience, reflected Ms. Oweis. In addition to meeting my Israeli counterparts and understanding more about the health system in Israel itself, I have encountered people from so many different cultures and learned about the different ways that people deal with each other worldwide.

Dr. Bayo Fatunmbi, from Ibadan in Oyo State in Nigeria, was impressed at the way public and private medicine sit alongside each other in Israel. A specialist in health management and a former assistant director in health research and statistics for Oyo State, he hopes to implement some aspects of this mixture of public and private medicine on his return to Nigeria.

I come from the southwestern region of Nigeria, explained Dr. Fatunmbi, which is a more wealthy and better educated part of Nigeria. We have a good health infrastructure in Oyo State but in recent years we have faced serious economic problems. As a result the free health system that we had has been replaced by cost-sharing in which patients are asked to pay for medication and some health services.

Dr. Fatunmbi observed that as a result the private health sector was growing rapidly in Nigeria while the public health system was declining. In Israeli hospitals doctors are allowed to offer private consultations, he said, even though these are public hospitals. This is a system I would like to introduce in Nigeria. I have spoken to some key people back home and there is a good chance that we can implement this. Our government sector must start collaborating with the private sector to stop the brain drain of our best doctors, many of whom are going abroad.

Dr. Fatunmbi, a devout Christian, was impressed by the peacefulness of Israel. We hear about terrorism and the Middle East conflict in the media but I only wish we had the same level of cooperation among Nigerians as we have here among Jews, Christians and Muslims.

Armada Acharya, from Kathmandu, Nepal, was also surprised at how peaceful Israel is. The country and the people are so beautiful, she commented. I have met so many young Israelis who have visited Nepal and enjoy talking about their visit. I have had so many meaningful experiences here in Israel.

Ms. Acharyas project has had to tackle malnutrition and endemic diseases as well as a rising AIDS epidemic and routine adolescent pregnancies, detrimental to long-term health for the regions teenage females.

We have worked through the community, explained Ms. Acharya. The statistics show an improvement over the past decade, but the true mark of success is when I see women in the community there standing up and trying to convince others of the importance of family planning or even simply hand washing.

In Israel Ms. Acharya has found the MPH program has offered her new insights on the problems of her country and in particular she has found some of the elective courses, such as AIDS epidemiology, health policy and mother and child health, especially relevant. Her end-of-year project dealt with the subject of adolescent pregnancy and she developed a program based on education and counselling by local people.

Dr. Yogesh Choudhri, who is in charge of the planning of Indias hospitals and health care planning facilities for the countrys Ministry of Health in New Delhi, was impressed by the health facilities that he saw in Israel, but feared that lack of funds was preventing India from implementing the kinds of programs that Israel has.

Israel spends 9% of its GDP on health care, he explained, while we allocate only 3.4%. And of course Israels GDP per capita is much higher.

Nevertheless, Dr. Choudhri still feels that much can be done to improve the quality of health care in India while reducing costs.

The introduction of modern management techniques would be of great assistance, he emphasized. I have been studying Israels cost containment procedures and I think we have a major scope for reducing the length of hospital stays in our country. Of course India is a very large and complex country. The medical system differs throughout the country but there is a lot of access to public health and of course health care is inextricably linked to politics and economics.

Dr. Choudhri was also able to benefit from the multi-cultural aspect of the program by working together with a Turkish participant of the MPH course on a project concerning the control of hepatitis in Turkey. I think the same model is applicable to India, he said.

Among the 1998/99 course participants was Paul Mange, from Kandes in Enga Province, Papua New Guinea, who works as the community health officer for the Chevron Oil Company. Malaria is our main problem and our main killer, he stated bluntly. So clearly one of my priorities during my year in Israel will be to investigate how Israel succeeded in eradicating malaria.

For Dr. Mariano Barahona, from Boaco in Nicaragua, his first months in Israel were painful as he watched his country being buffeted by Hurricane Mitch. Thank God my own family are safe and well, he reported. But the country has suffered terrible damage. I was warmed to see how concerned Israelis were by the disaster and how some people organized to send help to the region.

Dr. Barahona, Director of the Primary Health Care Program in Boaco, 90 kilometers from the capital Managua, explained that Nicaragua is the second poorest country in Latin America. You name it we have it, he said. Malnutrition, gastroenteritis, diarrhea, respiratory problems. We desperately need family planning clinics.

Dr. Neumark commented that the cross-fertilization of cultures within the program is not limited to the students. We at the School learn new concepts about public health and community medicine from the course participants, he said, as much as they learn from us. He quoted a rabbi in the Talmud, the 2000-year-old primary source of the Jewish religious law: I learned much from all my teachers, even more from my friends, but from my students I learned the most.

As we enter the next millenium, the School is gearing up to host the 25^th International MPH Course beginning in October 1999. Together with the support of MASHAV, the School continues to train public health experts from the six continents who are impacting individually and collectively on the status of health of the peoples of their countries and the world.