Biomedical subjects
Publications and source records attributed to T H Tulchinsky.
Many long-term care facilities have been established in Israel over the years by different agencies and with varying levels in the quality of care. This paper considers the importance of written official standards and their relationship to supervisory procedures and presents a framework for the establishment of such standards.
Infants attending six Family Health Centers of the Israel Ministry of Health in various Jewish and Arab localities in the Hadera subdistrict were examined for hemoglobin levels at 6 and 12 months of age. The prevalence of anemia (hemoglobin less than 11 g/dl) among Jewish infants rose from a total of 44.7 to 60% from 6 to 12 months. For the Arab infants, the prevalence of anemia increased from a total of 43.7% at 6 months to 71.0% at 12. The prevalence of severe anemia (less than 10 g/dl) for the Jewish infants rose from 4.5 to 13.1% and for the Arab infants from 7.7 to 19.6%. Of the Jewish infants with a hemoglobin level less than 10 g/dl at 6 months, 50% were still less than 10 g/dl at 12 months. Of the Arab infants less than 10 g/dl at 6 months, 36.4% were still at that level at 12 months. The lack of routine iron supplementation as a preventive procedure and the routine use of cow's milk for infant feeding are the probable causes of this high prevalence of iron deficiency anemia.
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Prevention is a key element of primary health care, as defined by the Alma-Ata Conference and promoted by the World Health Organization. Developed as well as developing countries are giving renewed emphasis to prevention in the planning of health care. Israel has much to gain by placing high priority on prevention in its health policy.
Health care systems throughout the world are being scrutinized because of their growing cost in relations to national wealth. At the same time, techniques for evaluating health care with respect to appropriateness, quality and resource allocation are being developed. These techniques are multifactorial since they must relate to all aspects of health care including: characteristics of the population being served; available health care resources; measures of the process and utilization of care; measures of health care outcomes; peer review, including quality assessment of health care providers; consumer attitudes, knowledge, and compliance; care provided for "tracer" or sample conditions; and economic cost-benefit studies. Evaluation in health care assumes that a health care system and the providers of health care within that system are responsible and accountable for the health status of the population. It must, however, recognize that health services are not the sole determinants of health status; social, economic and cultural factors also play key roles. A comprehensive approach to evaluation in health care is outlined in this review. Many of the components that are available in the Israeli health care system are described; others that remain to be developed are discussed. Evaluation is an integral part of a comprehensive health care system; the components of evaluation must be built into any national system. As long as rationality is expected of health care, evaluation is an essential element of the overall system.
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Measles continues to occur in epidemic waves in Israel, Gaza, and the West Bank, causing morbidity and mortality. In Israel, immunization of infants against measles began in 1967, and 90% had been immunized by the mid-1980s. In Gaza and the West Bank, where immunization of infants against measles began in 1973 and 1976, respectively, the immunization rate reached 75% in the late 1970s and increased to greater than 90% in the 1980s. Measles epidemics, which previously had occurred in 5- to 7-year cycles, occurred every 2-4 years in the 1980s and affected individuals who were older than those affected in previous years. Israel's commitment to eradicating measles by 1992 will require a substantially expanded immunization program in comparison with the traditional program that requires immunization of infants alone. The benefits of several alternative immunization strategies considerably exceed their costs. A new, two-dose immunization will be needed as a minimal strategy, and a campaign for administering booster doses to school-aged children may be required as well to achieve control and eradication of measles. Measles is a serious but preventable public health problem; appropriate strategies must be devised by national and international public health officials to control the disease in developing and developed countries.
A measles outbreak began in Ramallah District in the West Bank in the period just before the outbreak of the Gulf War in 1991. After a local control program, the outbreak was contained to a total of 236 reported cases, including one death, but sporadic cases appeared over the ensuing months. An epidemic of measles followed 2-3 weeks later in Beer Sheva district in Israel, initially among the Bedouin population just prior to the outbreak of the war, then spreading to the Jewish population. The epidemic reached its peak during the war in February, continuing into March. There were a total of over 433 reported cases, with 203 hospitalizations and 7 deaths. The epidemic was slowed by curtailment of school and other civilian activities, and a mass vaccination campaign reaching 60,000 children, but was spread by crowded conditions in hospital, and was spread to other parts of the country by internal population migration. An epidemic of a preventable disease occurring during a national emergency adds to the burdens of the health system. The public health system must be prepared to contain epidemics and other public health threats in wartime, employing standard control methods developed and practiced during peacetime. Routine immunization policies should take into account the possibility of a civilian epidemic during national emergencies, and the need to assure protection of both the civilian and military population in preparation for such contingencies.
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Occupational causes of cancer are difficult to establish because of the long latency period and difficulty in identifying occupational linkages. This study provides a regional analysis of cancer incidence and mortality as a method of identifying localizing factors in cancer that can be followed by more specific epidemiologic investigation. In this study we analyze the regional standardized mortality ratios (SMRs) for site-specific cancers, by age, sex and continent of birth for the years 1983-86, for the Jewish population of Israel. Elevated total malignant and benign neoplasm SMRs were found in Acre (SMR 109, P < 0.05), Haifa (104, P < 0.05) and Tel Aviv (107, P < 0.001). The only other statistically significantly elevated SMRs were found in Acre for lung cancer (133, P < 0.05) and leukemia (171, P < 0.05). Age and sex-standardized incidence ratios (SIRs) by regions are also presented for the years 1980-81 for the Jewish population. Haifa had elevated SIRs for colorectal cancer (126, P < 0.001), breast cancer (118, P < 0.01) and lymphomas (126, P < 0.05). Elevated lung cancer SIRs were found in both Acre (145, P < 0.05) and Ramla (143, P < 0.05). Male to female incidence ratios (MFIRs) for ages 30+ for the Israeli Jewish population are also presented. Elevated bladder cancer MFIRs were found in the heavily industrialized Haifa region (7.69 vs. 4.62 P < 0.05). For Ramla residents, bladder and oronasopharyngeal cancer MFIRs were approximately three times the national average (not statistically significant). Ramla also had elevated MFIRs for lung cancer (14.9 vs. 3.4 nationally, P < 0.01), as did Acre (7.6 vs. 3.4 nationally, P = 0.06). These elevated MFIRs are suggestive of occupational exposure from the cement and asbestos factories in the Ramla and Acre regions. Regional analyses of cancer mortality and cancer incidence (using SMRs, SIRs and MFIRs) can serve as a basic tool for identifying sentinel markers of excess rates. Our findings indicate regions where we should undertake case-referent studies in order to identify potential risk factors and where to target possible preventive programs.
Asbestos workers have long been recognized as a high risk group for the development of mesothelioma and other cancers. In this study we collated from a variety of sources 26 mesothelioma deaths that occurred between 1978 and 1990 among a cohort of some 4,441 former workers from an asbestos-cement plant in northern Israel. Since the expected number of deaths for this number of Israeli males in this age-group over this period is 0.12 cases, the risk of this disease was more than 223 times the national rate, age and sex adjusted [standardized mortality ratio (SMR) = 22,351, P < 0.001]. The mean years of exposure of persons who died from mesothelioma was 16.2 (SE 2.5). The mean latency period for mesothelioma cases from onset of exposure to death was 25.6 years (SE 1.3). Additional follow-up systems are needed to ensure complete reporting of asbestos-related diseases, including epidemiologic follow-up of asbestos-exposed workers after cessation of their work, with regular analysis of death and cancer registry data for high risk groups. Asbestos-related cancer is an important element in cancer epidemiology that requires further development in Israel. Studies of former workers, their families and of persons who worked or attended school adjacent to the asbestos-cement factory, as well as follow-up of other former worker groups exposed to asbestos are recommended.
Success in control of poliomyelitis since 1978 and eradication of cases since 1988 in Gaza and the West Bank was achieved by use of a combination of oral polio vaccine and inactivated polio vaccine despite presence of the wild virus in the environment and among visitors from endemic areas. This approach may be a useful strategy in the international struggle to control or eradicate poliomyelitis.
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