Immunisation – a Jewish question? Problems and Solutions.
Topic: “Immunisation – a Jewish question? Problems and Solutions?”
Date: Monday 8th May 2017
19:00 Buffet Reception G02 Roberts Building Foyer, UCL, London WC1E6BT (entrance from Malet Place)
19:45 Panel Discussion G08 Roberts Building, Sir David Davies Lecture Theatre, UCL, London WC1E6BT
There has been considerable recent publicity about the decline in uptake of the MMR vaccine – and of other immunisations – in the strictly observant London Jewish community.
Several Association members have been involved in this debate; and, at their request, in late 2016 representations were made to the public health authorities about the best way to tackle the problem.
Six months later we are told that progress has been made, and this discussion meeting will provide an opportunity to hear about it, ask questions, and draw lessons for the future.
The topic will be introduced by Dr Tammy Rothenberg (Paediatrician at the Homerton Hospital). She will be followed by Ms Laura Sharpe (Chief Executive of the City and Hackney GP Confederation) who will update on the current situation and on new plans. Rabbi Avraham Pinter, (Chair of the Charedi Jewish Community Health Forum), Dr Joseph Spitzer (a local General Practitioner), and Dr Jonathan Cohen (UCLH Paediatrician, involved particularly in handling infectious diseases) will participate. A visiting Nigerian Public Health Physician, Dr Rilwan Raji (who trained at the Hebrew University School of Public Health, sponsored by the Pears Foundation) will comment on how he handles health promotion questions such as this, albeit in a different context. After questions and answers from the floor, Dr Fiona Sim (Past Association President, and past Chair, Royal Society of Public Health) has agreed to summarise and suggest possible future directions.
Please notify the Association Administrator as soon as possible (e-mail: firstname.lastname@example.org) whether or not you will be able to attend.
Annual Dinner 2017
The annual dinner took place on Tuesday 23rd March 2017 at St John’s Wood Synagogue Hall, 37-41 Grove End Rd. Lord Turnberg was the main speaker at this event.
The dinner was chaired by the London President, Miss Jo Franks, who introduced the speakers and who succeeded skillfully in making sure that the proceedings ran smoothly.
Over 150 doctors and medical students were present.
At the start of the evening a minute of silence was observed for those killed the previous day on Westminster Bridge and outside the Houses of Parliament. It was noted that Lord Turnberg had been in Parliament at the time and had not been allowed to leave; and that Dr Sebastian Vandermolen (a junior doctor present at the dinner) had been one of the St Thomas’s doctors who had gone on to the bridge to tend to the injured.
The loyal toasts were proposed by medical student leaders Jessica Franklin and Avi Korman.
The toast to the Association was proposed by Dr Abigail Swerdlow, junior doctor trainee in psychiatry, who reflected on the activities during the past year..
In his response Prof Katz thanked her on behalf of the Association not only for her toast but also for her contribution to all aspects of junior doctor activities, including the dinner. He highlighted that several junior doctors had contributed to the Association’s programme, during the past year, citing Dr Noam Roth and Dr Adam Levine, who had participated in recent meetings, and Dr Brett Bernstein who had reported on the Anglo-Israel Cardiovascular Meeting. He commended the medical student elective reports which were included in the brochure, and reflected that the Association is the sum of its members.
In her introduction to the guest speaker Ms Franks reminded those present about Lord Turnberg’s contribution to British medicine, and congratulated him on his recent birthday for which a celebratory cake had been included in the desserts.
In his address Lord Turnberg outlined the main features of his recent studies about the Balfour Declaration, which will be published shortly. He noted that the origins of British support for Jewish settlement in today’s Israel dated back to well before the time of Balfour, as evidenced by Lord Shaftesbury’s campaign for the “restoration of the Holy Land to the Jews”. He summarized Balfour’s early career, how he had been influenced by Joseph Chamberlain, and how the role he played in 1917 had to be seen in parallel with the Sykes-Picot agreement which was at that time still secret. He emphasized that although the Balfour Declaration was an important document of principle, the real legal substance of British involvement in the Zionist endeavor emerged from the San Remo Conference in 1920.
Dr Michael Fertleman introduced his remarks by quoting from one of Lord Turnberg’s prescient reports: “We found a health service under pressure. Services across the whole spectrum of care, from those in the community and primary care to those in hospitals, were sorely stretched. Although the impact of these pressures was most keenly felt in the care of elderly people and those with mental illness, others were not immune from the failures to meet an acceptable standard of service . . .Furthermore, there is evidence to suggest that the pressures are increasing.” Dr Fertleman noted that this item was reported in Parliament in 1999, and that by a quirk of fate the next speaker was a Dr Tonge….He concluded that all present were grateful not only for Lord Turnberg’s talk but also for his eloquent and passionate commitment to Israel.
Elective in The Oncology Department, Shaare Zedek Hospital Medical Centre, Jerusalem
Shaare Zedek Hospital is located next to Har Herzl in southwest Jerusalem and is the fastest-growing hospital in the capital. The hospital has 1000 beds and treats over 600,000 patients a year in over 30 inpatient departments and 70 outpatient clinics. In 2014, over 22,000 babies were born in Shaare Zedek, more than any other hospital in the Western World (1).
I spent three weeks in the Department of Oncology at Shaare Zedek, with the generous support of the Jewish Medical Association. There is a friendly electives coordinator who helped me arrange the elective. My objectives were to gain a deeper understanding of the diagnosis and management of the malignancies; to learn how these conditions affect the lives of patients of different cultures; and to practise speaking to staff and patients in Hebrew and improve my vocabulary.
My time was split between the oncology ward, outpatient clinics and departmental meetings. On the ward, there were weekly ward rounds with Dr Amiel Segal, the Director of Inpatient Oncology, and also Prof Nathan Cherny, head of palliative care. I was included in the ward rounds and doctors went out of their way to explain what was going on and to ask me questions. I used the ward rounds to learn as much Hebrew as possible, and found the medical Hebrew surprisingly easy to pick up. The ward staff were very friendly and I was constantly fed coffee and cakes by the head nurse!
The outpatient clinics were an opportunity to learn about the diagnosis and management of the common cancers, mostly breast, bowel and lung. I spent time with five different consultants, each with a unique approach, and learnt a lot about communicating difficult news and patient-centred management plans. I also had the chance to take my first ever history in Hebrew, and with some difficulty I succeeded in gathering a full history of a patient recovering from a colonic resection due to cancer. I was also encouraged by one consultant to read a paper from the Israeli medical journal Harefuah, and so I spent the next week reading my first Hebrew paper, on the treatment of bowel cancer with peritoneal metastases with cytoreductive therapy combined with intraperitoneal hyperthermic chemotherapy. These experiences gave me a lot more confidence in communicating and learning in Hebrew and using every patient encounter as a linguistic as well as medical learning experience.
There was a wide variety of departmental meetings that I had the option of attending. For my first few days the doctors were kind enough to speak in English for my benefit! Every Thursday morning at 8am there was a kosher breakfast with presentations about the latest clinical research in oncology and how it might affect practice. There was also a weekly gynae-oncology meeting, a breast cancer meeting, radiology meeting and nuclear medicine meeting, which involved the review of PET scans. The weekly ward meeting included very interesting discussions and debates about the management of difficult cases, for example a lung tumour which histologically was identified as a squamous cell carcinoma but also had a component of adenocarcinoma.
Yom Hazikaron was a special day with a ceremony outside the hospital led by Professor Halevi, director of the hospital. This was attended by many staff and patients and particular attention was given to those soldiers who died while fulfilling medical duties.
I am very grateful to the Jewish Medical Association for their generous support of my elective.
Eitan Mirvis Imperial College School of Medicine
Elective in The Anaesthetics Department, New Somerset Hospital, University of Cape Town Medical School, Cape Town, South Africa
As part of my elective I spent just over three weeks in the busy anaesthetics department of New Somerset Hospital, a public hospital based in the picturesque Waterfront area of Cape Town. I had a number of objectives, which included getting hands-on with all the different aspects of the anaesthetics role, and gaining an insight into the different lifestyles and healthcare needs of the diverse population and, in particular, of the Jewish community.
The elective more than lived up to my expectations. The whole team, from the doctors to the nurses to the porters, were all extremely friendly and welcoming and I got to know them quite well during my time there. My days started at 7.30am and tended to finish at around 6pm. From day one, I was allowed to get involved with the entire care of the patients. This started with meeting the patients, getting to know them a bit, performing a thorough anaesthetics assessment, explaining the anaesthetic and reassuring the patient. This was a very rewarding and educational part of my role. I was then allowed to manage the patient’s airway and perform a variety of practical procedures. These included some more routine things such as intravenous cannulation and also some more difficult procedures such as endotracheal intubations and LMA insertions, depending on the operation and patient. This was an amazing experience as I am considering a career in anaesthetics but had never had the opportunity to perform these procedures. It was such a thrill to learn these new skills and every procedure on every patient was very rewarding, as was helping to wake the patients up and ensure their post-operative care was optimal.
During my time in the operating theatre, I learned a lot about how the anaesthetic machine works and essentially how to give an anaesthetic from beginning to end. The staff were often keen to teach and I learned a great deal of physiology and pharmacology as well. I spent quite a lot of my time in the Obstetric Theatre and was lucky enough to learn a lot more about obstetric anaesthesia in addition to performing the spinal anaesthetics.
Although the hospital did not have a formal outreach service, the anaesthetists would go and assess sick patients on the ward, particularly those who were post-op or who were being considered for an operation. I went with, and helped, in the assessments and treatment and found this a very useful and rewarding part of the elective. This really gave me the confidence in assessing and treating the critically ill patient, which will help me in my role as an FY1 next year.
In addition to getting a very hands-on experience of anaesthetics, I was also able to see a lot of conditions and scenarios that I had not seen in the UK. These included end-stage AIDS patients, systemic TB infections, trauma such as stabbed hearts and much more.
My day started and ended with attending daily services in the Sea Point area of Cape Town, which, in addition to staying there over Shabbat, allowed me to get to know the Jewish community of Cape Town. I met doctors, medical students, dentists and a few teenagers considering a career in medicine and enjoyed interacting with them and getting to know them. I was also able to see quite a bit of Cape Town and beyond, which is truly a beautiful city, with so much diversity. Thanks to the grant from the Association, in addition to being able to get to Cape Town, I was able to see and do a lot more and really felt that I got a flavour of what life is like for the Jewish community of Cape Town and for all the diverse population of Cape Town, from a healthcare perspective and what life in general is like.
Edgar Brodkin UCL
Elective in Primary care, Roatan, Honduras
When deciding elective destinations, I searched for a placement where I could make a contribution, whilst gaining confidence in my clinical skills in a challenging environment with limited resources. Clinica Esperanza on the island of Roatan, Honduras had all this and so much more! The clinic functions as a combination of primary care and emergency medicine, in part due to the fact that the local hospital with an A&E has not received medical supplies for over 6 months.
One of the most challenging parts of working in a foreign environment, yet also one of the major benefits, is the vast cultural differences that inevitably exist. Roatan is no exception. Learning more about such differences was one of my elective objectives, and one that was most certainly achieved. I was soon struck by the fact that the typical age of first pregnancy is 18, malnutrition is widespread with limited opportunities for work and an endemic obsession with sugary, fizzy drinks. I saw that it is not enough to simply take a history and examine a patient. The area they live, the job they do and their religious beliefs are completely intertwined with their health outcome. For me, this was a learning point that I will undoubtedly take with me everywhere I go.
I relished the opportunity to practice health promotion in a place where few patients achieve more than a primary school education. One example of this was a patient we diagnosed with type II diabetes for the first time. This diagnosis required me to educate the patient about nutrition, such as avoiding fried and sugary foods, as well as trying to warn her of the potential complications, her treatment options and invite her questions, all of which while talking in a foreign language. I found this to be surprisingly rewarding, especially when she returned for a follow-up appointment the following week with much improved glucose levels, and bringing stories of the changes she had made to her diet.
There were certainly aspects of the placement which far exceeded my expectations and even surprised me. One example was having the opportunity to gain new perspectives towards global health and learn about the differences in medical practices across the world, such as the local ‘bush medicine’. In an area with a large obese and Afro-Caribbean population, there is an unusually low incidence of cardiovascular disease. Whilst of course there are many factors that can cause this, I learnt not to be too quickly dismissive of remedies that have been used for thousands of years.
One of my learning objectives was to practice clinical techniques such as cannulation and suturing. Unfortunately I do not feel I had sufficient opportunities to fulfil this objective, owing to the fact that the clinic functioned mainly as a primary care unit, and thus most emergencies went to the emergency room at the local hospital. However I don’t believe this negatively impacted on my experience but it does mean I will endeavour to gain more exposure to such procedures during my DGH placement.
I was, however, very pleased to have the opportunity myself to make a difference to the clinic, one that will hopefully be sustained long after I leave. I was delighted to be awarded a bursary from the RCOG to allow myself and Rebeca to complete a research project during the elective placement. The recently introduced cervical screening programme was highlighted as an area that is underfunded and in need of improvement. The haphazard introduction of this programme has meant many patients may be being missed due to the opportunistic recruitment of patients, as well as results not being delivered appropriately. Through developing a new data collection system, as well as retrospectively collecting data from the smears already completed, we have identified patients who need to be recalled for urgent follow up, as well as making recommendations that hopefully ensure that the limited resources of the clinic are directed more effectively, thus allowing more patients to be helped.
During my elective, I found that the impact of poverty further compounded in a health system requiring patients to pay for consultations, investigations and medications. Decisions weren’t made solely on the basis of what would be best for the patient and, having been educated within the luxury of a National Health Service, I found this particularly challenging. However, I recognise that in a time of austerity and budget cuts, we will all have to factor limited resources into patient care. Thus, having more confidence in my ability to diagnose, or at least treat empirically without expensive investigation as well as recognising when these are justified will benefit all of my future patients.
The impact on my professional practice
The time I spent at the clinic has undoubtedly changed my professional practice, as well as my own outlook. Early on in our placement, we had an emergency situation of a young boy who was desperately ill. Seeing a team pull together so seamlessly, needing few words to communicate whilst battling with limited resources was incredible, despite the heart-wrenching circumstances. On a daily basis I had to adapt to the limited availability of tools we so frequently take for granted, which left me with no option but to develop my clinical accumen. Further, being able to work in an independent manner but with plenty of supervision from experienced doctors encouraged me to hone my decision making skills, and gave me confidence.
I enjoyed the diversity of the patient presentations and had the opportunity to work in gynaecology, saw many paediatric patients and managed a vast array of general medical patients. Communicating complicated information in another language was a difficult but important lesson. I realised that the challenge of working with patients from different cultural and ethnic backgrounds is so much more than just a language barrier, and this is even more relevant when working back in the UK. I will endeavour to understand how to approach topics such as sexual health or alcohol drinking in each new community I work with.
If I returned to the clinic, which I certainly hope to do, I would change some of my objectives to allow me to gain even more from the opportunities we were presented with. One would be to learn more of what is normal. Seeing such an array of patients daily is the perfect opportunity to practice many clinical exams, such as using otoscopes and ophthalmoscopes to be able to appreciate physiological variants as well as pathology. Clinical knowledge can also be gained in the specialities of tropical diseases and nutrition. Members of the clinic run nutrition classes in the community and I would have liked to be involved in running such classes.
Another area which can be developed in this environment is decision making skills. The wealth of support from experienced doctors encouraged me to be independent whilst still being safe within my personal limits. Whilst at the clinic I took part in a community outreach programme, where members of the clinic go to local communities and give nutrition classes, hand out food parcels and education to prevent delayed presentation when illnesses develop. I would love to have done it more often. We have suggested that the clinic includes a weekly visit to the community in the volunteer program in the future.
I believe I was able to contribute to the clinic through our research project, and providing recommendations which will be used to apply for funding for an HPV testing programme. Further, each volunteer gave a teaching session, and I contributed to the shared knowledge of hypertension, and was able to highlight differences between UK prescribing practices, and the USA.
I would like to continue to help the clinic by raising awareness of their work. I will have the opportunity to do this when I present our research to the RCOG, in the hope of encouraging visiting gynaecologists to choose a placement in Roatan, which could allow the re-opening of the birthing unit at Clinica Esperanza, and provide expertise that could be used to train local doctors in techniques such as colposcopy and ultrasound.
I had many exciting, unexpected and educational experiences during my placement at Clinica Esperanza and would thoroughly recommend it to any medical student considering an elective in the developing world.
Brooke Calvert ( UCL)
Elective in The Trauma Unit, Chris Hani Baragwanath Academic Hospital, Soweto
In December 2013 I left the UK bound for Johannesburg for my medical elective in the Trauma Unit of Chris Hani Baragwanath Academic Hospital, Soweto. Affectionately known as Bara, this vast hospital is the only one in Soweto, serving the entirety of its 5 million inhabitants. With a world-wide reputation matched only by that of the area in which it nestles Bara is the polar opposite of the hospitals in which I have been so far; as such I was excited but extremely nervous about working in the Trauma Unit.
The trauma unit alone has 184 inpatient beds, 4-round the clock trauma theatres, a triage area with space for over 50 trolleys, 10 resuscitation bays and 10 dedicated ICU beds. This all sounds very impressive and gives the illusion of a well-resourced, adequately funded unit. However it is important to bear in mind that Baragwanath rarely operates under 100% capacity, more often 150%, and is underfunded to the degree that the doctors need to provide resources such as paper, printers and sometimes gloves.
When pay-day rolls around for 5 million Sowetans or the famed Pirates play The Kaiser Chiefs in front of 90,000 strong crowd the World’s most infamous township gives it’s only hospital a run for its’ money; often causing the unit to close for 2-hour periods in order to begin to clear the backlog. The level of violence in Johannesburg is like nothing I had ever seen before, not saying much for a middle-class 24-year old from West London, but when you consider that not a day went by at Bara without more than twenty stabbings or shootings this statement would ring true for most.
What is the source of the endless stream of accidents and emergencies at Bara? Well, quite simply it is The Sauce. A lethal mixture of township-brewed hooch, unemployment, overcrowding in a vicious cycle of poverty. Whether shot for a wage packet, hit by a drunk-driver, involved in a bar brawl, crushed by a collapsing wall or caught in a shack fire, it is fairly certain that at least one of the above is to blame.
My days began at 6:30am with ward-rounds followed by ward jobs, assisting in theatres and manning the surgical ‘pit’. Students were expected to do two 30-hour on-call shifts a week in addition to normal days. Apart from infinitely improving my clinical skills, teaching me procedures seldom needed in UK hospitals and honing my decision making prowess, this enabled the trauma team to truly bond. Everyone who works in the trauma unit is extremely helpful and friendly, no matter how busy the day is everyone is pleased to see you and all the registrars and consultants take the time to teach you, whether it’s for an hour during a ward round or for the two minute walk to the CT scanner at 3am. Every moment was used as a teaching opportunity and every teacher was happy to do it.
The demographic of patients seen at Bara often only complicated the task in hand, with 80% HIV positive, 60% with TB and drug resistance on the rise; treating patients was always a balancing act of treatment, adverse-effect and seemingly unsurmountable infection. Confounded by ever-changing available medication, some thirty different language profiles and more often than expected losing patients in the 10km of corridors and shack-like wards, sometimes for days at a time.
I learnt a huge amount at Baragwanath, not least volumes about trauma medicine and working in a resource-scarce environment. However more importantly I gained infinite teamwork skills and now understand that no matter how difficult the working environment and how busy each day, a good, cohesive team, at every level from porter to consultant can transform a potentially disastrous scenario into one that is difficult, stressful and unbelievably exhausting but ultimately extremely satisfying, most importantly successful and even enjoyable.
This was not an easy elective to go on, I did not have weekends or evenings to explore and I found the level of violence in a community that lacks autonomy extremely challenging; however it is definitely one of the best experiences of my life, which cannot begin to be expressed in a page. I met an immensely capable and welcoming team who gave me a unique opportunity to work with staff and patients who are some of the most friendly, vivacious and appreciative people I have come across. I am extremely grateful to the Jewish Medical Association UK for helping me to go to South Africa and I would recommend Baragwanath as an elective for anyone in search of a brilliantly satisfying yet challenging experience.