The European Jewish Medical Forum took place from 31st August to 2nd 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.