Dr. Yehuda Neumark, a lecturer at the Braun School, opened the conference, held on the Hadassah campus, with a critical look at the Hebrew University's School of Public Health & Community Medicine -past, present and future. He called upon planners of public health programs everywhere to achieve more balance between training, research and service. He noted that backing from the Soros Foundation will allow health professionals from Russia and other eastern European countries to come to Jerusalem to train in public health, and a new donor has made it possible to offer a limited number of scholarships on the PhD level. Neumark also remarked upon the shift in class demographics -the influx of participants from Eastern Europe and the presence of Palestinian and Jordanians among alumni -the fruit of the peace process.
Among the changes Dr. Neumark believes are necessary to meet changing needs: strengthening training in mental health and public health ethics in the curriculum; training in disaster preparedness and management; and establishment of multidisciplinary and cross-institutional frameworks -with public health reaping benefits from new discoveries and full utilization of the Internet for communication among graduates.
Dr. Joshua Cohen, a former advisor on health policy with WHO's director-general's office in Geneva, delivered the keynote address -devoted to "Public Health Challenges of the 21st Century." Assisted by a rich array of graphs and slides, he illustrated the differences between developing and industrialized countries in terms of life expectancy at birth, infant and maternal mortality rates, GDP and population growth; ratio of health personnel per capita and availability of health services and demonstrated that the situation in developing countries is not monolithic: In general, developing countries wrestle with communicable diseases while industrial countries cope with non-communicable diseases. Yet, measures of economic and demographic growth; parameters of longevity such as life expectancy at birth, infant and maternal mortality; prevalence of AIDS, malaria and tuberculosis; ratios of doctors/nurses per capita -all vary from region to region and even within regions.
The statistics plague policy-makers with very sticky human questions -such as the quandary facing public health personnel in Africa where an enormous number of children have AIDS contracted from their mothers: Should public health officials encourage breast feeding or endanger newborns by possible exposure to suspect water sources?
If one needs proof of the importance of sociological factors on health, Dr. Cohen noted that one of the poorest states in India has a very high literacy rate among women. Operating in a poor but literate socioeconomic environment, WHO statistics showed public health work in the province was very effective because providers and recipients could really communicate. As for the importance of economic factors, in industrialized nations where incidence of AIDS is as high as some developing regions, the impact on national profiles of "cause of death" are mitigated by expensive drugs, while lack of such options in developing countries leaves prevalence of infection as a major killer.
The second day of the gathering, Professor Mark Clarfield, director of the Division of Geriatrics at the Israel Ministry of Health, presently on study leave, delivered a talk entitled "We are Not Getting Any Younger: Aging Around the World." Clarfield had some surprises to share: While much of the talk about aging has focused on "baby boomers" in the western world -the boom in births following the Second World War -statistically in absolute terms, 60% of those over the age of 65 in the world live in the world's less developed regions! Professor Clarfield said that presently there are health-related forces at work that both retard and enhance life-spans in developing nations: On one hand, firstly, there is a significant increase in smoking among the young. Secondly, high blood pressure remains untreated to a large extent. Thirdly, AIDS is taking its toll: AIDS not only impacts on longevity of the patient, he noted; it also carries a very heavy burden for senior citizens in AIDS-ridden societies, for more and more elderly grandparents are being left to care for children orphaned from parents belonging to the middle generation who have succumbed to the disease!
On the other hand, those children who indeed survive to age 5 are generally endowed with a constitution that will carry them at least to age 65. Secondly, health status on a national level -measured in water quality, scope of vaccinations, levels of nutrition and health services -are improving, influencing the aging of local populations all over the world.
Professor Clarfield concluded, stressing that the challenge in developing countries today in terms of geriatrics has shifted: It is no longer a question of aging per se, but "successful or unsuccessful aging": whether elderly populations will enjoy general wellbeing and an active life, or be destined to debilitating ill health and passivity in their later years.
On the first day of the conference the graduates met in regional group discussions (Asia, Africa, America, Europe and Mediterranean regions) together with school staff members for an exchange of their experiences with regards to public health challenges they are facing in their respective regions. The groups -some 20 participants in each -also allowed graduates from different years to get acquainted so they can continue collaboration and communication when they return to their respective regions, networking that ran throughout the three-day gathering during breaks in the meetings.
Then on the second day each group shared its deliberations with all participants in a plenary session lead by Dr. Jaime Gofin, chairman of the Alumni Association and director of Community-Oriented Primary Care (COPC) teaching programs. Despite the differences among countries, Dr. Jaime Gofin noted that graduates were able to share and elaborate their assessments of the challenges at regional level and also to make proposals on the content of the training for the human resources required to cope with their specific health problems. They provided suggestions as well about what role the Braun School and its graduates should play in the issues under discussion.
The African group reported that the main challenges facing their continent are AIDS, malaria, tuberculosis and malnutrition. One of the primary needs is a multisectorial approach that will attack problems from a social, economic and educational standpoint -not solely health. The Asian group reported that the main challenges they face are communicable diseases and chronic conditions. In many cases, health solutions could be enhanced by decentralization of services and partnerships among sectors -such as collaboration between academic and service institutions. The European group defined the major problems facing their region as medical disabilities, substance abuse, non-communicable diseases and mental illness. One of the ways health matters in Europe might be improved is to plan and provide training according to the needs of specific areas -not a universal "all-European" approach. The Central and South American group's discussion focused on the issue of health as a right rather than a commodity, and lack of equity in access to health services. The group suggested that limited resources could be amplified by improving multidisciplinary care, with all health personnel -doctors, nurses, etc. -working as a team, and by improving ways to document and disseminate work that has been done, so all public health personnel in the region can benefit from their experience. The Mediterranean group focused primarily on problems, not solutions -noting that health in the region is colored by what was labeled "conflictual conditions" and socioeconomic inequalities. Among the avenues for change raised was increasing health promotion and preventive medicine -a field largely absent in most countries in the region.
How can the School and its graduates be instrumental in solving problems raised? The African group suggested more training in public health advocacy, spreading the Community-Oriented Primary Care (COPC) model (an integration of individual clinical care with public health activities) to the local level and organizing alumni on a regional basis. The Asian group advocated more training in communication skills, in-situ workshops on the regional level and establishment of a distance-learning network. The Mediterranean group called for more training and development and funding of research. Participants from the Americas called for adding to the curriculum more coursework in community participation and administration, praising what they perceive as one of the program's greatest assets -its international health approach.
The "Public Health Challenges in the 21st Century" Conference climaxed with the graduation ceremony of the 25th graduating class of the International Public Health Master's degree program. The keynote speaker at the graduation ceremony for 23 international students from 16 countries who comprise the Class of 2000, held on the closing day of the three-day gathering, was U.S. Surgeon-General and Assistant Secretary of Health and Human Services Dr. David Satcher. The chief physician of the United States said that one of the overriding challenges of the 21st century is development of a global system of public health that will address the glaring disparities in health care between nations.
Dr. Satcher focused his address on defining the major problems in public health facing both developed and developing countries. Among these he listed AIDS, which Dr. Satcher labeled "the worst pandemic disease in history. It is not just a health problem but also a security problem for many countries," particularly in Africa.
The Surgeon-General also cited tobacco use as a particularly severe problem in developing countries. With the decrease in smoking in the U.S. due to health education, the tobacco companies have shifted their marketing efforts to less developed countries, aggravating the public health situation there. "Nicotine," he charged "is the most addictive drug known to man." The Surgeon-General also referred to smoking as a "pediatric disease," since so many young people become addicted to tobacco at a very young age and then cannot separate themselves from it. He called for a community approach of public education to overcome this problem.
Infant mortality is an area in which there are great disparities between rich and poor countries, but even within the United States, Dr. Satcher noted, there are vast differences in the level of health services to majority and minority populations. It is because "public health has no borders," said Dr. Satcher, that a course such as the International Master of Public Health program at the Hebrew University-Hadassah Braun School of Public Health & Community Medicine is so important.
Among the "millenium graduating class" who received their MPH degrees at the ceremony were participants from Russia, Nepal, Ghana, Guyana, Albania, South Africa, Colombia, Turkey, the U.S., Cyprus, Uganda, China, Kenya, Tanzania and Israel -including the School's second graduate from Jordan, Dr. Ahmed Madmouj, and the 29th graduate from the Palestinian Authority, Muna Ahmead.
Graduates Look Backward and Forward
Our Shalom Magazine reporter asked a number of participants to share with all our readers, and MPH alumni who were unable to attend the Conference, their memories of the course, what they are doing and what problems they face today.
Dr. Josephine Ojiambo, from Kenya, a senior health planner and head of a national lobby group of female physicians, was familiar with the program through close kin who had been to Israel in the 1970s and 1980s, including a cousin who graduated the MPH course while she was still an intern. Working as a primary care physician in Nairobi threw into relief the challenge of managing health services -leading to her decision to pursue public health & community medicine as a career path. A scholarship allowed her to attend the 1988-89 International MPH course. "The course had a tremendous influence in shaping my vision -particularly first-hand exposure to community-oriented public health services and employment of team dynamics observed in the Kiryat Yovel health center in Jerusalem," she recalled. "My dissertation, on Dynamics of Multiple Social Roles and their Effect on the Health Status of Men and Women, was invaluable in subsequent application of public health study methods to researchable and topical concerns, in UN and UKHS programs in which I played a role." Fighting AIDS through a strategy of behavior change is now a major challenge facing Kenya, she said. She hopes to deepen collaboration with colleagues at the School of Public Health to improve health policy research analysis and advocacy in her country.
Ana Santander, from Bolivia, is associated with the Central University of St. Andrews' Faculty of Medicine (UMSS). She participated in the 1979-80 International MPH Course. Having trained in dermatology in Venezuela prior to doing her Master's in Israel, she cited the importance of cross-cultural exposure outside Latin America -human contact and exchange of knowledge among teachers and participants, and the clear focus on public health practices in developing countries. While she had worked as an epidemiologist prior to receiving her Master's, the course cemented her decision to opt for a career in public health, gave her the resources needed to do a better job and provided a model for "holistic, integrated and integral health care." The "tools of community-oriented primary health care" acquired subsequently served as the foundation for health programs Santander developed back in Bolivia. "Health problems in my country are still communicable diseases, like 20 years agowith the additional burden of the chronic and social diseases," she explains. "But, I consider the main public health challenge now to be: How can we enhance the mission of public health, together with health reform. At present public health is being minimized by a growing emphasis on health centers. Focus on efficient administration is gaining, but raises quandaries: How can equity and quality deal with cost-benefit analysis?"