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Having undertaken the majority of my final year elective at Great Ormond Street Hospital, I was keen to spend some time in Israel. I joined the Hadassah Paediatrics Department on the Ein Kerem campus for a week in October 2012, with the intention of learning more about the Israeli medical system in general and paediatrics in particular, with a view to emigrating to Israel and specialising in paediatrics.

I stepped off the El Al night flight early on Sunday morning, and made my way bleary eyed to Ein Kerem, Jerusalem, where I was welcomed by Ayelet, the elective organiser, a medical student herself. I was immediately struck by the hospital’s pleasant appearance, replete with a shopping mall, which compared starkly with the somewhat dreary-looking NHS hospitals we often find ourselves. The paediatrics inpatient department occupies a floor in the relatively newly built “Mother and Child Pavilion”, a modern building linked to the main hospital, with outpatient clinics, obstetrics, and neonatal and paediatric intensive care on the other floors.

The day began at 8am, when junior and senior staff alike meet to handover patients from the previous night, and to discuss management of the more difficult cases. On several days of the week, this was followed by departmental teaching, either given by one of the trainees or by a clinician from elsewhere. I was very impressed by the standard of material presented, which I felt surpassed that of comparable meetings I have attended in the paediatrics departments of the North Middlesex and UCL Hospitals. Interestingly, Israeli doctors tend to present in Hebrew with a smattering of English phrases, yet their lecture slides are almost entirely in English. Of note, several senior doctors not responsible for ward cover that week also attended these morning meetings to contribute to discussions on patients’ care, something I have not observed in the UK.

The doctors split into their two ‘teams’ to carry out ward work prior to the ward round starting at 11am. It is worth mentioning that senior doctors responsible for patients on the ward are all subspecialists, as the concept of a general hospital paediatrician does not exist in Israel as it does in the UK. The majority of Israeli paediatricians are generalists working in the community, and a minority subspecialise and form the corpus of hospital paediatricians. For example, the consultant I joined is a paediatric neurologist. Nonetheless, all subspecialists must maintain their competence and knowledge of general paediatrics as patients under their care while they are responsible for the ward cover the gamut of general paediatrics.

While the ward round was comprehensive, it reflected a style of practice somewhat outdated (for the better) in the UK. The team would enter a patient’s room and have a discussion about their care without involving the patient or their parents, and without any introductions from the doctors. Questions would be fired at the parent to clarify the history, and often the team would leave the room without providing any update on the patient’s progress. I felt that the communication skills and bedside manner in Israel were somewhat lacking, although my Israeli medical student counterparts assured me that this is starting to change.

I joined the Hebrew University final year medical students on the ward for their teaching. They received consultant teaching most days of the week (UCL take note!), which was to a high standard and was similar in style to what I was used to. I found that my knowledge was generally similar to the Israeli students although they certainly had a better grasp of pharmacology than UCL medical students.

I also had the opportunity to join some clinics, which generally were only scheduled in the morning. I joined Dr David Zangen, a paediatric endocrinologist whom Prof Katz had introduced us to during a Student JMA tour in 2009, and Professor Michael Wilschanski, a British paediatric gastroenterologist who had studied at the Royal Free Medical School.

The working day pleasantly ends at 4pm, after which the night shift team takes over in A & E and on the wards (they do a 26-hour shift), although I had the impression that many doctors work in community clinics afterwards to supplement their modest income.

In terms of patient demographics, the majority were Haredi or Arab, with the remainder being secular and ‘national religious’ Jews, which reflects the current trends in the changing Jerusalem population. It was immensely useful to have Arab and Russian doctors on the team in overcoming language barriers.

Finally, my description would not be complete if I did not describe the unique experience of working in an Israeli hospital environment. Looking out of the windows at the panoramic views of the Jerusalem hills surrounding the hospital (see the image below) was emotionally stirring and made day-to-day life working there feel more meaningful. I felt a bond with staff and patients alike unparalleled during the past few years I have spent in UK hospitals; joining the hospital synagogue services where one would pray alongside all sorts of people from patients and doctors to hospital porters and chefs had a very natural feel to it.

I would like to thank the Jewish Medical Association for their generosity in supporting me to have such an enjoyable and worthwhile week in Hadassah, Ein Kerem.

Leo Arkush
UCL

I spent my elective in autumn of 2008 at Hadassah, Ein Karem, Jerusalem for 6 weeks in the departments of Internal Medicine and Neurology. Both departments had a heavy and varied case load, and included HDU bays with intubated patients. I attended and contributed to lengthy and discursive ward rounds, and attended departmental meetings and journal clubs. I vastly improved my medical Hebrew and I compiled a dictionary of over 800 words intended for the JMA(UK) electives’ website. In Israel, medical students are taken seriously and are expected to be well read and so I learnt a lot of medicine as well as deepening my understanding of Israeli medical care.

Non-medical highlights of my elective included the mandate-period Rockefeller Antiquities Museum, a debate on the state of Israeli democracy launching a book by Shulamit Aloni, and an “Alternative Tourism Group” trip to Bethlehem, Dheisheh and Hebron.

Bernard Freudenthal
Final Year Medical Student – University College London

During my internship, most mornings I would arrive at the hospital at about 8am for the paediatric ICU ward round. This involved the ICU consultant, a couple of residents/interns, nurses and two Chinese doctors who were being trained in Israel by SACH. The Israelis would obviously speak among themselves in Hebrew, and although I do speak basic Hebrew, I could not keep up with their fast, medically-based conversations. The Chinese doctors certainly could not either. So the ward rounds would be conducted—often with a polite reminder from me—in English.

Some mornings and afternoons I would go to the operating theatre, where I saw cardiac surgery being performed on children with congenital problems such as Tetralogy of Fallot or septal defects (i.e. problems with the architecture of the heart and its great vessels). At other times I would attend the paediatric cardiology clinic where children were seen for pre-operative assessment and for follow-up. I saw lots of echocardiography (cardiac ultrasound) being performed there. Dr Abrahams, a friendly Ethiopian doctor being subspecialty trained in paediatric cardiology as part of SACH, was based mostly in the paediatric cardiology clinic and, like the other doctors, was always happy to teach me when time allowed. The clinic was a fun place to be. Many of the children in the waiting room would be running around, chasing each other, dancing, posing for photographs, or generally being boisterous, which was great considering many of them could not do this before their operations; their heart simply had not been strong enough. That goes to show just how much of a difference SACH is making to their lives, both in terms of quality and longevity.

I saw lots of patients but the one that stuck in my mind the most was a Kurdish child (about 10 years old) on the paediatric high dependency unit, and his mother. Unfortunately, his congenital heart condition and surgery had been more complicated than normal and he was very unwell. His mother was sat by his bedside all day long (possibly all night long). Neither the child nor his mother spoke a word of Hebrew, English or Arabic, and none of the staff spoke Kurdish. All communications were done by gesticulation. I cannot imagine how frustrating this must have been for them. They cannot possibly have fully understood what was going on in terms of the child’s progress. The boy was very pale, often tearful, and his mother often had a tired and forlorn expression on her face. A couple of times a day I went to say hello (I would just smile and wave), and sometimes would get a smile out of them. His mother would often get out of her chair to stand when I arrived. She would do this for every doctor, nurse or volunteer, seemingly out of respect. Every time I tried to intimate that this was unnecessary but she still did it. Anyway, on a positive note, towards the end of my internship the boy was looking much better. He was more ‘smiley’, and the colour had returned to him. His mother was also visibly happier…and so was I.

On another note, it was amusing to see how the quintessentially casual, laid back Israeli attitude was just as prominent in the hospital as outside of it. This held true even in the hi-tech and intense environment of the ICU where the medical care has to be—and of course is—razor sharp. Personally, I like the fact that the ICU consultant wore jeans and a t-shirt, and how I was allowed to wear casual clothes. In that particular respect, it could not be further removed from the hospitals in the UK, where every aspect of clothing is subject to ‘hospital policy’, down to the jewellery, watches and ties that are worn (or more accurately are not worn). I thought the cleanliness and attention to medical hygiene was excellent in the Wolfson Hospital, and there appeared to be no rampant nosocomial infection epidemic, even though the doctors were allowed to wear watches. All in all, I thought the relaxed environment had a very positive impact on the staff, the patients and their families. There were lots of smiles all round.

As part of the internship, I spent one day in the SACH House, where I joined in with the children playing games and generally being downright silly, along with some Canadian girls and an another English medical student, who were volunteering there. Again, it was amazing to see the mothers of the children from such vastly different countries and cultures all socialising in the kitchen whilst they were making dinner.

All in all I had a great time during my SACH internship. It was fun, inspiring and educational, and you really have to see it for yourself to understand what a special atmosphere there is throughout the SACH infrastructure. As a medical student with an avid interest in cardiovascular health and disease, it was a fantastic experience, and as a Jew I feel very proud of what’s being done in Israel for this huge multicultural spectrum of children. I would like to thank everybody at SACH for allowing me such a wonderful opportunity, and the Jewish Medical Association (UK) for their generous scholarship. I intend to visit again next time I am in Israel, and I would encourage you to do the same.

Warren Backman
University College London

I spent four weeks on the neonatal intensive care unit (NICU) and the last two weeks with Ambulance Victoria’s Paediatric, Infant and Perinatal Emergency Retrieval (PIPER) team at the Royal Children’s Hospital in Melbourne, Australia.

On the very busy neonatal ICU I was quite self-directed with clinical opportunities as and when they presented themselves. I learnt how to cannulate neonates and take heel prick bloods and capillary blood gases, which the nurses taught me how to do on the wards and have since been incredibly useful skills for my foundation jobs.

Typically my day was around 8am-4pm. I attended handover and ward rounds in the morning and then helped the junior doctors with their jobs. I was able to sit in on family meetings and interesting psychosocial meetings with social workers, music therapists, physiotherapists and OTs. I also joined the teaching day for the junior doctors, participating in SIM sessions and physiology teaching. There was also a fascinating NICU specialist ethicist who I observed for a little bit. On NICU there were also bedside surgeries (e.g. exploratory laparotomies) as RCH is the main centre for Paediatric Surgery in Melbourne which I was able to observe. The hospital also hosts regular lunchtime lectures and Grand Rounds for anyone to attend which were interesting and useful for those interested in Paediatrics.

Early on I was offered opportunities to get involved with academic research. I completed an audit as part of a wider research project at the RCH looking at the long-term neurodevelopmental outcomes at 2, 5 and 8 years of neonates born with features of VACTERL association which I really enjoyed and found very interesting; in particular I looked at the incidence of multiple VACTERL association in neonates admitted to NICU with tracheo-oesophageal fistula or oesophageal atresia over a ten year period. I have since presented this audit as a poster at a conference at the John Radcliffe Hospital, Oxford which was very well received.

For my last two weeks I joined the Neonate Emergency Transport service, which retrieves unwell neonates from all over Victoria (and sometimes beyond) and brings them to tertiary centres for further investigation and management and/or surgery. This was an incredible experience as I got to join the team on trips to other hospitals in the city and outskirts as well as on aeroplane trips to hospitals further away from Melbourne in Victoria to collect patients. From a learning perspective it was a bit different from the skills-based experience on NICU as it was more acute and more case-based around the babies we were retrieving. My NETS experience was not part of my original elective plan, however I asked if I could spend some time with the team after observing their handover of their patients to the NICU and I enjoyed my first day with them so much I spent another two weeks there!

I applied for this elective placement at the Royal Children’s Hospital (RCH) through the University of Melbourne external students’ elective programme and I would highly recommend it to anyone interested in pursuing a career in Paediatrics.

Sarah Simons
Nottingham

Choosing my elective specialty was the easy part; I have always had a particular interest in cardiology and want to pursue it as a career. However, location was more tricky; I wanted a large English speaking country, and, having done a previous placement in the US (which I enjoyed tremendously), I settled on Canada. More specifically, Montreal.

My elective experience can be divided into three broad sections: the cardiology, the healthcare system, and the country.

I was lucky enough to be allocated time in each of the three main hospitals in Montreal (Montreal General, Royal Victoria, and Jewish General), and spent time in many different areas of cardiology: coronary care unit, ward and emergency consultations, echocardiology, electrophysiology, and clinics. Without the pressures of upcoming exams, I applied myself as much as possible, and was rewarded with ever-increasing responsibilities as the team saw my capabilities. The basics of cardiology, as with much of modern medicine, are a universal language for doctors. Hence, I tried my best to notice the subtle differences, such as different scoring systems (eg TIMI as opposed to GRACE) and drug regimes, in an effort to understand their benefits and drawbacks. Communicating with patients for whom English was a second language was also challenging at times, especially when trying to elicit symptoms with more nuanced vocabulary; towards the end I felt as though my more detailed questioning was certainly improving.

Montreal’s hospitals all fall under Quebec’s nationalised healthcare system, in which private healthcare is illegal. On reflection, this has many benefits, not least that all clinicians dedicate all their clinical time to all patients, rich or poor. However, drawbacks such as extensive waiting times for basic scans and operations are certainly an issue. Moreover, the fact that “staff” doctors (equivalent to consultants) are almost exclusively paid per patient within the hospitals, has distinct positives, such as an emphasis on working efficiently to maximise income, but brings the possibility of abusing the system and not providing the best possible care for each patient, in the interests of time.

Lastly, spending my time in Quebec, Canada’s largest province, has been an unforgettable experience. Montreal is a unique city in North America, with both a European and North American flavour, and has an overall atmosphere somewhere in between Paris and New York. Although there are tensions between the French-speaking Quebecois population and English speakers, the people I interacted with from both sides of the debate were immensely welcoming. Touring around the historical sectors of Montreal, Quebec City, and Ottawa, visiting museums and national landmarks, and viewing some areas of outstanding natural beauty have helped me to understand the richness of Canada’s history, and Quebec’s place within it. Not to mention, the food was delicious, and Quebec’s favourite dish, the poutine (chips, cheese and (parev) gravy) made me certain of one thing – I’ll be back for more!

I have thoroughly enjoyed my elective experience, and am thankful to the Jewish Medical Association for their financial assistance in this endeavor.

Brett Bernstein
UCL

[organised by BIRAX and the Jewish Medical Association (UK) and BIRAX]

The European Jewish Medical Forum took place from 31^st August to 2^nd September 2015 at Ort House in London. The Forum was organised by the Jewish Medical Association (UK) together with the Overseas Fellowship of the Israeli Medical Association. 

Dr Zeev Feldman, World Fellowship Chairman of the Israeli Medical Association, and a paediatric neurosurgeon at Sheba Medical Centre / Tel Aviv University Medical School, welcomed participants, and highlighted his serious concerns about the delegitimisation of Israel in the academic world, including in European medicine. 

There were four talks which addressed current medical issues that are topical and important to the Jewish community in the UK, and are also relevant to Jewish doctors from other parts of Europe, and from Israel.

Prof Tim Cox: “A Sad Tale of Three Cities” – Paris, London and New York

Prof Tim Cox (metabolic physician and researcher based at Addenbrooke’s Hospital and Cambridge University), has made significant contributions to the study of Gaucher’s Disease and Tay – Sachs disease, and has supported many UK Jewish affected families. His talk explored the association between neurological forms of Gaucher’s disease and other neurological diseases such as Parkinson’s, and described the enzyme replacement therapy now available. Tay Sachs and Sandhoff diseases, more common amongst Jews but also occurring in others, can be avoided by preventive screening. Gene therapy using a viral vector has dramatic results in animal models but there are many unresolved issues before this can be introduced in man.

Dr Adam Levine: Genetics of inflammatory bowel disease in Ashkenazi Jewish families

Dr Adam Levine did his research as an MBPhD student at University College London (UCL) under the supervision of Prof Tony Segal. He outlined why there must be a genetic component in inflammatory bowel disease (IBD) with failure to limit the inflammatory response. The recently described  NOD2 variant distribution is not enough to explain the known high incidence in Ashkenazi Jews.  This led him to recruit what is now the largest IBD family ever identified, and allowed him to define a novel variant in the Colony Stimulating Factor receptor B amongst them. Finding this variant not only helps to explain the high incidence in the Ashkenazi Jewish community, but also is informative: the type of variant is very consistent with the current model that a defect in acute inflammation is implicated in the pathogenesis of Crohn’s disease.

Dr Ranjit Manchanda: Population based screening approach(es) for BRCA 1/2 genes

Dr Ranjit Manchanda is a consultant and senior lecturer in Gynaecological Oncology at Bartshealth and Barts Cancer Institute, Queen Mary University, London. His research interests include risk prediction, screening and prevention of gynaecological cancer, and population based approaches to genetic testing. He was an investigator and research lead on the recent GCaPPS trial, which looked at these issues in relationship to the BRCA genes known to be implicated in cancer amongst Ashkenazi Jews. He described this work and reported that his study had shown that population testing in the community can be done, and is cost effective. This has enabled him to identify 18 / 30 women with mutations. These would not have been found on standard screens.

Prof Ian Roberts: Post mortem imaging as an alternative to medico-legal autopsy

Prof Ian Roberts is based in the Department of Cellular Pathology at John Radcliffe Hospital, Oxford, and Oxford University. He is the acknowledged UK authority on minimal invasive autopsy techniques, and has been responsible for rigorous research studies in this field based upon accurate standardisastion. Recently he has initiated a service which has been of considerable value to bereaved Jewish and Muslim families.

In Prof Roberts’ talk he described how he had become involved in this topic, and explained that in order to develop the service properly he had decided that there were five questions that needed to be addressed: (1) What is the accuracy of post-mortem imaging in diagnosis of cause of death in adults? (2) Can radiologists accurately identify which cases may be diagnosed using post-mortem imaging and do not therefore require full autopsy? (3) What is the relative accuracy of CT and MRI scans in detecting post-mortem pathologies? (4) What is the interobserver variation in radiological diagnosis of cause of death? (5) Does increased experience of reporting post-mortem imaging improve diagnostic accuracy? He showed data that post mortem CT was more accurate than MRI based upon discrepancy rate from autopsy of 32% versus 43%. The inter-observer variation between radiologists was 25%, and he discussed how this might be reduced. In addition he illustrated his talk with examples of the innovations he has introduced as part of his work, in particular post mortem coronary angiography followed by CT scanning, which has helped to improve the accuracy of the minimal invasive methods considerably in what had previously been a common problem area.

There were two talks which focussed in particular on the controversies about Israel and Israeli medicine that have emerged in Europe over the past few years. Two speakers analysed some of the fallacies and falsehoods that have been most widely disseminated. 

Adv Leah Wapner: The Israeli Medical Association’s role in International Medicine 

Adv Leah Wapner is Secretary – General and Legal Advisor to the Israeli Medical Association (IMA), and is also a legal advisor to the World Medical Association. In her talk she outlined described the background to the IMA’s work – how it is required to act as a professional union, self-regulatory body, evaluate ethics and maintain professional standards. Nationally the IMA advocates the rights of patients and helps shape national policy. Internationally the IMA not only represents Israel but also plays an active role in the World Medical Association (WMA), the European Federation of Medical Associations (EFMA), the Standing Committee of European Doctors (CPME) and the European Union of Medical Specialists (UEMS).

In the WMA IMA Dr Eidelman (IMA President) and Dr Blachar (former IMA President) have played leading roles. The IMA is represented on numerous work groups, and IMA statements on several subjects have been adopted by the WMA. These include Drug Prescription, Violence against Women and Girls, Violence in the Health Sector, Collective Action by Physicians, Aesthetic Treatments and Non-Commercialisation of Human Reproductive Material. Adv Wapner is Secretary General of EFMA, and the IMA has observer / associate member status with CPME and UEMS.

The strong relationships with other national medical associations which result from these links are valuable, as they help to ensure the IMA is aware of experience in other countries, and can learn from it. Regrettably, they are also important in combatting anti-Israel activities by supporters of the Boycott, Divestment and Sanctions (BDS) movement. There have been several such campaigns – in general attacking the IMA, and specifically accusing the IMA of complicity in torture and calling for Dr Blachar’s resignation when he was WMA President. Adv Wapner said that these campaigns are particularly pernicious because the involvement of Israeli doctors – for example, in provision of humanitarian aid to Gaza, and most recently in the handling of wounded and sick Syrians – is ongoing.

She concluded her talk with a discussion of the IMA’s position on force feeding, where the Association has taken a lead in Israel in opposition to it, telling Government that force feeding is recognised as a form of inhuman and degrading treatment, and should not be permitted.

Adv Wapner’s presentation to the Forum can be accessed at:–The IMA’s Role in International Medicine – Adv Leah Wapner

Prof David Stone: Has Israel damaged Palestinian health? 

Prof David Stone is Emeritus Professor of Paediatric Epidemiology at Glasgow University, and has monitored and rebutted anti-Israel material that has appeared in the medical press.

In his talk Prof Stone said that the publication of this material represents a case study of the politicisation of medicine. He proposed that although Virchow had noted that “medicine is a social science, and politics is nothing else but medicine on a large scale”, nonetheless the explicit or implicit adoption of a strongly political position in an inappropriate medical context is politicisation and alien to medical values.

He gave three examples of such politicisation from Rita Giacaman (Lancet, 2009), Aimee Shalan (Spectator, 2013) and Richard Horton (Lancet, 2009). To explore his question further he asked (1) whether or not there was proof that Israeli policies and practices were indeed designed to degrade health services and infrastructure, and (2) what the resultant impact had been. He used a wide range of data sources available in the public domain, and pointed out that between 1967 and 2013 Israel and the Palestinian territories shared high birth rate, decreasing death rate with rise in life expectancy, and net inward migration from other countries. The UNICEF 2012 report showed that the fall in infant mortality / 100 live births between 1950-5 and 1985-90 was very similar in the two areas (87% versus 84%) and paralleled that seen in other Middle Eastern countries. Vaccination rates were the same; and underweight nutrition (where data are not available for Israel) amongst Palestinian children was similar to that seen in Jordan and Lebanon. He had also looked at provision of water and electricity supply in the West Bank and Gaza which had risen dramatically between 1972-5 and 1992.

His conclusions were that the central allegation – that Israel has systematically damaged Palestinian health/healthcare – is not evidence-based; on the contrary, Israel had substantially improved Palestinian public health from 1967 ground in the face of formidable obstacles; and that Israeli policies post-1967 had in fact been designed to improve healthcare/infrastructure in the West Bank and Gaza as rapidly as possible in keeping with WHO Alma Ata  declaration (1981) (“Health For All by the Year 2000”). Yet, despite this evidence, anti-Israel “medical” rhetoric obscures reality, obstructs peace efforts and contributes nothing to Palestinian health; and thus the false allegations should be recognised as “politicised” medicine.

Prof Stone noted that this politicisation is not a new process. There have been mounting concerns about the role of the Lancet particularly since 2009, and this journal has become the most prestigious purveyor of a distorted narrative of Israeli culpability. He considered that the journal is failing to meet minimal standards of non-partisanship, accuracy and objectivity. He quoted from an NGO Monitor study which showed 264 items about Israel – Palestine in 2001-14: 221 of these were “Palestinian”, of which 65% were opinion and commentary, compared to “Israeli”, of which 26% were in that category, with 74% medical. He said that this was a pattern which had been exacerbated in 2014 with publication of the Manduca at al letter, and by the editor’s refusal to retract it. At least two of the authors of that letter had links to anti-Semitism and neo-Nazism.  He believed that NGO ethical guidelines should prohibit exploitation of allegations to justify political positions and agendas and commended the principles expressed in the NGO Monitor document “The Political Abuse of Medicine, Morality and Science” (Jerusalem 2013) which is accessible at http://www.ngo-monitor.org/article/ngo_malpractice_the_political_abuse_of_medicine_morality_and_science

Prof Stone believed that there were very fundamental general medical principles at stake: (1) the damaging impact of propaganda that is masquerading as ‘humanitarian concern’ or ‘science’ needs to be recognised; (2) the role of medical scientists, professional bodies and journals in disseminating politicised and misleading analyses needs to be scrutinised better; and (3) the international medical community needs to hold individuals and organisations that abuse their positions to account.

Prof Stone’s presentation to the Forum can be accessed at:– Has Israel damaged Palestinian Health? – Prof David Stone

In addition a fuller version is also accessible:

http://fathomjournal.org/has-israel-damaged-palestinian-health/

There were two talks which focussed on the extraordinary – and often underestimated – medical challenges that doctors in Israel have had to meet in recent years. 

Dr Tzaki Siev-Nir: Operation Tzuk Eitan, Summer 2014: Transferring from a Civilian Rehabilitation Department to Absorb the Injured

Dr Tzaki Siev-Nir, is director of the Orthopaedic Rehabilitation Department at Sheba Medical Centre. He was responsible for shifting from a civilian rehabilitation department to absorb the injured victims from Operation Tzuk Eitan – the war in Gaza – in summer 2014.

In his talk Dr Siev – Nir explained that there are no military hospitals in Israel, so that civilian hospitals have to be used to provide services. For such hospitals key challenges in planning and organisation are that you cannot estimate in advance the duration of the conflict, the number and flow of casualties, the civilians who meantime need “ordinary care”, and how often civilians as well as soldiers will be injured in densely populated areas. Hence you have to prepare to absorb a large number and to have facilities for rapid patient flow.

The principle of immediate involvement of rehabilitation services following admission, and more rapid transfer to rehabilitation care is important. Starting rehabilitation earlier gives a perspective of hope. The idea of a “new department” is always floated ignoring that it is difficult to identify, recruit and train new staff; but extra staff time is needed to address the complexity of injuries and changed patient mix. Therefore skilled retired personnel were used; and 16 additional psychologists were recruited.

Dr Siev-Nir said that the complexity of the injuries is important, but one should not underestimate the concurrent medical problems, the emotional issues including not only acute distress, but also depression and post – traumatic stress disorders. Family issues are important – the doctors need to recognise that you are dealing with children, or at most young adults, who are at the same time soldiers, and that family may have difficulty in the “letting go” which is an essential part of rehabilitation.

One of the problems of management in rehabilitation include coping with pain – training in staff about sedation, use of regional blocks, novel agents including cannabis – used where indicated in liquid form – and decisions about wound care – favouring primary and early closure, which decreases surface area, prevents secondary infection, eliminates the need for graft and leads to scars that are more flexible and allow for early movement sooner. This wound care can be facilitated using Regulated Negative Pressure Assisted Wound Therapy.

These problems have to be seen against a background of organizational problems – the department has to cope with the Israel Defence Forces and its spokespeople, with Palestinians who are either in the rehabilitation process when the war started, or are admitted during it, and with the Ministry of Defence,,who handle long term care issues but must not be brought in too soon because it can convey a poor image about recovery.

Dr Siev-Nir concluded his talk with some unusual examples. Virtual reality could help to engage the patient in real life situations – within a controlled environment one could learn to cope with challenges, and create an environment to treat phobias. In a soldier with a brachial plexus and arterial injury a cardiac arrest had led to a stroke with a resultant visual deficit, and training on a colour feedback monitor on movement proved useful – not only to the patient but also to the doctor involved in treatment..

Prof Anthony Luder: Syrian conflicts and casualties: a perspective from Ziv Hospital in Tzfat

Prof Anthony Luder is Director of Paediatrics at Ziv Medical Centre, Safed and Vice-Dean of the Faculty of Medicine in the Galilee (Bar Ilan University), with responsibility for clinical sciences. His research interests are in paediatrics, genetics and metabolic medicine. In his talk Prof Luder spoke about the recent experience of the medical centre in handling Syrian patients.

As background Prof Luder explained that Ziv is a 331 bed hospital, with 1200 staff. 77,000  patients per annum are seen in Accident and Emergency, and annually there are 220,000 out -patient attendances. He also summarised the humanitarian crisis of the Syrian civil war: the UN estimated 350,000 deaths, more than 1 million injured, and more than 6.5 million refugees. Many Syrian medical facilities have been destroyed and it is estimated that 70% of trained personnel have left the country.

The first time that Syrian patients were brought to Ziv was in February 2013. Since these initial seven civilian cases the trickle has become a steady flow. As a Haaretz editorial commented, this is basic humanitarian aid: one cannot “stand idly by while the injured suffer”. By 2015 ~500 Syrian patients have been treated. 17% are children, and 70% overall have orthopaedic problems, but the range is very wide – for example, ophthalmology, urology, and. even obstetrics and gynaecology. In a series of 100 of these patients the male: female distribution was 9:1 and the age range was 2-51 years. Roughly half of the trauma cases were “polyorgan trauma”. 41% were gunshot wounds, 23% were blast injury and 9% were related to road traffic accidents.

Prof Luder described some examples of the problems encountered. Certification of births had to

be anonymised as “born in Israel” would not be acceptable. A 12 year old girl was admitted with sepsis which proved to be due to swabs in her abdomen left after a previous operation; at further surgery she was found to have a dysgerminoma of the ovary, and thus she remained at Ziv for three months to receive the requisite chemotherapy. An 8 year old girl who had pyoderma gangrenosa was found to be suffering from a rare leucocyte adhesion deficiency syndrome and treatment – bone marrow transplantation – was arranged. He showed some striking examples of orthopaedic rehabilitation, and of amputees who had been fitted with prostheses.

Prof Luder concluded his talk by asking the question: what has been the impact of these events on the healthcare professionals working with Syrian patients? To answer this question Ziv Medical Centre is supporting a research project based on interviews and questionnaires, and the outcome of  this will be published in the future.

There were two panel discussions both of which were chaired by Dr Lawrence Buckman (former chair of the British Medical Association General Practice Committee and London President of the Jewish Medical Association (UK).

One of these discussions explored the current status of Brit Milah in Europe. This was introduced by Dr Simon Cohen (consultant physician, UCL), who showed that debate on this subject is not new, and gave cartoon examples where the borderline between criticism of Brit Milah and anti-semitism had been crossed. Prof David Katz (Prof of Immunopathology, UCL) discussed the legal and regulatory framework in which Brit Milah is practised in the UK, compared with Europe, and explained the details of the recent UK Family Law judgement which concluded that neonatal male circumcision for religious reasons is permissible. Prof Laurence Lovat (Professor of Gastroenterology and Laser Medicine, UCL; also a mohel) spoke about the Initiation Society, the UK’s oldest Jewish organisation, responsible for Brit Milah. Prof Giorgio Mortara (gastroenterologist and President of the Italian Jewish Medical Association) provided an Italian perspective and also tabled a report from Dr Refoel Guggenheim (Paediatrician, Switzerland). Prof Anthony Luder (Paediatrician, Ziv Hospital and Bar-Ilan Medical School, Tzfat) reported on a recent attempt to interfere with the traditional Jewish practice of neonatal male circumcision by European paediatric organisations and how these had been resisted successfully as a result of hard work by the Israeli paediatrics community.

The second discussion took up the theme posed by Dr Feldman at the beginning of the meeting with presentations from Mr Michael Whine, who is the Director of Government and International Affairs at the UK Community Security Trust (CST), and is the UK expert on racism and intolerance on the UK delegation to the Council of Europe. Mr Whine also acts as Consultant on Defence and Security to the European Jewish Congress, and represents it at the Organisation for Security and Cooperation in Europe.  He gave an overview of how anti-Israel propaganda is promulgated and disseminated. Prof Daniel Hochhauser (Professor of Oncology, UCL) spoke about his experience in combatting anti-Israel and anti-Semitic prejudice in the medical press as well as in many other fora, and Prof David Stone presented his paper on “has Israel damaged Palestinian Health? A case study of the politicisation of medicine”, which is summarised above.

Throughout the Forum there was considerable discussion about how to take forward some of the important topics raised; about how better to educate and inform Jewish physicians; and about how to encourage them to participate in joint initiatives of mutual interest. All present were asked to put forward their priorities, and it was agreed that these would be circulated and used as a basis for a forward plan of European Jewish medical activities.