Happy Birthday, Roy Uadri?

Just for fun: you can catch Arie and me as a pair of shadows to the left side of this video...well, if your eyes are really good. Hip hop/reggae/funk star Royale (Roy Uadri) performed a birthday show in Tel Aviv that included guests from as far as New York to local celebs like Shai 360. At one point, he performed with an a capella group (calling it "gospel ivrit" - oy!). Roy's resume is quite respectable (having performed with big names like Hadag Nachash and Subliminal). His guitarist, Danny Weissfeld, has also opened and performed alongside big names on both sides of the ocean (yes, even Kelly Clarkson).

I wasn't the only one to thank Arie for the show--Roy made certain to swing by and thank Arie personally for coming. Seems this up-and-coming Israeli star knows Arie from a chance discussion of Israeli hip-hop in a cafe earlier...anyway, enjoy the clip!


Mi Ba - Roy Uadri

(from http://www.myspace.com/royuadri)

A Closer Look at an Example of Healthcare in Israel; Potential Lessons for America and Other Countries

I could go on at length about how all Israeli citizens have access to care and the tragedy of our system to guarantee the right to health for all citizens. I could again point out that our system is most expensive for the average taxpayer because we don't cover all citizens. I could throw in a sarcastic comment driving home the point by saying, "Maybe if our country were one of the wealthiest countries in the world we could break the Top 35 countries in health systems on the World Health Organization list by providing more widespread care to citizens, but, alas..." Since I handled this topic in a previous post, I'll spare you this discussion and emphasize other issues regarding healthcare in Israel.

In this post, I will address aspects of Israeli healthcare using Hadassah Hospital in Jerusalem as an example that emphasize the impact the regional situation has had on the provision of care and the patient population found in the hospital. First, to understand Hadassah, one must look at the history of the hospital system. Founded in association with the American women's Zionist organization of the same name, two hospital locations of the Hadassah Medical System can be found in Jerusalem today. While a previous Hadassah building existed in Hebron in the 1920's, that location was abandoned following the 1929 Hebron Massacre and the first building in Jerusalem was erected in 1934 on Mount Scopus at Hebrew University's campus in East Jerusalem. On April 13, 1948, a medical convoy of doctors, nurses, medical students, and other staff (77 in total) were massacred en route to the hospital, forcing Hadassah to shut down operations at the hospital and seek the opening of a a Hadassah hospital in a new location in Jerusalem. While the armistice agreement with Jordan in 1948 permitted one military convoy to cross from West Jerusalem to East Jerusalem and the Hebrew University campus every two weeks, the Mount Scopus hospital was not reopened until 1975, long after the Six Day War in 1967.

In 1961, Hadassah Hospital's campus on Ein Kerem in West Jerusalem opens its doors to what would become the center of one of the most advanced medical systems in Jerusalem, in Israel, and in the world forty years later with funding again from the Hadassah Woman's Zionist Organization of America. Hebrew University's medical school, dental school, school of nursing, and school of public health are all located on this campus. It has also become a popular tourist destination, given the stained glass windows representing the twelve tribes as donated by Marc Chagall in 1960 to the campus synagogue. Phew, that's about enough background information--if you're really itching for more, click here to go the Wikipedia article.

View from Hadassah Hospital, Ein Kerem, overlooking West Jerusalem neighborhoods on a foggy morning


Chagall stained glass windows; holes remain in a few windows since Chagall said he could never quite regain his original inspiration when he was asked to repair windows damaged during the Six Day War in 1967

Today, Hadassah Hospital in Ein Kerem is a bustling campus with rapid development. Hadassah has already broken ground on yet another multi-million dollar building on their campus with funding from Michael Bloomberg, the mayor of New York City. Additionally, in 2005, the center was nominated for the Nobel Peace Prize due to its commitment to equality in treatment, ethnic and religious diversity, and struggle to build bridges to peace. Given the reduced resources in the Palestinian Authority (PA) medical system, attempts have been made to provide advanced training and resources to foster an advanced medical system in the PA. While this project has met many difficulties and challenges along the way, the commitment to care of all people in the region can be seen by the number of patients who represent Jews and Arabs, Palestinians and Israelis, and patients who come from all over the world. The medical staff is almost equally as diverse, representing Jewish citizens of Israel, Arab citizens of Israel, and East Jerusalem Palestinians (during the Second Intifada, access to Israel was limited to Palestinians, with the exception of residents of East Jerusalem who continue to maintain increased rights to travel in Israel).

Many challenges for patient care in this multi-layered and complex system remain. Prior to the Oslo accords, care of Palestinians was covered by Israel. However, part of the push to increased autonomy for Palestinians included their removal from the national health plan of Israel. Today, decisions about the coverage of medical care for Palestinians are made by the Minister of Health in the PA. Changes of the minister from Fatah to Hamas to Fatah in the PA have altered what is covered by the PA government for patients in Israeli hospitals. One physician I met argued that it would be great to pay out of pocket for every bone marrow transplant and help everyone, but it is just not logistically feasible and doesn't solve the issue of disparity between the two medical systems.

I had the opportunity to visit the Pediatric Hematology-Oncology Unit at Hadassah and learned that the challenges continue even further. While the pathologies and the diagnoses are as complex as those found at hospitals elsewhere in the world (we saw one child that likely had a rare Protein S deficiency), regional issues further complicate the approach to diagnosis and treatment (this same child has minimal documentation from her hospital in the PA and many months went by with out any progress on her diagnosis before she was referred to Hadassah in Israel). Referral and communication can be very challenging between the two worlds as will be discussed further.

In pediatric oncology, the presence of a fever can be life-threatening and a patient on chemotherapy may need to come in within 30 minutes. While a number of Palestinian may only be 15 minutes away from Hadassah and just outside Jerusalem, security checkpoints may increase travel time by 3 or 4 hours (assuming that checkpoints are open and military intelligence has received no information regarding an imminent security threat). While Hadassah maintains some contacts in the Israeli military, but the reality of hastening a patient through security remains difficult. Again, the situation is infinitely complex--soldiers are wary of the massive crowd of Palestinians waiting to get through and conjure up the images seen at checkpoints of an 11 year-old wearing a bomb and one can somewhat understand why some soldiers may be reluctant to approach anyone seeking rapid movement through a busy checkpoint. On the other hand, the checkpoints and border security continue to represent a barrier to human rights and access to emergency health services for many Palestinians in both the West Bank and Gaza and can have tragic consequences. The merits of the checkpoints, whether between Israel and the West Bank or Gaza or internally in the West Bank between two Palestinian cities, remains a complicated and tense issue. (A great deal would be answered if statisticians could link the number of checkpoints to the prevention of terror attacks in Israel and, separately, in the West Bank and then if a group of philosophers and diplomats resolved the conflict between the human rights of Israelis to live free of suicide bombings versus the rights of Palestinians to live and work unimpeded by and free of security checkpoints dotted all over the West Bank.)

As mentioned earlier, communication and referrals remain another issue for Palestinian patients. Since access to Hadassah can be challenging, patients are given letters with specific instructions and phone numbers of physicians to call at Hadassah should the patient arrive at a Palestinian hospital in an emergency. Hadassah physicians lament many times never receiving the phone call. Speculation has been that some Palestinian physicians may see it as a sign of shame to call a Israeli physician but, above and beyond this, a referral to an Israeli physician in some of the more politicized and harsh regions of the West Bank (e.g., a pro-Hamas town) could be seen as "collaboration with Israel" and lead to a rapid death sentence at the hands of a group of masked men. This may be the same reason that while many Israeli physicians fighting for peace hope that taking care of a Palestinian patient leads to return to their communities and change any beliefs held about Israelis or Jews but that the reality may be that these patients from more politicized communities return home to never discuss that they were in an Israeli hospital.

Given these challenges and not knowing when a Palestinian family may be able to arrive, physicians at Hadassah do not present patients with times for appointment--only days. Unique in this environment, one family has been observed to be present first thing on every appointment day although they come from a town known for radicalism near Hebron. While everyone is relieved that care is able to be provided to the child rapidly and consistently, medical staff are far from free of the ills of gossiping and speculation and believe he may be able to move rapidly because he may actually be a "collaborator," helping the Israeli Shin-Bet security forces by providing intelligence information about people in his town, or may be linked to the upper echelon of Fatah (PA Chair Mahmoud Abbas' political party).

Another set of challenges with the care of patients can be found in the religious Jewish community. Haredim, also known as the ultra-Orthodox, on the principles of strict interpretation of Jewish doctrine, consider their rabbi's opinion to be of the utmost importance. Jewish law binds these Jews to protect their bodies (they are on loan from God) and the maintenance of good health is required. As a result, the rabbi often times agrees with the medical decision making of the physician. Nevertheless, occasionally, these opinions differ and make life challenging for the physician. For example, one pediatric oncology patient needs lower extremity amputation soon for removal of a dangerous life-threatening osteosarcoma but the rabbi thinks the leg can be spared by delaying and having the whole community pray for the child. Many times, patients in the Haredi population present late in the development of a disease as do Palestinian patients.

Center of the pediatrics building at Hadassah Hospital, Ein Kerem

The regional conflict has influenced more than the patient and medical population at Hadassah. During the Second Intifada, a number of threats and three actual attacks were leveled against hospitals in Israel. As a result, Hadassah (and other hospitals in Jerusalem and elsewhere in Israel) beefed up security and began to prepare for some of the worst-case scenarios. Many details of the architecture and buildings reflect this increased security. Hadassah, in addition to the other hospitals of Jerusalem, has also dealt with the victims of some of the worst suicide bombings in Israel and, as a result, has become a world leader in emergency care and the rapid deployment of care following mass casualty incidents. The main building is capable of handling everything from missile attacks to biochemical warfare to even an indirect nuclear attack (the building has a separate air supply and resources to last for weeks). I will let the following pictures provide some examples:

"Sewer cover" representing a system to deploy showers rapidly in the event of a biochemical attack found outside the buildings at Hadassah

Thick steel doors for the protection of both patients and medical staff

"Biological terror - medical guide," with instructions in Hebrew for patients with anthrax, pneumonic plague, botulism, and smallpox

Internal cell phone antenna for maintenance of communication at all times (physicians in Israel carry cell phones instead of pagers; interestingly enough, a recent study found that cell phone use instead of pagers reduces the number of medical errors in America)

A spacious trauma bay inside the Emergency Room

Portable x-ray machine hangs from the ceiling to be rapidly deployed to any trauma bay for use

Container of nails found in patients during surgery following a suicide bombing (bombs are oftentimes packed with nails to increase damage caused by the explosion)

Even beyond mass casualty incidents, emergency medicine in Israel relies on advanced technology; here, ambulances are equipped with digital cameras to provide physicians with photos of car accidents so they can determine where impact occurred and where patients are likely to have injuries

Hadassah and other medical systems in Israel represent challenging, meaningful, and stimulating environments for medical staff to work and provide care for diverse patients. While the challenges and the effects of regional conflict may be frightening, I want to refer you to the previous post. Given the advanced services of Hadassah, I was still impressed with how quiet the emergency room and the trauma bays were for one of the largest hospitals in Israel and a major contributor to emergency care for Israeli citizens. Compared to our inner-city hospital back in the United States, where it is regular to see patients in beds in the hallway with "room numbers" placed on the wall, Hadassah presents a striking difference and it is unclear how such hospitals in the United States would deploy services rapidly in a mass casualty incident.

Given the great tragedies of recent history here, we can only hope that this relative period of calm in the region permits physicians to focus on advancing care for a diverse population and share the lessons learned during tougher times with hospitals around the world.

On a positive note, I'll leave you with some pictures around City Hall in Jerusalem during Hanukkah:

A Theoretical Letter

Dear Israelis seeking travel to the United States,

The Ministry of Tourism advises against any travel to the United States at this time. The threat of violence and terrorism continues in the United States. Violent crimes in the United States far exceeds that found in Israel and any other Western country. The homicide rate is 2-3 times higher than Israel per capita and, in spite of continuing violence, firearms are easily accessible to all citizens. Attempts to buy back weapons from citizens, such as have been conducted in the West Bank in recent years, have never been successfully initiated in the United States. United States policymakers have an ongoing relationship with the gun lobby that prevents any changes from being made to policy that endangers all Americans. Access to firearms that far exceed those used during hunting are easily accessible, even to individuals with a criminal record or a history of violence in certain states. These firearms are additionally available to all civilians without any training in the use of firearms.

Israelis often forget that the streets of major U.S. cities are unlike our streets in major cities such as Tel Aviv or Jerusalem. Should travel to the United States be necessary, extreme caution should be used for anyone walking in major cities during the day and especially at night and we advise against anyone walking alone (male or female). Caution should always be used and travel to public places should be avoided whenever possible.

Again, the State of Israel advises against any form of travel to the United States at this time. Please contact the Ministry of Tourism for further updates regarding the security situation in the United States.

Obviously, the above text is a parody of the U.S. State Department's letter regarding travel to Israel published in January, 2007. While this travel warning has been superseded by an updated travel warning that takes into account the fact that the threat has been reduced, I am going to take this opportunity to write something extremely edgy and critical of what I see as a tragedy due to defense of a dangerous policy in the United States at this time. If you are easily offended, I urge you to reconsider reading on. Nevertheless, I think that the following is an essential opinion to provide about our American culture and policy with regard to guns.

As you are no doubt aware, a tragedy occurred in Omaha last week. (Unfortunately, at the time of proofing this post, I can also add the tragedies at a Colorado church and a Las Vegas bus stop.) News of these tragedies reached all the way around here and Israelis, no doubt, are aware of what occurred. In Jerusalem, I noticed that the flag at the United States consulate flew at half-mast. As harsh as this sounds, I posit the following question: how many tragedies have to occur before we Americans get it? The ongoing policy of "guns freely available to anyone and everyone" is endangering every single person in our country.

I am constantly reminded of the misconception many have outside of Israel when they ask, do you feel safe in Israel? Bombarded with the dramatizing of the 24-hour news channel (remember that Fox News is not the only channel guilty of turning world events into entertainment), it is no wonder people think this country is on the fritz. And yet, the amount of violent crime is so minimal even in the biggest of cities here in Israel. Granted petty crime (theft) is significant, murder or rape occurs so infrequently in cities as large as Tel Aviv that it makes huge news here when it does occur. Go beyond even the grand-daddy New York City--think about any medium or small-sized city in the United States and consider how many news stories focus on violent crime on the 6:00 news. Hey, even our vice president is guilty of shooting someone.

What about guns here in Israel? Aren't they everywhere? On one's first trip to Israel, it can be very disconcerting to see so many young soldiers in uniform or off-duty soldiers in civilian clothing carrying M-16's. It is far from uncommon to be riding a train or a bus and not sit next to someone carrying a weapon (especially on a Sunday morning, when maybe 70-80% of people on the morning public commute are young adults fulfilling their national service requirement and heading to their assignments). Security guards stand in front of shopping malls, bus stations, bars and restaurants also carry weapons. Every bag taken into a facility is thoroughly checked and a commonly question given to someone entering one of these establishments is, Neshek? (translation: Weapon?)

Yes, guns are everywhere and, yet, the homicide rate in Israel even with the threat of terrorism is far, far less than that in America. Put simply, we have a huge problem in the United States--the amount of violent crime in our country significantly exceeds that of pretty much any other nation in the West. One does not even need to watch the film Bowling for Columbime to understand this point.

In Israel, every single person who carries a weapon has had extensive training using that weapon. They know how to continually make certain the safety is on, they know never to leave their guns out of their sight for a single moment, and, for the most part, they have learned to confirm as best as possible that a target is truly a threat before pulling the trigger. Civilians, for the most part, do not carry guns in Israel and their use is constantly monitored and controlled. Rarely are guns ever accidentally or purposely fired at civilians in Israel (note: I am not including volatile parts of the West Bank or Gaza, either under Israeli or PA control; also note that even given recent events, many parts of the West Bank under PA control are still much safer than cities in the United States when one refers to the homicide rate per capita).

Now compare this scenario to the United States, where anyone and everyone can get a gun. A very limited security check needs to be conducted before someone can purchase a gun. The person can have virtually no training in use of the firearm and how to make sure the safety is checked and the gun is properly stored. Oftentimes, children tragically find a parent's gun or an untrained, nervous individual pulls the trigger in a tense situation. In the trauma bays of major cities, physicians see the tragedies that guns cause daily in the United States. Even al Qaeda likely discussed that it is easier to buy guns in the United States than in Afghanistan.

And let us not forget the countless tragedies that have occurred in recent years in the United States because of who has been able to acquire deadly weapons. How many times must we bear witness to events before something changes, such as those that occurred in Columbine, after Hurricane Katrina in and around the Superdome, at Virginia Tech, last week in Omaha, this week in Colorado and Last Vegas, and numerous other examples? Not a single policy changes after these events--lobbying by the NRA is way too powerful and laws seem to go in the opposite direction in some states (e.g., Jeb Bush's recent "success" in Florida). We seem to be so "gun-ho" about our Second Amendment rights to use guns to protect ourselves from tyranny and oppression, yet we fail to see our own hypocrisy (I see Bush as both tyrannical and oppressive but I think few would think that using guns would be a proper course of action and I would never even consider such a thing as a morally appropriate way of fostering change in our modern society).

Now, imagine the following. Imagine the Supreme Court reinterprets the Second Amendment and recognizes that the right to guns prohibits the right to live free from fear and violence in our society. Imagine a world where we can let our young adults walk around at night without a fear of mugging, murder and rape, as youth do and feel safe doing in most places here in Israel. Imagine we provide a better tomorrow for our children where they do not live in a "Wild West" worsened by newer and more advanced semi-automatic weapons of destruction. Imagine if we united after our national tragedies of internal violence as we did after September 11 and recognize the need to change policies to protect the future of America. Imagine we recognize far more people die from the terror of guns and American terrorists that use them than from nationally-motivated terrorism in the United States. Imagine a world where the delegalization of guns reduces their demand and, while illegal weapons would still be available in underground markets, with fewer guns out there, police could more easily monitor and track their whereabouts. Imagine a future where America becomes a shining example to other countries of a people free from fear and violence.

Unfortunately, in the absence of change, this possibility remains fiction and Israelis remain safer avoiding travel from the "volatility" of the Middle East to the street violence of gun-toting America. Do you feel safe in America?