Volume 1 No. 3 Volume

ISRAELI-PALESTINIAN PUBLIC HEALTH MAGAZINE APRIL-MAY 2005

Israeli Perspective Challenges Facing the Nutritional Status of Israel

Palestinian Perspective Armed Conflict and Food Security

Special Interview Marc Lalonde, Former Canadian Minister of Health and Social Welfare

OurOur NutritionalNutritional StatusStatus ProgressProgress oror Inertia?Inertia? Advisory Board Members: Dr. Sameer Abdalla Mission Statement Director, Palestinian Economic Research Institute (MAS), Ramallah bridges, the Israeli-Palestinian with health care. Developed with Prof. Joseph Abramson Emeritus Professor of Social Medicine, Public Health Magazine, is a unique health care professionals, decision Hebrew University, Jerusalem Dr. Ahmad Abu Tawahena publication conceived, written, edit- makers and academics in mind, the Clinical Psychologist,Clinical Supervisor, Gaza ed, produced and managed jointly magazine covers public health top- Dr. Rafik Al Husseini Deputy Director General, Director of by Palestinian and Israeli academ- ics relevant to both populations and Operation, Welfare Association, Jerusalem ics and health professionals under seeks to analyze the impact of the Prof. Alean Al-Krenawi, PhD Chairman, Spitzer Department of Social Work, the sponsorship of the World Health conflict on the health and well-being Ben-Gurion University, Beer Sheva Organization (WHO). The maga- of both societies. In both structure Dr. Dan Bar On Chair, Department of Behavioral Science, zine embodies the WHO paradigm and content bridges is a coopera- Ben Gurion University, Beer Sheva of “Health as a Bridge for Peace”: tive endeavor seeking to build rela- Prof. Zvi Bentwitch Chairman of Board, the integration of peace-building tionships, links and common under- Physicians for Human Rights - Israel concerns, strategies and practices standing. Dr. David Chinitz Senior Lecturer, Health Policy and Management, School of Public Health, Hebrew University - Hadassah, Jerusalem Prof. Orly Elpeleg Table of Contents Head of Metabolic Disease Unit, Shaare-Zedek Medical Center, Jerusalem Editorial 3 Dr. Eyad El Sarraj by Fathi Abumoghli Chairman, Gaza Community Mental Health Programme Challenges Facing the 4 Ms. Tamar Gozansky Nutritional Status of Israel Former Member of Knesset Israel, Lecturer in Ben Gurion University, Beer Sheva by Dorit Nitzan Kaluski, Ted Tulchinsky Prof. Miriam Hirschfeld and Elliot M. Berry Michlelet Emek Izrael Dr. May Kaileh Armed Conflict 8 Family Health Officer, UNRWA, West Bank and Food Security Dr. Joseph Katan by Ziad Abdeen Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv Prevention of 13 Dr. Omayah Khammash Micronutrient Malnutrition Director of MARAM Project, West Bank Dr. Sharif Munzer by Ziad Abdeen and Ted Tulchinsky President's Advisor for Health Affairs, Former Deputy Minister of Health, PNA, West Bank Interview with Marc Lalonde, 14 Prof. Avinoam Reches Former Canadian Minister Chairman, Ethics Committee, of Health and Social Welfare Israel Medical Association Dr. Varsein Shaheen by Saleem Sakakini and Shiri Ourian Director of Research and Planning, Mothers, the Newborn Welfare Association, Jerusalem Dr. Abdel Aziz Mousa Thabet and Children 16 School of Public Health, Highlights from the World Health Al-Quds University, Jerusalem Report 2005 Dr. Nihayah Tilbani Head Business Department, Cover Photo: Ilya Melnikov How to… Wheat Flour 18 Faculty of Economics and Administrative Enrichment and Fortification: Science, Al-Azhar University, Gaza Dr. Theodore Tulchinsky Serving Mutual Needs Associate Professor, Braun School of Public by Omar Dary Health, Hebrew University - Hadassah, Jerusalem News Items 24 Prof. Sam Tyano Prof. of General Psychiatry and Child and Study Break from the Conflict 27 Adolescent Psychiatry, Tel Aviv University, by Noa Cedar Tel Aviv A Day in the Life - Prof. Abdeen 28 Editorial Board: Treats His Students' Wounds Dr. Ambrogio Manenti by Lily Galili Head of Office, WHO West Bank and Gaza Prof. Hani Abdeen A Day in the Life – Prof. Carmi 30 Coming soon: Dean, Al-Quds Medical School, Diagnoses Life During the Conflict Al-Quds University, Jerusalem www.bridgesmagazine.org Dr. Fathi Abumoghli by Abd el Raouf Arnaout National Health Officer, WHO on Nutrition: 32 WHO West Bank and Gaza Ms. Randi Garber The Editorial Board invites submissions Determinants and Consequences JDC-Middle East Program, Jerusalem of letters, comments or articles on public WHO Literature Review Dr. Itzhak Levav Consultant to WHO, Jerusalem health to bridges at: Readers’ Forum 34 [email protected] by Jaime Gofin Production team: Ben Or Consulting / Letters to the Editor 35 Goldfinger Communications This publication contains the views of independent authors and does not necessarily represent the opinion of the Editorial Board or ABS-Palestine the Advisory Board individually or collectively on any matter. The named authors alone are responsible for the views expressed in Maria Restrepo WHO West Bank and Gaza this publication. The designations employed and presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of Hagit Maimon Graphic Designer its authorities, or concerning the delimination of its frontiers or boundaries. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its issue. 2 bridges April-May 2005 time decreasing the costs and effort needed. One of the main achievements in NutritionNutrition nutrition has been the ability to focus on the common interests concern- ing the issue of micronutrient mal- nutrition through joint conferences andand PeacePeace as mentioned in the joint article by by Fathi Abu-Moghli Tulchinsky and Abdeen. The authors call for the establishment of a joint Israeli-Palestinian nutrition working riting an edito- transfer to our audience the Canadian group, as an advisory body to report rial for a scien- experience in health promotion and regularly to the Palestinian Author- tific magazine is how we can utilize the principles of ity and the Israeli ministries of health a real hard task. health promotion to advance peace. and nutritional related issues. It is even harder In Dr. Omar Dary’s “how to” article As a Palestinian, I am confident Wto write the editorial for a magazine on fortification, he states that 40% of that when my Israeli colleagues read like bridges, which has a mandate to the need for flour in the West Bank is about the extent of diseases related to

integrate peace building concerns, Photo: strategies and practices with health

care and to encourage Israeli and Pal- UNDP/PAPP, George Azar estinian professionals to raise pub- lic health issues of common concern as well as analyze the impact of the conflict on the health and well-being of both societies. No matter how conflicts separate and create gaps between people, still common interest and common hard- ships bring them back together. Poverty, disabilities and nutrition are the themes of the first three issues of bridges and women’s health will be the topic of the next issue. These top- ics are aspects we deal with through our daily lives, without thinking of borders, gender, color and ethnicity. covered by imports from Israel. There- malnutrition among children, women The feedback we have received so fore, through collaboration between of child-bearing age and elderly in the far is very positive and encouraging, Israel and the Palestinian Author- occupied Palestinian territory, they indicating that the path we have cho- ity, imported flour could be forti- will realize that these trends in mal- sen is correct and we shall proceed fied according to Palestinian stand- nutrition are related to levels of pov- with our mission, knowing that this ards. This could eventually lead to an erty and unemployment never seen demands hard and continuous work. improvement in the nutritional status to this extent before. The deteriora- We ask for the support of all health that prevails in the Palestinian society. tion of social determinants are strictly practitioners; we ask them to provide What might come as a surprise to connected with closures and curfews us with new ideas and to use bridg- the Palestinian reader, are the facts caused by Israeli military activities. es as a source of creative and com- presented in the article by Kaluski et All health professionals are aware mon activities on the ground. We are al, “Challenges Facing the Nutrition- that the continuation of the military grateful to those who have already al Status of Israel”, which show that measures will intensify the heath cri- taken time out from their busy days, Israeli society suffers from deficien- sis and there is no path out, except to like Ted Tulchinsky and Ziad Abdeen, cies in iron, iodine, vitamin D and fol- end the occupation and having two and served as co-editors of this edi- ic acid. This common problem shared independent, neighboring states. tion of bridges, significantly shaping by the Israeli and Palestinian societies Health professionals take advan- the content of the following pages. could open the gates for future joint tage of their special position in both I would like to thank Marc Lalonde, cooperation in order to obtain the societies, and promote this solution, former Canadian Minister of Health, most suitable tools to resolve com- in order to ensure social well-being for giving bridges the opportunity to mon health problems and at the same for Israelis and Palestinians.

April-May 2005 bridges 3 Challenges Facing the Nutritional Status of Israel by Dorit Nitzan Kaluski, Ted Tulchinsky and Elliot M. Berry Ilya Melnikov photos: 4 bridges April-May 2005 .an elevated waist-hip ratio ישראל סובלת משילוב פרדוקסאלי של ﺗﻌﺎﻧﻲ اﺳﺮاﺋﻴﻞ ﻣﻦ ﺗﻨﺎﻗﺾ ﺷﺎذ Socio-economic status affected צריכה מופרזת של קלוריות (סוכרת) ﺣﻴﺚ ﻳﺘﺮاﻓﻖ وﺟﻮد ﻣﺸﻜﻠﺔ زﻳﺎدة women more than men. 36.9% in the לצד מיעוט בצריכה של מרכיבי מזון ﺗﻨﺎول اﻟﺴﻌﺮات اﻟﺤﺮارﻳﺔ ﻣﻊ ﻧﻘﺺ ﻓﻲ lowest tertile for SES had a BMI >30 (מזינים נחוצים). micronutrients בעוד שנדיר למצוא בקרב האזרחים תת اﻟﻤﻐﺬﻳﺎت (اﻟﺪﻗﻴﻘﺔ compared with 17.7% in the upper תזונה ברורה, רבים מהם סובלים מרמת وﺑﻴﻨﻤﺎ ﻳﻌﺘﺒﺮ) ﻧﻘﺺ اﻟﺘﻐﺬﻳﺔ اﻟﺤﻘﻴﻘﻲ one (p < 0.001). The figures for men תזונה נמוכה מהרמה הרצויה. הדבר משול ﻧﺎدرا" ﻓﻲ اﺳﺮاﺋﻴﻞ ﻓﺎن اﻟﻌﺪﻳﺪ ﻣﻦ were 25.3% and 19.5% respectively למכונית שפועלת על "דלק לא מתאים או اﻟﻤﻮاﻃﻨﻴﻦ ﻳﺘﺒﻌﻮن ﺣﻤﻴﺔ ﻏﻴﺮ ﻣﻨﺎﺳﺒﺔ non-significant). Multiple logistic) בעל אוקטן נמוך מדי". ﻣﺜﻠﻬﻢ ﻣﺜﻞ اﻟﺴﻴﺎرة اﻟﺘﻲ ﺗﺴﻴﺮ ﺑﻮﻗﻮد regression analysis indicated, that at כתוצאה מכך, נבצר מאנשים למצות ﻣﻨﺨﻔﺾ اﻻوﻛﺘﺎن. -the same weight, women in the low את מלוא היכולת הגופנית, הקוגניטיבית ان اﻟﺴﻴﺎﺳﺔ اﻟﺼﺤﻴﺔ اﻻﺳﺮاﺋﻴﻠﻴﺔ اﻟﺨﺎﺻﺔ והחברתית - מה שמוביל לאי מיצויו של ההון ﺑﺎﻟﺘﻐﺬﻳﺔ ﺗﻮاﺟﻪ ﺗﺤﺪﻳﺎت ﺗﺘﻌﻠﻖ est SES were almost four times more ﺑﻤﻜﺎﻓﺤﺔ اﻟﺴﻤﻨﺔ وﺑﻨﻔﺲ اﻟﻮﻗﺖ likely to be obese than those in the האנושי והחברתי. נותרו אתגרים רבים לעתיד. מדיניות התזונה ﻣﻜﺎﻓﺤﺔ ﻧﻘﺺ اﻟﻤﻐﺬﻳﺎت اﻟﺪﻗﻴﻘﺔ ,highest SES. These data identified של בריאות הציבור של ישראל ניצבת واﻻﻣﺮاﺿﻴﺔ اﻟﻨﺎﺗﺠﺔ ﻋﻨﻬﻤﺎ. draw attention to target populations בפני אתגרים רבים במאבק בהשמנת יתר, .for community interventions במיעוט הצריכה של מרכיבי מזון מזינים -With regard to children, pre ובתחלואה. liminary data from the Adolescent Health and Nutrition Survey (MABAT srael shares similar eating and the development and progression of Youth), which was carried out on a lifestyle habits and effects these non-communicable diseases. national cluster sample of 5,268 stu- of socio-economic status dents between 7th to 12th grades, (SES) on health with Western Nutritional Database shows that the situation is better in Europe. As a multiethnic soci- During the past few years, the Min- this age group, compared with that Iety, Israel could be used as a living istry of Health has embarked on a of adults. 4.1% of the sampled popu- "laboratory" to study the interac- series of nutritional surveys of adults, lation had BMI for age <5th percen- tions between cultural determinants, children and the elderly. The First tile; 12.8% were at risk for obesity nutritional status and health out- Israeli National Health and Nutrition (8595th percentile). Over- alized countries, Israel has the par- conducted on a representative sam- all, 18.5% of Israeli adolescents were adoxical combination of problems ple of 3,246 adults (52.4% women) overweight and obese. Nevertheless, of excess caloric intake (diabesity) aged 25-64 years old (mean 43 years the results differ in different sec- with those of micronutrient deficien- old). Some of the relevant findings tors. The prevalence of overweight cies. While frank under-nutrition is are presented. and obesity in the Arab sector was rare, many citizens have suboptimal higher than the Jewish, 21.4% and diets, which may be compared to a Obesity on the Rise 15.4%, respectively. Also, the rates car running on “inadequate or low Body mass index (BMI) is an indi- were higher among those from lower octane fuel”. As a consequence, they cator that is calculated by adjusting socio-economic status. are unable to achieve their full phys- body weight for height. Thirty-nine It is important to note that these ical, cognitive and social potential percent of the sample was over- findings are similar to those from with a consequent reduction in the weight (25< BMI <30), and 22.9% the United States two decades ago. human and social capital. At-risk (women, 25.8% men, 19.9%) was Needless to remind us that the cur- populations include the lower socio- obese (BMI 30). Overall, 62.2% of rent US rates of overweight and economic sectors and the elderly. the sample had a BMI 25. The rates obesity among adolescents of 46% The background health situation is of obesity increased with age in both should mobilize us to act today with that: Arab and Jewish population groups prevention programs to stop over- • the major causes of mortality are and both genders. This trend was weight and obesity from growing in from cardiovascular disease; particularly noticeable among Arab our country. • more than 55% of the adult popu- women – more than 50% of them lation is overweight or obese; aged 45-54 and 70% of those aged Micronutrient Deficiencies • 14% of women above the age of 45 55-64 were obese. Risk groups for micronutrient defi- have osteoporosis; After adjusting for age, Arab men ciencies (MND) include infants and • 10% of adults have hypertension were 1.1 times, and Arab women 1.4 children, adolescents, adult wom- and 5-6% has diabetes (20% above times more obese than their Jewish en and men and the elderly. Some 65 years). counterparts. Almost 35% of the sam- MNDs are best addressed by fortifi- • In women over 75 years, cancer is ple had an elevated waist-hip ratio – cation of basic foods. Others require the leading cause of death. Nutrition over 50% of the women and 15% of specific supplements such as vita- and lifestyle have a major impact on men. Among Arab women, 66% had min A and D and iron for infants,

April-May 2005 bridges 5 which has been part of Israeli pub- Sheets reveal that in 50 years there tors of even relatively wealthy soci- lic health program for many years. has been a marked increased con- eties. Recent recommendations for Pregnant women have received iron sumption of an energy dense diet, supplements of vitamin D up to the and folate supplements for many high in fat and sugar. The nutrition age of adolescence will also need to decades and this has contributed to transition is marked by a shift away be considered in the future. a steady decline in rates of anemia from diets based on indigenous sta- In Israel there is a wide use of of pregnancy. Various studies other ple foods, such as grains and pulses, sophisticated and non-sophisticat- than MABAT in Israel have shown fruits and vegetables, towards more ed marketing techniques. As in any high levels of iron deficiency and global diets that include more proc- place in the world, the industry rec- anemia, iodine deficiency, vitamin D essed food, more foods from animal ognizes that good marketing tech- deficiency, and folic acid and vitamin origin, more added sugar, salt and niques lead to greater consumption B12 deficiency and other B deficien- fat. Currently, 70% of the foods are of products, greater profit and fre- cies have occurred in recent years. currently imported into the country. quently, over consumption. Chil- The mean folic acid intake in Israel This shift, combined with a decline dren, deluged with marketing mes- is less than 200 microgram per day in energy expenditure and leads to in women throughout the population a rapid increase in obesity and its and blood concentrations of folate associated health problems. Moreo- are also suboptimal. This is surpris- ver, the dietary habits of the Israeli- “These findings are ing considering the wide variety of Arab community have been moving similar to those from vegetables available in the market, from the Mediterranean-type diet to thus suggesting decreased accessi- ones more like those eaten in north- the United States bility to healthy foods. The MABAT ern Europe and the USA. As shown two decades ago. data show that the consumption above, the Arab community in Isra- Needless to remind of fruit and vegetables is less than el is suffering the most from obesity the recommended intake of over 400 and its consequences. us that the current US g/d. More than 50% of people living rates of overweight below the poverty line consume less Plans for the Future than the recommended level. Most of There are many challenges for the and obesity among the poor consume less than 380g/d of future. It is recognized that health adolescents of 46% fruits and vegetables. The situation and other non-health sectors have should mobilize us regarding vitamin B12 intake is simi- prime responsibility for the food lar, reflecting a low intake of meat in chain in Israel. Stakeholders may to act today with these sectors of the population. The have contradictory attitudes towards prevention programs socio-economically compromised the problem, its causes and solu- to stop overweight eat less than 70g/d of meat, poultry tions. Food producers, importers and and fish. Also, dairy consumption is farmers may advocate the need to and obesity.” less than recommended in the low- promote individual choice, knowl- er SES with median consumption of edge and physical activity, while 150 g/d. Clearly, this cannot provide ministries, academia, health profes- sages targeted especially to them the recommended level of calcium sional, human rights advocates and are misled. Mass marketing by the intake. These and other findings lead consumers may emphasize the state food companies dilutes the effect to a variation in the well-known say- responsibility for providing a healthy of health promoting messages. The ing of Brillat Savarin such that “tell environment with equal accessibility MOH and others who are engaged me what you eat and I will tell you to healthy food. in health education cannot compete your socio-economic status.” Folic acid supplements for women with the budget used by the indus- of the age of fertility have been only try for marketing. Thus, legislation Indigenous and partially successful, but will continue has to be called into this cycle and Mediterranean Diets to be important even when folic acid make its effect to restrain unethical Rapid dietary changes resulting fortification of flour is implemented. advertising especially directed at from economic development and Vitamin and mineral supplements for children. market globalization are having a the middle aged and elderly are not As in many other countries, in Isra- significant impact on the nutrition- yet practiced uniformly and remain el, unhealthy food items are cheaper al status of the Israeli population. in the realm of individual practice, than healthier foods. Thus, the poor The process of "nutrition transition" but may become a future issue with get the worst of choices. Healthy has led the changing nutritional-web increasing knowledge and aware- diet is not accessible for them and since the commencement of the state ness of micronutrient importance thus education and labeling cannot in 1948. Data from the Food Balance and relative deficiencies among sec- suffice. In fact, the poorest member

6 bridges April-May 2005 of societies is actually encouraged come into effect in late 2005 or early Dr. Dorit Nitzan Kalulski is Director to make unhealthy choices because 2006. Other nutrition related policies of the Israeli Health Ministry's Food and the least healthy choices are the only of the Ministry of Health are directed Nutrition Administration. ones they can afford. In the current to alleviate food poverty, tailor diets Dr. Ted Tulchinsky is Associate Professor global environment, taxation and for different sectors of the popula- at the Hebrew University-Hadassah Braun pricing ("price control") are tools tion and to promote an environment School of Public Health and active in to increase the accessibility of peo- that encourages healthy diets and development of schools of public health ple from low socioeconomic status life styles. in former Soviet countries. to a healthier diet. This should be It is clear that these plans will not Dr. Elliot M. Berry is the Director of better utilized in Israel. It is worth work without strategic alliances and the Hebrew University-Hadassah Braun supporting the link between agri- partnerships with the food indus- School of Public Health and Head of the cultural policy, including subsidy try, agriculture and NGOs (as in the Department of Nutrition and Human programs, to the health of our pop- school lunch programs). The key ele- Metabolism.

ulation. A gradual and well coordi- ments, as stated above, are increased References 1. Tulchinsky TH. Vitamin enrichment of basic nated change can have a minimal accessibility to a healthy diet with foods: the case-for-action in Israel. Isr J Med Sci. negative impact on the farmers and education. Continual efforts are 1993;29:58-61. 2. Tulchinsky TH [ed]. Proceedings of the economics while making a substan- being made to promote nutritional Israeli-Palestinian Conference on Micronutrient tive effect on health. These changes knowledge at different levels such as Deficiency Conditions and their Prevention. Public Health Reviews, 2000;28:1-264. can change the preferences of farm- encouraging breast feeding, school- 3. Kaluski DN, Goldsmith R, Ben-Arie OM, Mayer C, Green M. The first Israeli national ers and hence, promote health even based interventions for nutrition and health and nutrition survey (MABAT) as a policy better. exercise and constructing appropri- maker. Public Health Rev. 2000;28:23-26. 4. Nitzan Kaluski, D, Tulchinsky TH, Haviv A, With regard to micronutrient defi- ate dietary guidelines. Israel’s public Averbruch Y, Lowe S. Miccronutrient deficiencies ciencies, legislation is nearly com- health nutrition policy will continue in Israel: a bibliography of resources. Public Health Reviews, 2000;28:231-244. pleted to ensure iodization of all salt with promotion of appropriate food 5. Nizan Kaluski D, Tulchinsky TH, Haviv A, used in the home and in food pro- fortification, supplementation, food Averbuch Y, Erachmiel S, Mayshar I, Berry E, Leventhal A. Addition of Essential Micronutrients duction as well as fortification of 3% security issues, monitoring along to Foods – Implication for Public Health Policy in Israel. Isr Med Assoc J. 2003;5:277-80. milk with vitamin D and the fortifi- with the 5 “E’s” – education, employ- 6. Tulchinsky TH, Nizan Kaluski D, Berry E. Food cation of flour with iron and B vita- ment, empowerment (especially for fortification and risk group supplementation are vital parts of a comprehensive nutrition policy mins including folate and vitamin women), and enabling environment for prevention of chronic diseases. Eur J Public B12. The new regulations should and exercise. Health. 2004;14:226-28.

April-May 2005 bridges 7 Armed Conflict and Food Security A Nutrition Profile of the West Bank and Gaza Strip by Ziad Abdeen

?he concept of food secu- What’s the Status אוכלוסיות הסובלות ממחוסר במזון, -rity – a condition where In 2002, under-nutrition and mal מצויות בסכנה של תת תזונה ומחסור -all people in a popula- nutrition reached alarming propor קשה ברכיבים מזינים. ילדים, ובעיקר תינוקות וטף, המצויים tion have, at all times, tions. The deteriorating economy בתקופה של גדילה מהירה והתפתחות the physical, social, and and reduction in marketplace (for גופנית וקוגניטיבית חיונית זקוקים (Teconomic access to sufficient, safe, food) and the workplace (for income לתזונה הולמת ולכן הינם רגישים ביותר ,and nutritious food that meets their were strong contributors. By 2003 לשינויים באיזון התזונתי. -dietary needs and preferences for an global chronic malnutrition (indicat העובדה שקיים בכלל מחסור במזון -active and healthy life—has emerged ing long-term inadequate nutrition במקומות כמו הגדה המערבית ורצועת as a critical concern for populations al intake leading to stunting) among עזה, מקומות בהם השווקים משופעים affected by armed conflicts. children 6 to 59 months of age was במזון ואין בעיית בצורת, מעידה על ההשפעות הבלתי נמנעות של הסכסוך Food security involves not only 12.7% in the Gaza Strip and 9.2% in על הכלכלה, הגורמות למחסור במזון. the physiological needs of the popu- the West Bank. lation, but also how the population Under normal circumstances, the balances other needs required for agricultural production in Palestine life and living. Food insecure popula- could contribute significantly to a أن اﻟﻤﺠﺘﻤﻌﺎﺗﺎﻟﺘﻲ ﻻ ﺗﺘﻤﺘﻊ ﺑﺎﻻﻣﻦ .tions are at risk for malnutrition and nutritious diet for its population اﻟﻐﺬاﺋﻴﻤﻌﺮﺿﺔ ﻟﺴﻮء اﻟﺘﻐﺬﻳﺔ -micronutrient deficiencies. Children, However, fluctuations in actual farm وﻧﻘﺼﺎﻟﻤﻐﺬﻳﺎت (اﻟﺪﻗﻴﻘﺔ micronutrients especially infants and preschool age land productivity, combined with وﻳﻌﺘﺒﺮ) اﻷﻃﻔﺎل وﺧﺎﺻﺔ اﻟﺮﺿﻊ وأﻃﻔﺎل -children are the most sensitive to limited financial and other resourc ﺳﻦ ﻣﺎ ﻗﺒﻞ اﻟﻤﺪرﺳﺔ اﻷﻛﺜﺮ ﺣﺴﺎﺳﻴﺔ -changes in food security since they es to support agricultural produc ﻟﺘﻐﻴﺮات اﻷﻣﻦ اﻟﻐﺬاﺋﻲ ﻷﻧﻬﻢ اﻟﻔﺌﺔ اﻷﻛﺜﺮ -require adequate nutrition during tion, have contributed to problemat ﺣﺎﺟﺔ ﻟﺘﻐﺬﻳﺔ ﻛﺎﻓﻴﺔ ﺧﻼل ﻓﺘﺮة اﻟﻨﻤﻮ this period of rapid growth and criti- ic outcomes. Much of the Palestinian اﻟﺴﺮﻳﻊ واﻟﺘﻄﻮر اﻟﺠﺴﻤﻲ واﻟﺠﻨﺴﻲ. cal physical and cognitive develop- population is either under-nourished ان اﻟﺸﻌﻮر ﺑﺎ ﻟﺤﺎﺟﺔ اﻟﻰ اﻟﺤﺪﻳﺚ ﻋﻦ اﻷﻣﻦ اﻟﻐﺬاﺋﻲ ﻓﻲ ﻣﻜﺎن ْﺗﻤﺘﻠﻲ -ments. Most importantly, access to or vulnerable to insufficient nutri ﻓﻴﻪ اﻻﺳﻮاق ﺑﺎﻟﻤﻮاد اﻟﻐﺬاﺋﻴﺔ وﻳﺘﻤﺘﻊ food and health is a basic human tional intake, and depends on food ﺑﻤﻮﺳﻢ اﻣﻄﺎر ﺟﻴﺪ ﻣﺜﻞ اﻟﻀﻔﺔ اﻟﻐﺮﺑﻴﺔ right enshrined in international aid which also has not always been وﻗﻄﺎع ﻏﺰة ﻳﻘﻮدﻧﺎ إﻟﻰ ﺣﻘﻴﻘﺔ ﻋﺪم human rights and humanitarian law adequate due to donor fatigue, lack اﻟﻘﺪرة ﻋﻠﻰ اﻟﺘﻐﺎﺿﻲ ﻋﻦ ﺗﺄﺛﻴﺮات اﻟﻨﺰاع to which occupying powers have the of resources and reduced import of ﻋﻠﻰ اﻻﻗﺘﺼﺎد اﻟﻤﺤﻠﻲ وﻗﺪرة اﻟﻨﺎس ﻋﻠﻰ -responsibility to protect. The fact food items including food aid pack اﻟﻮﺻﻮل ﻟﻠﻐﺬاء. that food security is even an issue in ets for food assistance. Nonetheless, a place like the West Bank and Gaza humanitarian assistance provided Strip where food is plentiful in the to Palestine in response to findings marketplace and recent rainfall has of severe levels of acute and chron- been adequate, attests to the inevi- ic malnutrition in 2002 likely con- table effects of conflict on the local tributed to slight improvements in economy and thus the population’s the nutritional situation. Howev- ability to access food. er, since the Palestinian population This article aims to present the in the West Bank and Gaza Strip current nutritional status of the Pal- continues to grow, the demand for estinian population and serves as a food increases. Availability of food, call for action. in general, has declined since the

8 bridges April-May 2005 photos: Osama Silwadi

inception of the second Intifada in ets of vulnerable people, located par- successful husbandry of meat and September 2000. ticularly in Gaza, Jenin and Nablus. dairy animals, along with coastal Two studies conducted in 2000 and fishing in Gaza. The current situa- Sources of Energy 2002 provide insights into changes in tion, has introduced constraints to Results of a series of Palestinian the nutritional intake since the 1996- availability and access to food per Central Bureau of Statistics (PCBS) 1998 period and during the first two capita. Food production has declined household surveys indicate that years of the Intifada. The First Pal- 2.9% since the institution of clo- between 1996 and 1998 Palestinians estinian National Health and Nutri- sures and curfews. Real per capita consumed an average of 2,114 kilo- tion Study was conducted in 2000 incomes have dropped 46% since calories, a level of daily food ener- and the Nutritional Assessment of 1999 prompting households to cut gy consumption considered suffi- the West Bank and Gaza Strip was consumption spending. Food prices cient for individuals engaged in light conducted in 2002. Comparisons of have increased, with some fluctua- physical activity. The Food and Agri- data between the two studies indi- tions, since the beginning of the Inti- cultural Organization of the United cate marked declines in protein, fada in September 2000 (Table 1). Nations (FAO) reports that breads carbohydrate and fat intake among Table 1. Change in Annual Food Price and cereal products were the prima- women of reproductive age. Given Indices, 1998 to 2003 ry source of food energy, represent- that carbohydrates and fats consti- Marketing Food Price % Change ing 49% of the calories consumed, tuted 49% of the calories consumed Year Index (per year) followed by oils and fats (13.3%), in 1996-1998, and represent relative- 1998-1999 119.67 8.80 and sugars and other sweeteners ly inexpensive sources of calories, it 1999-2000 121.30 1.38 (13.1%). Protein consumption was is likely that energy consumption, 2000-2001 120.50 -0.66 at an estimated level of 56.3 g, rep- as represented by kilocalories, also 2001-2002 122.79 1.90 resenting about 10% of the total dai- declined. 2002-2003 128.08 4.31 Source: FAO Report ly dietary intake. While access to food was relatively secure during the Trends in Food Supplies Production is just one source of 1996-1998 period, unequal distribu- In general, Palestinian communi- food in Palestine. Imports from Isra- tion of the available food did create ties have traditionally enjoyed rela- el and other countries contribute some food insecurities among pock- tively rich agricultural produce and to the available food supply (FAO

April-May 2005 bridges 9 photo: 2003). Further, in 2002, food aid rep- By 2003, a similar survey indicated Anthropometric Data resented an important segment of that 25% of households placed food In 2002, the population indicated UNFPA/Steve Sabella available food, although the total at the top of their list of assistance alarming levels of global acute mal- amount needed was estimated at needs, followed by jobs and money. nutrition (GAM – short-term acute 126,000 tons and actual deliveries inadequacies of nutritional intake were approximately 43,000 tons less What about the Children? leading to wasting) and global than had been planned. Food consumption including chronic malnutrition (GCM – longer At the household level, access to intake of key macro and micronutri- term inadequate nutritional intake food has also declined due to eco- ents has declined since 2000. Medi- leading to growth retardation and nomic reasons. Gross national per an energy (kilocalorie) intake among potential negative developmental capita income in the West Bank and children 1-5 years of age, inclusive, consequences). A repeat assessment Gaza Strip declined from US$1,839 has declined (Figure 1) conducted in 2003 indicated some in 2000 to US$1,462 in 2001 and improvements, as shown in Table 3. Figure 1. Median Energy Intake US$1,166 in 2002. The World Bank (Kcal/day) Among Children Table 3. Comparisons of Malnutrition indicated that in 2002-2003, 60-70% Prevalence Rates: 2002 and 2003 of the population fell below the pov- West Bank 2002 2003 erty line, compared to 46% in 2001 GAM 4.3 3.1 and 31% in 2000. GCM 7.9 9.2 Gaza Strip GAM 13.3 3.9 Food Security and Insecurity GCM 17.5 12.7 In 2003, FAO reported that 40% of TOTAL Palestinian households in the West GAM 7.8 3.4 Bank and Gaza are chronically food GCM 11.7 10.7 insecure, and that 70% of the popu- Source: FSANS 2003 lation faces either real food insecuri- Nonetheless, a large portion of Source: FSANS 2003 ty or the constant threat of food inse- (WB – West Bank, GS – Gaza Strip) the population of Palestinians under curity (Table 2). While food aid and the age of 5 is vulnerable to vary- cash assistance programs increased A number of households have ing degrees to nutritional deficien- in 2002 the assistance has not always restricted purchase and consump- cies and their consequences. The been able to fully meet the demands tion of animal proteins, restricted global acute malnutrition prevalence of the chronic poor and growing or abandoned fruits from their diets by district is depicted in Figure 2 for numbers of new poor, partly due to and are relying on less expensive rate of wasting. lack of resources FAO 2003. foods including breads, potatoes, Figure 2. Global acute malnutrition Table 2. Food Security Status in lentils and seasonal vegetables. Data prevalence by district, 2003 West Bank and Gaza by Percent (FSANS Report) of the Population from the FSANS 2003 report indi- West Gaza Total cates decreases in nutrient (micro Status Bank Strip and macro) intake. Food 40 A 24-hour dietary recall study con- Insecure 39 41 ducted in the West Bank and Gaza Vulnerable* 33 28 31 Strip in 2002 indicated that 50% of Food Secure 28 31 29 children 1-3 years of age and 75% of * Vulnerable indicates those vulnerable to food insecurity in the near future assuming no children 4-5 years of age were eating improvement in current conditions less than 80% of the recommended Source: FAO 2003 daily allowances of energy intake for Food insecurity varies among the their ages (Al-Quds, CARE, Johns districts and governorates of the Hopkins University, USAID). The West Bank and Gaza, with Jenin, same study showed that 10% of chil- Salfit, Gaza and North Gaza having dren and 25% of their mothers were the largest relative proportions of consuming inadequate amounts of Micronutrient Deficiencies – food insecure populations, ranging protein. Consumption of carbohy- the Critical Data from 45-55%. drates had decreased by 15%. The 2003 FSANS assessment indi- The growing limitations on house- Almost all infants are breastfed. cates alarming levels of micronutri- hold access to food are reflected in Unfortunately, exclusive breastfeed- ent deficiencies in children less than the fact that the PCBS survey in 2002 ing, recommended for the first 6 5 years of age, using an intake of found 12% of households where months of life, is not widespread and < 80% of the US Recommended Dai- food was their top priority need rel- early introduction of foods, including ly Allowances (RDAs) for each mac- ative to humanitarian assistance. inappropriate foods, is widespread. ro or micronutrient as the cut off for

10 bridges April-May 2005 tion should be identified, treated, and referred across the spectrum of health providers and facilities require a uni- form approach. A well publicized strategy that includes donors, NGOs and local health providers and that ensures continuity of nutritional care between antenatal, postnatal, sick children and primary care clinics, as well as social services would address the frequently missed cases of under- nutrition. Further, a means of clinic- based nutritional monitoring needs to occur beyond that which occurs at routine clinic visits (anthropomet- ric measurements usually take place at the time of immunization which for most children is rarely beyond 15 months of age). Children in the 3-5 year age range are at risk of macro and micronutrient deficiencies—this group is not captured well either for surveillance or intervention since they are less likely to be presenting to clinics for routine primary care. Much has been discussed regard- ing nutritional surveillance and a sentinel mechanism as a part of an nutritional deficiency as shown in The Prospect of a Response early warning system for acute mal- Table 4. Stakeholders—donors, national nutrition and for monitoring malnu- • Among 1-3 year old children there and international NGOs, and research trition—yet nothing to date has been was an 8.3% decline in median dai- institutions—should work within the organized. Either a household or clin- ly energy intake and 13.2% for 4-5 framework of the Palestinian Nation- ic- based approach would be benefi- year old children. Trends in Gaza al Nutritional Strategy developed in cial, although the latter is more feasi- are of particular concern, since the 2003 by the Palestinian Ministry of ble and easier to establish. A network decrease in energy intake among 4-5 Health (MOH) for focused interven- of UNRWA, MOH, and NGO clinics year old children reached 19.2%. tions. Likewise, the MOH should take in each district and in critical access • In stark contrast to 2002, and to the lead in coordinating donors and areas (villages at risk from the sepa- any other normally nourished socie- NGOs in all areas, including gather- ration barrier, villages surrounded by ty, older children in the 2003 sample ing and monitoring data that guides settlements, zones of high poverty) were consuming on average fewer interventions. Aside from operations, could be easily identified and a data- calories than the younger children. the MOH can oversee the delicate base developed. Monthly nutritional This drop in daily calorie intake as task of ensuring macro and micro- input could be collated and sent to children age is a marker for increas- nutrient deficiencies are adequately the two Health Information Centers ing food insecurity. addressed. in Nablus and Gaza City, analyzed, interpreted, and disseminated to key Table 4. Percentage of Micronutrient Deficiency in 1-3 Year Olds and 4-5 Year Prevention: Malnutrition stakeholders. Anthropometric data Olds in West Bank and Gaza, 2002 and Food Consumption serve as indicators of household food West Bank Gaza The role of the MOH is to ensure security and add to FAO’s Food Inse- 1-3 4-5 1-3 4-5 the standardization of nutritional curity and Vulnerability Information Micronutrient year year year year Deficiency olds olds olds olds indicators and the protocols for nutri- and Mapping System proposed for Protein 4.5 12.7 8.0 18.7 tional deficiency management across the Palestinian Territories. Vitamin A 64.1 75.1 79.5 88.1 all providers. UNRWA clinics cur- The relatively easy reversible nature Vitamin E 50.7 51.3 41.5 49.3 rently measure weight for age. MOH of acute malnutrition makes a preven- Folate 56.6 76.3 53.9 77.6 clinics measure weight for height. tive approach more preferable. This Iron 81.4 84.4 88.7 87.3 NGOs may use a combination. How assessment would argue that in addi- Zinc 95.0 95.2 94.4 93.3 cases of acute and chronic malnutri- tion to anthropometric monitoring,

April-May 2005 bridges 11 periodic 24-hour energy assessments ”A number of households have restricted purchase should be followed to monitor medi- an daily kilocalorie intake of vulner- and consumption of animal proteins, restricted able groups over time. In the face of or abandoned fruits from their diets and are ongoing deterioration in the Palestin- relying on less expensive foods including breads, ian economy and the increasing level of household food insecurity, further potatoes, lentils and seasonal vegetables.” decline in the nutritional status of young children is inevitable. based, where possible. For instance, Lifting the Threat population-based strategies such as Access to nutritional food for the Interventions: Malnutrition fortification of common foods, which Palestinian population, that mitigates and Food Consumption though cost-effective, require signifi- the risks of acute malnutrition as well Before implementing specific inter- cant start-up costs, should thus be sup- as macro and micronutrient deficien- ventions, monitoring mechanisms ported by population studies that dem- cies, requires immediate attention should ideally be in place in order to onstrate its effectiveness. For example, and priority. There is an urgent need evaluate their effectiveness and cost- no population-based study to date for international investment to fund benefits sufficiently, but they should has examined the benefit of iron for- practical, ‘on the ground’ programs not delay the opportunity for action. tification of flour in a Middle Eastern in the West Bank and Gaza to ensure Interventions should be evidence- population. food security and alleviation and A variety of food interventions are prevention of nutrient deficiencies State of Nutrition already in varying stages of develop- especially under jeopardy by armed Document in oPt ment and implementation. Fortifica- conflict. The Palestinian Ministry of Health (MOH) tion remains the most likely effective with technical support from the WHO, Dr. Ziad Abdeen is a public health UNICEF and other stakeholders developed population-based approach since the nutritionist. He is a professor and director a review based on available nutrition population is eating below RDA lev- of the Al-Quds University Nutrition and information in the occupied Palestinian els for all micronutrients. Past experi- territories (oPt) from the past ten years. ence with the 24-hour recall method Health Research Institute and an Adjunct The key findings were presented during has demonstrated that the diet has lit- Professor of public health sciences at the a workshop in Ramallah (March 20-22, tle day-to-day variability thus making University of Toronto, Canada. 2005). the fortification intervention easier to Bibliography • Iron-deficiency anaemia is the major Abdeen Z, G Greenough, M Shahin, M Tayback: monitor. Wheat flour and oil remain nutritional problem in oPt, and vitamin Nutritional Assessment of the West Bank and the most viable candidates as fortifi- Gaza Strip. Jerusalem, 2002. A deficiency and rickets in Gaza are Abdeen Z, G Greenough, B Dandies, R Qasrawi: micronutrient deficiencies of concern. cation vehicles. Iron, B-complex vita- Food Security and Nutritional Assessment of the West Bank and Gaza Strip, 2003. Jerusalem, • Wasting in young children remains an mins, and folate can be added to flour 2003. [FSANS 2003] insignificant problem. and vitamin A to oil. Cereals, juices, Al Quds University, CARE International, Johns Hopkins University, Maram Project: Health • Stunting levels among the under-five milk, and margarine are expensive Sector Bi-weekly Report, #13: The Yearly children appear to be increasing. for most households to purchase and Report, May 2002-May 2003. Jerusalem, 2003. • Studies vary in their findings of the [HSBR 13] for that reason less useful as fortifica- Al Quds University/Johns Hopkins University/ influence of the Intifada on rates of CARE. The Nutritional Assessment of the West malnutrition among children. tion vehicles. Bank and Gaza Strip, Jerusalem. Sept 2002 Fortification and supplementation Food and Agriculture Organization of the • Vitamin A and D and iron United Nations: Report of the Food Security supplementation of school-age children strategies, although cost-effective in Assessment, West Bank and Gaza Strip. Rome, 2003. [FAO 2003] are in place. The effectiveness and the long-term compared to the ulti- Institute of Food Science and Nutrition, Zurich, coverage of these programs requires mate cost to society, do require what Switzerland. International Nutritional Anemia Consultative Group Symposium 2003, Morocco. closer examination in view of the high some donor agencies and NGOs may International Nutritional Anemia Consultative levels of anaemia, vitamin A deficiency feel are prohibitive start-up costs. Group : Guidelines for the Use of Iron and possibly rickets. There is also a need Supplements to Prevent and Treat Iron Such organizations may be less Deficiency Anemia. ILSI Press, 1998. http:// for harmonization of related protocols hni.ilsi.org/file/b2_VUHUQ8AK.pdf and guidelines. inclined to embark on such ambi- Ministry of Health: Health Status in Palestine tious interventions. Fortification in 2002, Ramallah, July 2003. • A major gap in programming is Skinner HA, Abdeen Z, Abdeen H, Aber P, Al- the absence of a national nutrition particular, has high start-up costs and Masri M, Attias J, Avraham K, Carmi R, Chalin C, El Nasser Z, Hijazi M, Othman Jebara R, surveillance system. requires ongoing quality assurance. Kanaan M, Pratt H, Raad F, Roth Y, Williams • A massive food aid operation was Ideally, foods can be fortified in- AP and Noyek A. Promoting Arab and Israeli launched after 2000 which is viewed as Cooperation: Peacebuilding through Health country rather than imported and it is Initiatives. Lancet. (2005, in press). having been instrumental in addressing particularly in this area that technical Zlotkin S, Arthur P, Antwi KY, Yeung G. food insecurity at household level and Treatment of anemia with microencapsulated expertise from the Israeli Ministry of ferrous fumarate plus ascorbic acid supplied as thus preventing and lowering levels of sprinkles to complementary (wea ning) foods. malnutrition. There is no documented Health and the World Health Organi- Am J Clin Nutr. 2001;74:791-5. zation’s Eastern Mediterranean Office USAID/Maram Project. Nutrition Programs: evidence, however, that food aid has had Challenges and Opportunities Conference, any impact on nutritional status. could be supportive. Amman, Jordan, January 2004.

12 bridges April-May 2005 Prevention of Micronutrient Malnutrition A Joint Proposal for Israel and the Palestinian Authority by Ziad Abdeen and Ted Tulchinsky

icronutrient malnu- al and international standards. cases of FTT. trition has been a 2. Micronutrient supplements should 3. Fortification of basic food products subject of concern be provided free of charge, on a rou- should be required on food products for many years. A tine and continuous prophylactic including: joint Israeli-Pales- basis, to ALL persons in the follow- a. All flour should be fortified with Mtinian conference on micronutrient ing groups: iron, folic acid and vitamin B com- conditions (Jerusalem, 2000) was a. All infants and toddlers up to plex; followed by a joint workshop of the age 2, including vitamins A, C, D, b. All milk products should be for- Academies of Science of the United and iron; tified with vitamins A and D; Sates, Israel, the Palestinian Author- b. Vitamin D supplements should c. All salt used in households, food ity (PA) and Jordan (August, 2000). be given to all children from aged preparation and in food industries A recent conference on child nutri- one month to the end of adoles- including animal husbandry should tion and prevention of micronutri- cence; be fortified with iodine; and ent deficiencies was sponsored by c. Women of fertility age should d. The MOH of the PA and the Isra- Tufts University (USA), Al Quds and receive multi-vitamins (with iron, el MOH should cooperate with oth- Ben-Gurion Universities (February vitamin B complex, folic acid and er relevant ministries to ensure that 2005), with various studies show- vitamin C) especially during preg- manufacturers of flour, milk prod- ing nutritional deficiencies in the nancy and breast feeding; ucts and salt produced in Israel, or Israeli and Palestinian populations. d. Primary health care programs imported and sold in Israel and the A follow-up of the Academies con- operated by all health providers (the PA are fortified and monitored; ference is planned for May 2005 to Israeli and PA Ministries of Health, 4. Monitoring of nutrition sta- recommend governmental and non- UNRWA and NGOs) should adopt tus should be carried out annually governmental interventions, specifi- similar standards and programs of including: cally fortification of basic foods and micronutrient prevention; and a. Anthropometric studies; supplementations for specific popu- e. Failure to Thrive (FTT) centers b. Studies of iron deficiency ane- lation groups at special risk. should be established within exist- mia should be carried out annu- The public health interventions ing health services (PA, UNWRA, ally; needed are clear and based on local NGOs) providing primary care to c. Studies should be carried out of findings and world experience. We the West Bank and Gaza areas, urinary iodine levels; call on the government of Israel and with a common program of edu- d. Studies of vitamin D levels; the Palestinian Authority to proceed cation, supplementation and day- e. Reference laboratories should be immediately with the longstanding time feeding support for referred developed and personnel trained;

recommendations of food fortifica- photo: and tion as well as mineral and vitamin f. Cooperation between academic

supplements for vulnerable groups Osama Silwadi centers and ministries of health in our two populations. Palestinians should be maintained eat food manufactured in Israel and 5. Educational activities in nutri- improved health and well being of tion should be developed and car- both population groups is of strong ried out in conjunction with inter- mutual interest. national aid agencies for the general Below are our joint recommenda- public, health care providers, food tions for the improvement and pre- manufacturers and others. vention of micronutrient deficiencies 6. A Joint Israeli-Palestinian Nutri- in Palestine and Israel. tion Working Group (IPNWG) should 1. The Palestinian Ministry of Health be established as an advisory body, (PA MOH) and relevant NGOs should reporting regularly to the PA and work together to promote National Israeli Ministries of Health, interest- Nutrition Programs based on region- ed NGOs and the general public.

April-May 2005 bridges 13 Health Promotion – A Tool for

HopeAn Interview with Marc Lalonde, Former Canadian Minister of Health and Welfare by Saleem Sakakini and Shiri Ourian

ore than 30 years ing and largely affected the outcome were introduced in Canada, bounced ago, when you of our analysis. We were able to look back to Canada from abroad. served as the Cana- at a very broad context of health and It was finally successful due to a dian Minister of that’s how we came up with the basic combination of the persistent pur- Health and Welfare, concept that health had to be defined suit of a broad health policy over Mthe term “health promotion” was by biology, environment, lifestyle and 20 years and the support of public introduced in the influential report, health services. Although health serv- health organizations in the field as “A New Perspective on the Health ices are represented in more than 90% well as the adoption of health promo- of Canadians”. What were the origi- of the expenses in the field of health, tion by former United States Secre- nal inspirations for introducing this we realized, that if we looked at the tary of Health Education and Welfare, concept into health policy? causes of mortality and morbidity, a Joseph Califano who mounted major The concept of health promotion good number of those causes, would health promotion and disease pre- had been in existence long before this be effectively affected by addressing vention programs and the adoption report was published in 1974. The measures that had to do with tack- of health promotion by Simone Veil, perspectives of health in the report ling methods of prevention like life- the former French Minister of Health, were based on the WHO’s broad defi- style and environment and more than Urban and Social Affairs. nition and holistic approach to health. just health care and treatment. It was not easy. Take wearing seat The concept of health promotion had Why do you think Canada suc- belts, for example. It was agreed been around but hadn’t been devel- ceeded so well in introducing health across the board at the national level oped from a policy approach. promotion and what were some of that this should be done. We issued a Increasing health insurance costs in the challenges along the way? press release that we support the man- Canada was a serious public health concern for Canadian citizens as well “You have to be ready to question the holistic concept of health in your society.” as the government. The natural reac- We involved the different sectors of datory wearing of seat belt. When we tion was to try and cut costs. We took government who never thought their got back home, we received heated a broad approach and examined the programs were health programs and criticism at the provincial and local entire concept of health. Interestingly, we involved them so that they felt that level who felt that this was a private the group that worked on this analy- improving health was in their hands. matter and that government had no sis in the health department was not At first, health promotion had more business in citizens’ cars. The Cana- solely made up of traditional health impact abroad than at home until dian provinces of Alberta and Nova workers. We were a combination of public health officials and activists Scotia resisted passing such legis- sociologists, medical doctors and started attending international con- lation. Finally, when the impact of myself, a lawyer, interested in pub- ferences and meetings. It was a boo- seat belt wearing was made evident lic policy issues. This mix of exper- merang effect, in which the concepts in other provinces and politicians tise made the process quite interest- of health promotion policy which became more educated, those resist-

14 bridges April-May 2005 ant provinces adopted the now com- than health, I’m afraid. I do believe, in Canadian communities where mon legislation. however, if efforts are made to help local violence and fundamentalism How would you apply health pro- people realize that their daily lives are serious concerns. These commu- motion in an area of armed conflict? are influenced by very similar factors nities have lost hope and we see the And can health promotion strate- that could be a very helpful step in consequences in terms of mortality gies be utilized to promote peace? improving relations and understand- and morbidity. So while exercise and Thankfully, that was a problem I ing. Start with basic things. Start lifestyle are critical, they are the easy did not have to address, which made working with those most in need. part. Dealing with deep social and things much easier for us. But there is Many of the public health and moral issues is obviously involved one area where people relate and can relief workers in this region are and undoubtedly more important. agree to work together. For instance, faced with unhealthy behaviors Last year you were inducted into the fate of children. Regardless of that are not the typical behaviors the Canadian Medical Hall of Fame. political or religious convictions, the like smoking and nutrition that You’ve also received the WHO Med- wish for children to be healthy and health promotion has tradition- al as well as the distinction of pub- lic health hero from the Pan Amer- ican Health Organization. What characteristics earn such honors? Well, these awards came a little later in my life after I had been in the practice of law for many years. When I left politics in 1984, I had been minister of many things. Frankly, I was very privileged to be allowed to pursue the health initiatives on a consist- ent basis for an extensive period of time which not every politician is afforded. In many ways, I was lucky. I think what is needed is a capacity to constantly re-question what are the factors affecting health and reorient yourself and reorganize your priorities. In 1974, in the “New Perspectives” publication, HIV is not have a good chance in life is mutu- ally addressed. Instead, they must mentioned anywhere. Now it is a al. Developing public health poli- deal with unhealthy behaviors that major and significant issue. You have cies that could help children should encourage social polarization and to be ready to question the holistic be able to relieve negative relations practices of discrimination, racism concept of health in your society. Each and should help develop communal and violence. Should we be apply- country has to analyze its priorities support and initiatives in education, ing a wider vision of health pro- and determinants of health which are immunization, feeding and proper motion and what are some of the most significant and where the action nutrition for the children. It’s hard to strategies you would recommend to is going to be most effective. This will combat such behaviors? be different from country to country “You have to be ready to question the holistic concept of health in your society.” In an environment like yours, and will change over time. imagine that people would refuse to broadening the concept of health pro- work together in that regard. This is motion is indeed, necessary. I can’t Marc Lalonde was Canadian Minister the obvious purpose that health pro- imagine what it is like to live in an of Health & Welfare from 1972-1977. He motion is supposed to serve. environment where you don’t know received international notoriety as the co- We need to work together to if your child will disappear in a sui- author of “A New Perspective on the Health improve respective communities out- cide bombing or your house will be of Canadians”. In 1988, Mr. Lalonde received side of the political community. Learn- destroyed. This is a difficult thing the WHO Medal for his contribution to ing to work together about issues that to deal with. Nonetheless, it is pos- health policy, and in 2002, he was selected are common to humanity should be a sible to act on issues of discrimina- by the PAHO as one of eleven Public Health factor of developing a sense of com- tion, poverty and violence with hope Heroes who have shaped the past 100 years munity and common interest. Issues – certainly a means of health promo- of international public health. Currently, he of war and peace are much larger tion. We are faced with similar issues is practicing law in Canada.

April-May 2005 bridges 15 he health of mothers and and children. Humanitarian crises, well as a need to facilitate access to children is a priority that pervasive poverty, and the HIV/AIDS responsive post-abortion care of high emerged long before the epidemic have all compounded the quality and to safe abortion services 1990s– it builds on a cen- effect of economic downturns and to the fullest extent allowed by law. tury of programs, activi- the health workforce crisis. With Women risk death to give life, but Tties and experience. What is new in widespread exclusion from care and with skilled and responsive care, at the last decade, however, is the global growing inequalities, progress calls and after birth, nearly all fatal out- focus of the Millennium Development for massively strengthened health comes and disabling sequelae can be Goals (MDGs) and their insistence on systems. averted. Every woman needs skilled tracking progress in every part of the care when giving birth, in an appro- world. Moreover, the nature of the Making the Right Technical priate environment that is close to priority status of maternal and child and Strategic Choices where she lives and respects her health (MCH) has changed over time There is no doubt that the technical birthing culture. Such care can best from a technical concern into a moral knowledge exists to respond to many, be provided by a registered midwife and political imperative. if not most, of the critical health or a health worker with midwife- The World Health Report 2005 problems and hazards that affect the ry skills, in decentralized, first-level identifies exclusion as a key feature of inequity as well as a key constraint to progress. Taking stock of the errat- ic progress to date, the report sets out the strategies required for the accel- erated improvements that are known Mothers, to be possible. It is necessary to refo- cus the technical strategies developed within maternal and child health pro- the Newborn grams, and also to put more empha- sis on the importance of the often overlooked health problems of new- and Children borns. In this regard, the report advo- cates the repositioning of MCH as Representing the well-being of a MNCH (maternal, newborn and child health). society and its potential for the future Highlights from the World Health Report 2005 Patchy Progress and Widening Gaps – What Went Wrong? health and survival of mothers, new- facilities. All women need first-level Although an increasing number of borns and children. maternal care while back-up care is countries have succeeded in improv- Antenatal care is a major success only necessary for a minority, but to ing the health and well-being of moth- story; demand has increased and con- be effective both levels need to work ers, babies and children in recent tinues to increase in most parts of the in tandem and both must be put in years, the countries that started off world. However, more can be made place simultaneously. with the highest burdens of mortal- by emphasizing effective interven- There is an urgent need to develop ity and ill-health made least progress tions and by using it as a platform for effective ways of organizing continu- during the 1990s. In some countries other health programs such as HIV/ ity of care during the first weeks after the situation has actually worsened, AIDS and the prevention and treat- birth, when health service responsi- and worrying reversals in newborn, ment of sexually transmitted infec- bilities are often ill-defined or ambig- child and maternal mortality have tions, tuberculosis and malaria ini- uous. The postpartum gap in provid- taken place. Progress has slowed tiatives, family planning, preparing ing care for women is also a postnatal down and is increasingly uneven for birthing and parenting. Pregnant gap. Although the picture of the within countries. women, adolescents in particular, unmet need in caring for newborns is Countries where health indicators may be exposed to violence, discrimi- still very incomplete, it shows that the for mothers, newborns and children nation in the workplace or at school, health problems of newborns have have stagnated or reversed have often or marginalization. Such problems been unduly neglected and underes- been unable to invest sufficiently in also need to be dealt with. And, there timated. Newborn mortality is a size- health systems. The health districts remains a large unmet need for con- able proportion of the mortality of have had difficulties in organizing traception, as well as for more and children under five years of age. access to effective care for women better information and education, as The greatest risks to life are in its

16 bridges April-May 2005 beginning, but they do not disappear force needed for scaling up maternal, riers to access have to be eliminated as the newborn grows into an infant newborn and child health services and users given predictable financial and a young child. The Integrated towards universal access is the first protection against the costs of seek- Management of Childhood Illness and most pressing task. The extra ing care, and particularly against the (IMCI) combines a set of effective work required for scaling up child catastrophic payments that can push interventions for preventing death care activities requires the equiva- households into poverty. To attain and for improving healthy growth and lent of 100,000 full-time multipur- the financial protection that has to development. IMCI has transformed pose professionals, supplemented, go with universal access, countries the way the health system looks at according to the scenarios that have throughout the world have to move child care – going beyond the mere been valued, by 4.6 million commu- away from user charges, be they treatment of illness. IMCI has three nity health workers. Projected staff- official or under-the-counter, and components: improving the skills of ing requirements for extending cov- generalize prepayment and pool- health workers to treat diseases and erage of maternal and newborn care ing schemes. On any given scheme to counsel families, strengthening the assumes the production in the com- two things are important. First, that health system’s support, and helping ing 10 years of at least 334, 000 addi- ultimately no population groups are households and communities to bring tional midwives – or their equivalents excluded. Second, that maternal and child health services are at the core of the health entitlements of the pop- ulation, and that they be financed in a coherent way through the selected system. Ilya Melnikov Financing is the main need under-

photo: lying the planning of maternal, new- born and child health care. First, increased funding is required to pay for building up the supply of servic- es towards universal access. Second, financial protection systems have to be built at the same time as access improves. Third, the channeling of increased funds, both domestic and international, has to guarantee the flexibility and predictability that make it possible to cope with the principal health system constraints – particu- up their children healthily and deal – as well as the upgrading of 140,000 larly the problems facing the work- with ill-health when it occurs. IMCI health professionals who are current- force. is bringing health care closer to the ly providing first-level maternal care While the financing effort seems to home, while at the same time improv- and of 27,000 doctors who currently be within reasonable reach in some ing referral links and hospital . do not have the competencies to pro- countries, in many it will go beyond vide back-up care. what can be borne by governments Moving towards In many countries, salary levels alone. Both countries and the interna- Universal Coverage are rightfully considered unfair and tional community will need to show There is a strong consensus that, insufficient to provide for daily liv- a sustained political commitment to even if all the right technical choic- ing costs, let alone to live up to the mobilize and redirect the consider- es are made, maternal, newborn expectations of health profession- able resources that are required, to and child health programs will only als. This situation is one of the root build the institutional capacity to be effective if together, and with causes of lack of motivation, lack of manage them, and to ensure that households and communities, they productivity and the various forms maternal, newborn and child health establish a continuum of care, from of brain-drain and migration: rural remains at the core of these efforts. pregnancy through childbirth into to urban, public to private and from This decade can be one of accelerat- childhood. This continuity requires poorer to richer countries. ing the move towards universal cov- greatly strengthened health systems At the same time, ensuring univer- erage, with access for all and finan- with maternal, newborn and child sal access is not merely a question cial protection. That will ensure that health care at the core of their devel- of increasing the supply of services no mother, no newborn, and no child opment strategies. and paying health care providers. For in need remain unattended – because Putting in place the health work- services to be taken up, financial bar- every mother and every child counts.

April-May 2005 bridges 17 photo: Ilya Melnikov

How to... Wheat Flour Enrichment and Fortification: Serving Mutual Needs by Omar Dary

ood nutrition is a basic their ill effects, which are mostly nutritionally equivalent to butter by requirement for hav- sub-clinical. Rich and poor societies the incorporation of vitamin A and ing a healthy, produc- are at risk of suffering from anemia, D. Vitamin C is added to fruit juices tive life and is mainly rickets, osteoporosis, anomalous to enrich its natural content of this based on a balanced growth and development, subopti- vitamin. Salt has become a source Gand diverse diet. However, these mal mental and physical perform- of iodine due to fortification with requirements are frequently not sat- ance and impaired response to dis- this mineral, which is not naturally isfied both in developed as well as ease and infections. The situation present in salt. in developing countries because of is worse in poorer societies where a variety of factors, including die- access to nutrient-dense foods, such Why Wheat Flour? tary restrictions associated with life- as milk, eggs and meat, is limited, Wheat flour has properties that style or aging and because of cultur- as is the case for Palestinian com- make it an ideal vehicle to sup- al, religious, political or economic munities under the current circum- ply many other micronutrients in reasons. The human diet is typical- stances. a safe and effective way. Wheat ly highly based on sugar, vegeta- During the last century, many coun- flour is usually produced in a few ble oils and fats and starchy foods, tries have raised awareness of and and centralized factories; it is con- which provide energy but are very even implemented ways to improve sumed very frequently and in sub- poor sources of essential vitamins the nutritional quality of some foods stantial amounts (greater than 100 and minerals. As a consequence, by means of the addition of essential g/day); vitamins are reasonably con- human beings continue suffering micronutrients. Thus, solid vegeta- served during bread preparation; from micronutrient deficiencies and ble fats such as margarine are made and the cost is affordable (less than

18 bridges April-May 2005 US$0.003/kg or less than 1% of the ment of bread dough with iron, and g/day. This amount might be low in consumer price). No other food has vitamins B-1, B-2, niacin and folic the case of Israel and would proba- those characteristics. Furthermore, acid, and fortification with vitamin bly need to be doubled. This change the chemical industry has produced B-12. It would be easier and more can be made in the Palestinian for- suitable forms of iron, folic acid and cost-effective to fortify the flour mulation; it would increase the cost vitamins A, D, and B-12 for flour instead of the dough. of fortification by US$0.15/metric fortification while maintaining the ton or 6% of the current cost, but requirements of kashrut and hallal. A Formulation Fit for this is highly feasible. Calcium has Similarly, the nutritional value Israelis and Palestinians not been integrated in the Palestin- of whole wheat grain is commonly Although current nutritional needs ian formulation because of the need restored in the refined white flour by are different for Israelis and Palestin- to have a local supplier of affordable the addition of vitamins B-1, B-2 and ians, the formulation accepted by the calcium. If Israeli authorities decide niacin. Prevention of beriberi, aribo- Palestinian Authority is safe for both to favor the acquisition of calcium to flavinosis and pellagra in the United communities and with minor adjust- be used in wheat flour enrichment, States, during the 1940s is attribut- ments could be made equally effec- it would also benefit the Palestinian able to the implementation of flour tive. Wheat flour consumption per consumers. enrichment according to federal capita in Israel is approximately half In summary, wheat flour enrich- standards. Chile has practically elim- than that in Palestine, which would ment and fortification is a good ini- inated iron deficiency anemia due to lead to a supply of micronutrients tiative that would favor health pro- enrichment of wheat flour with iron through fortified flour of approxi- motion of Israeli and Palestinian using ferrous sulfate. Recently, Chile, mately 0-50% of the daily nutritional communities, and may also become the United States and Canada have requirements. a common subject of mutual need, demonstrated that the incidence of However, the diet of most Israe- dialogue, compromise and under- neural tube defects in newborns is li communities is better than the standing between them. drastically reduced if women con- Palestinian diet and these nutri- sume flour enriched with folic acid. ent amounts would complement it Dr. Omar Dary was born in Guatemala well. Perhaps most Israelis would to a Palestinian father. He works in the Steps towards Flour not need to receive vitamin A and International Science and Technology Fortification D through fortified flour, but vita- Institute (ISTI) as the food fortification The Palestinian Authority, with min D deficiencies have been shown advisor for MOST, the USAID micronutrient technical and financial assistance in some population groups in Isra- program. He has served as an expert from USAID, has begun implement- el and the amounts are low enough consultant in food fortification and ing wheat flour enrichment and for- to ensure safe intakes of these two micronutrients for WHO, UNICEF, the Pan tification to increase the supply of vitamins for the general popula- American Health Organization, GAIN, the basic nutrients for Palestinian com- tion. In the Palestinian formulation, Micronutrient Initiative (MI), and the CDC munities. The formulation has been the minimum level of folic acid is 1 in the United States. designed to prevent any unnecessary mg/kg (approximate average of 1.5 excess intake of folic acid, iron, zinc, mg/kg), which means that the addi- Bibliography: and vitamins A and D for persons tional intake of this nutrient through Backstrand J.R. The history and future of food whose flour consumption is nearly the consumption of 100-200 g/day of fortification in the United States: A public health perspective. Nutr. Rev. 2002; 60:15-26. 400 g/day. The formulation would fortified flour is approximately 100 Bauerfeind J.C., Lachance P.A. (Eds) 1991. Nutrient additions to foods. Food and Nutrition supply 40-100% of the daily nutri- to 300 micrograms a day. Press, Trumbull, CT. USA. tional requirements of those nutri- Hertrampf E. Iron fortification in the Americas. Nutr. Rev. 2002; 60:S22-S25. ents plus vitamins B-1, B-2, B-6, B- Adjusting to Meet Our Needs Honein M.A., Paulozzi L., Mathews T., Erickson J., Wong L. Impact of folic acid fortification of 12 and niacin to persons with the Experience in the United States the US food supply on the occurrence of neural usual flour consumption of 200-400 and Canada has shown that addition- tube defects. J. Am. Med. Ass. 2001; 285:2981-6. Micronutrient Initiative (Ed). 1998. Food g/day. Once fortification is imple- al daily intake of 200 micrograms of fortification to end micronutrient malnutrition. mented, it is expected than more folic acid is effective to reduce inci- State of the Art. Micronutrient Initiative, Ottawa, Canada. 113 p. than 80% of the flour in Gaza and dence of neural tube defects, and this PAHO/ILS/USAID/INACG. 2002. Iron compounds for food fortification: guidelines for 60% of the West Bank would be for- level of folic acid may be adequate in Latin America and the Caribbean. Pan American tified accordingly to this formula- Israel. In the Palestinian formulation, Health Organization, Washington D.C. Ray J.G., Vermeulen M.J., Boss S., Wyatt R., tion. The remaining 40% of the West the minimum level of vitamin B-12 is Cole D.E. Association of neural tube defects and folic acid food fortification in Canada. Lancet Bank demand of flour is satisfied 0.0025 mg/kg (approximate average 2002; 360:2047-48. by importation, mainly from Israeli of 0.0030 mg/kg), which means that Tulchinsky T.H., Nitzan-Kaluski D., Berry E.M. Food fortification and risk group mills. the daily additional intake is 0.25 supplementation are vital parts of a Independently, some bakeries in to 0.6 micrograms when flour con- comprehensive nutrition policy for prevention of chronic diseases. Eur. J. Public Health 2004; Israel have already started enrich- sumption is between 100 and 200 14:226-28.

April-May 2005 bridges 19 How to... Wheat Flour Enrichment and Fortification: Serving Mutual Needs

זונה נכונה היא תנאי בסיסי הקמח לפי תקנים פדרליים. צ'ילה כמעט וחי– ליות טובה מתזונת הפלסטינים וכמויות רכיבי לחיים בריאים ויצרניים והיא סלה את האנמיה מחוסר ברזל בזכות העשרת מזון אלה ישלימו אותה היטב. ייתכן שרוב הי– מבוססת על כלכלה מאוזנת קמח חיטה בברזל באמצעות השימוש בברזל שראלים לא יצטרכו לקבל ויטמין A ו-D בא– ומגוונת. ואולם, לעתים קרו– גופריתי. לאחרונה הראו צ'ילה, ארה"ב וקנדה כי מצעות קמח מועשר, אך בקרב כמה קבוצות בות אין תנאי זה מתקיים לא ניתן להוריד באופן חד את תחולת המומים בצי– אוכלוסייה בישראל התגלה חוסר בויטמין D במדינות תמפותחות ולא במדינות מתפתחות נור העצבי ביילודים כאשר נשים צורכות קמח והכמויות נמוכות מספיק כדי להבטיח צריכה ממגוון סיבות, בהן הגבלות מזון הקשורות המועשר בחומצה פולית. בטוחה של שני הויטמינים האלה באוכלוסייה לאורח חיים או להזדקנות וסיבות תרבותיות, הכללית. בנוסחה הפלסטינית, הרמה המינימ– דתיות, פוליטיות או כלכליות. כלכלת האדם צעדים לקראת העשרת קמח לית של חומצה פולית היא 1 מ"ג/ק"ג (ממוצע מבוססת בדרך כלל על סוכר, שמנים ושומנים הרשות הפלסטינית, בתמיכה טכנית וכספית של 1.5 מ"ג/ק"ג לערך), שמשמעותו שהצריכה צמחיים ומזונות עמילניים, המספקים די אנ– של הסוכנות האמריקאית לפיתוח בינלאומי הנוספת של חומר מזין זה באמצעות צריכת רגיה אך הינם מקורות דלים מאד לויטמינים (USAID), החלה ביישום הוספת ויטמינים לקמח 200-100 גרם קמח מועשר ביום תהיה 100 עד ולמינרלים חיוניים. כתוצאה מכך, ממשיכים חיטה והעשרתו להגברת אספקת רכיבי מזון 300 מיקרוגרמים ביום בקירוב. אנשים לסבול מחסכים ברכיבי תזונה זעירים בסיסיים לקהילות פלסטיניות. הנוסחה תוכננה (micronutrients) ומנזקיהם שהם ברובם למניעת צריכה עודפת בלתי נחוצה של חומצה התאמה למילוי הצריכה תת-קליניים. הן חברות עשירות והן עניות נמ– פולית, ברזל, אבץ וויטמין A ו-D לאנשים שצו– הניסיון בארצות הברית ובקנדה הראה שצ– צאות בסיכון לאנמיה, רככת, אוסטיופורוזיס, רכים קמח בכמות שמתקרבת ל400- גרם ביום. ריכה יומית נוספת של 200 מיקרוגרמים חומצה גדילה והתפתחות בלתי תקינות, תפקוד שכלי הנוסחה תספק 100%-40 מהדרישות התזו– פולית יעילה בהפחתת שכיחות מומים בתע– וגופני תת-אופטימליות ותגובה מוחלשת נתיות היומיות של החומרים המזינים האלה לה העצבית, ורמה זו של חומצה פולית עשויה למחלות ולזיהומים. המצב חמור יותר בחב– להתאים לישראל. בנוסחה הפלסטינית, הרמה רות עניות יותר בהן הגישה למזונות עשירים המינימלית של ויטמין B-12 היא 0.0025 מ"ג/ בחומרים תזונתיים, כגון חלב, ביצים ובשר ק"ג (ממוצע של 0.0030 מ"ג/ק"ג בקירוב), שמ– מוגבלת. זה קורה בחברה הפלסטינית בתנאים שמעותה שהצריכה היומית הנוספת היא 0.25 הנוכחיים. עד 0.6 מיקרוגרמים כאשר צריכת הקמח נעה במאה האחרונה הגבירו מדינות רבות את בין 100 ל200- גרם ביום. כמות זו עשויה להיות המודעות לנושא ואף יישמו אמצעים לשיפור נמוכה במקרה של ישראל וקרוב לוודאי שיהיה הערך התזונתי של מזונות מסוימים באמצעות צורך להכפילה. ניתן לבצע שינוי זה בנוסחה הוספת רכיבי תזונה זעירים חיוניים. וכך, שמנים הפלסטינית; פעולה זו תעלה את עלות ההעש– צמחיים מוצקים כגון מרגרינה הופכים לשווי רה ב0.15- דולר לטונה מטרית או 6% מהעלות ערך תזונתיים לחמאה על ידי הוספת הויטמי– בתוספת הויטמינים B-1, B-2, B-6, B-12 וניאצין הנוכחית, אך הדבר בהחלט בר ביצוע. סידן לא נים A ו-D. למיצי פירות מוסיפים ויטמין C לאנשים שכמות הצריכה הקבועה שלהם היא הוכנס לנוסחה הפלסטינית בגלל הצורך בספק כדי להעשיר את תכולתם הטבעית של רכיב זה. 400-200 גרם קמח ליום. ברגע שתיושם הה– מקומי של סידן בעלות סבירה. אם הרשויות הי– המלח הפך למקור ליוד הודות לתיסופו במינרל עשרה, ניתן לצפות לכך שיותר מ80%- מהקמח שראליות יחליטו לתמוך ברכישת סידן לשימוש זה אשר באופן טבעי אינו נמצא במלח. בעזה ו60%- מהקמח בגדה המערבית יהיו מו– בהעשרת קמח חיטה, הדבר יועיל גם לצרכנים עשרים בהתאם לנוסחה הזו. יתר 40% מהקמח הפלסטינים. מדוע קמח חיטה? הנצרכים בגדה המערבית מסופקים באמצעות לסיכום, העשרת קמח החיטה היא יוזמה לקמח החיטה יש תכונות ההופכות אותו יבוא, בעיקר מתחנות קמח ישראליות. מבורכת שתתרום לקידום הבריאות של החב– למכשיר אידיאלי לאספקת רכיבי מזון זעירים בלא קשר לכך, כמה מאפיות בישראל החלו רות הישראלית והפלסטינית, ועשויה גם להפוך רבים אחרים בדרך בטוחה ויעילה. קמח חיטה כבר בהעשרת בצק לחם בברזל וויטמין B-1, B-2, לנושא משותף של צורך הדדי, דו-שיח, פשרה מיוצר בדרך כלל במפעלים מעטים ומרוכזים; ניאצין וחומצה פולית, ובהוספת ויטמין B-12. והבנה ביניהן. הוא נצרך לעתים קרובות מאד ובכמויות ניכרות יהיה קל וחסכוני יותר להעשיר את הקמח ולא (יותר מ100- ג' ביום); ויטמינים נשמרים ברמה את הבצק. ד"ר עומר דארי נולד בגואטמלה לאב פלסטיני. סבירה במהלך הכנת הלחם; מחירו שווה לכל הוא עובד במכון הבינלאומי למדע וטכנולוגיה כיס (פחות מ0.003- דולר לק"ג או פחות מ1%- נוסחה שמתאימה International Science and Technology Institute מהמחיר לצרכן). אין עוד מזון שיש לו תכונות לישראלים ולפלסטינים (ISTI) כיועץ להעשרת מזון של MOST, תוכנית אלה. יתר על כן, התעשיה הכימית מיצרת סוגים למרות שהצרכים התזונתיים הנוכחיים של רכיבי המזון הזעירים של הסוכנות האמריקאית של ברזל, חומצה פולית וויטמינים A, D וB-12- הישראלים והפלסטינים שונים, הנוסחה שקי– לפיתוח בינלאומי USAID. הוא שירת כיועץ מומחה המתאימים להעשרת קמח תוך שמירה על דרי– בלה הרשות הפלסטינית בטוחה לשתי הקהי– להעשרת מזון ורכיבי מזון זעירים בארגון שות הכשרות והחלאל. לות ובשינויים קלים תהיה יעילה במידה שווה. הבריאות העולמי, (WHO) ביוניצף (UNICEF), כמו כן, הערך התזונתי של גרגר החיטה המלא צריכת קמח החיטה בישראל היא כמחצית מזו בארגון הבריאות הכלל אמריקני בדרך כלל מוחזר לחיטה הלבנה המזוקקת על ידי שבפלסטין, דבר שיוביל לאספקת 50%-0 מה– (the Pan American Health Organization), הוספת הויטמינים B-1, B-2 וניאצין. את מניעת דרישות התזונתיות היומיות של רכיבי מזון זעי– בברית העולמית לתזונה משופרת (GAIN), הברי-ברי, האריבופלבינוזיס והפלגרה בארצות רים באמצעות קמח מועשר. ביוזמה לרכיבי מזון זעירים (MI) ובמרכז לבקרת הברית בשנות ה40- ניתן ליחס ליישום העשרת עם זאת, התזונה של רוב הקהילות הישרא– מחלות (CDC) בארצות הברית.

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How to... Wheat Flour Enrichment and Fortification: Serving Mutual Needs Ilya Melnikov העשרת קמח חיטה: סיפוק צרכים משותפים מאת עומר דארי

April-May 2005 bridges How to... Wheat Flour Enrichment and Fortification: Serving Mutual Needs

ﻣﺴﺘﻤﺮ ( اﺳﺘﻬﻼك اﻟﻔﺮد اﻟﻴﻮﻣﻲ أﻛﺜﺮ ﻣﻦ ١٠٠ ﻣﻦ اﻟﻄﺤﻴﻦ ﻓﻲ ﻏﺰة و ٦٠٪ﻣﻦ اﻟﻄﺤﻴﻦ ﻓﻲ ﺣﺎﻣﺾ اﻟﻔﻮﻟﻴﻚ ّﻳﻮﻣﻴﺎ ﻛﺎﻓﻴﺔ ﻟﺘﺨﻔﻴﺾ اﺣﺘﻤﺎل ﻏﻢ ). وﺧﻼل ﺗﺤﻀﻴﺮ اﻟﺨﺒﺰ ﻓﺈن اﻟﻔﻴﺘﺎﻣﻴﻨﺎت اﻟﻀﻔﺔ اﻟﻐﺮﺑﻴﺔ ﺳﻴﻜﻮن ﺿﻤﻦ اﻟﻤﻮاﺻﻔﺎت ﺗﺸﻮﻩ اﻟﻘﻨﺎة اﻟﻌﺼﺒﻴﺔ ﻋﻨﺪ اﻷﻃﻔﺎل. وﻣﻊ اﻟﺘﻲ ﻳﺤﻮﻳﻬﺎ اﻟﻄﺤﻴﻦ ﻳﺘﻢ اﻟﻤﺤﺎﻓﻈﺔ ﻋﻠﻴﻬﺎ اﻟﻤﻄﻠﻮﺑﺔ ﻟﻠﺘﻌﺰﻳﺰ. وﺑﺎﻗﻲ ال ٤٠٪ ﻓﻲ اﻟﻀﻔﺔ ذﻟﻚ ﻓﺈن ﻫﺬا اﻟﻤﺴﺘﻮي ﻣﻦ ﺣﺎﻣﺾ اﻟﻔﻮﻟﻴﻚ ﺑﺸﻜﻞ ﻣﻌﻘﻮل. ّأﺿﺎﻓﺔ اﻟﻰ أن ﺗﺰوﻳﺪ اﻟﻄﺤﻴﻦ اﻟﻐﺮﺑﻴﺔ ﺗﻐﻄﻲ ﻋﻦ ﻃﺮﻳﻖ اﻻﺳﺘﻴﺮاد وﺧﺎﺻﺔ ﻣﻦ ﻗﺪ ﻳﻜﻮن ّﻛﺎﻓﻴﺎ ﻓﻲ اﺳﺮاﺋﻴﻞ ﻓﻲ اﻟﺘﺮﻛﻴﺒﺔ ﺑﺎﻟﻔﻴﺘﺎﻣﻴﻨﺎت واﻟﻤﻌﺎدن ﻣﻌﻘﻮل اﻟﻜﻠﻔﺔ ( أﻗﻞ اﻟﻤﻄﺎﺣﻦ اﻻﺳﺮاﺋﻴﻠﻴﺔ. اﻟﻔﻠﺴﻄﻨﻴﺔ ﻓﺈن اﻟﺤﺪ اﻷدﻧﻲ ﻣﻦ ﻓﻴﺘﺎﻣﻴﻦ B١٢ ﻣﻦ ١٪ ﻣﻦ ﺳﻌﺮ اﻟﻤﺴﺘﻬﻠﻚ أو أﻗﻞ ﻣﻦ ٠,٠٣ ﺑﻤﺒﺎدرات ذاﺗﻴﺔ ﻓﺈن ﺑﻌﺾ اﻟﻤﺨﺎﺑﺰ ﻓﻲ ﻫﻮ ٠٫٠٠٢٥ ﻣﻠﻐﺮام/ ﻛﻴﻠﻮ ﻏﺮام (ﻣﺘﻮﺳﻂ دوﻻر ﻟﻜﻞ ﻛﻴﻠﻮ ﻏﺮام ) وﻻ ﻳﻮﺟﺪ ﻃﻌﺎم آﺧﺮ اﺳﺮاﺋﻴﻞ ﻗﺪ ﺑﺪات ﺑﺘﺰوﻳﺪ ﻋﺠﻴﻦ اﻟﺨﺒﺰ ﺑﺎﻟﺤﺪﻳﺪ ٠٫٠٠٣٠ ﻣﻠﻐﺮام/ﻛﻴﻠﻮ ﻏﺮام ) ﻣﻤﺎ ﻳﻌﻨﻲ أن ﻳﺸﺎرك اﻟﻄﺤﻴﻦ ﻓﻲ ﻫﺬﻩ اﻟﺨﺼﺎﺋﺺ. وﻓﻴﺘﺎﻣﻴﻨﺎت B٢,B١ واﻟﻴﻨﺎﺳﻴﻦ وﺣﺎﻣﺾ اﻟﺘﻨﺎول اﻹﺿﺎﻓﻲ ﺳﻴﻜﻮن ﺑﺤﺪود.٠٫٢٥ - أﺿﺎﻓﺔ اﻟﻲ ذﻟﻚ ﻓﺈن ﻣﺼﺎﻧﻊ اﻟﻜﻴﻤﺎوﻳﺎت ﻗﺪ اﻟﻔﻮﻟﻴﻚ وﻓﻴﺘﺎﻣﻴﻦ B١٢, وﺳﻴﻜﻮن ﻣﻦ اﻷﺳﻬﻞ .٦. ﻣﻴﻜﺮوﻏﺮام ﻋﻨﺪ ﺗﻨﺎول ١٠٠-٢٠٠ ﻏﺮام اﻧﺘﺠﺖ اﺷﻜﺎل ﻣﻼﺋﻤﺔ ﻣﻦ ﻓﻴﺘﺎﻣﻴﻨﺎت A,D,B- واﻷﺟﺮي اﻗﺘﺼﺎدﻳﺄ ﻟﻮ ﺗﻢ ﺗﻌﺰﻳﺰ اﻟﻄﺤﻴﻦ ﺑﺪل ّﻳﻮﻣﻴﺎﻣﻦ اﻟﻄﺤﻴﻦ. ﻫﺬﻩ اﻟﻜﻤﻴﺔ ﻗﺪ ﺗﻜﻮن ﻗﻠﻴﻠﺔ ١٢ ﻣﻦ أﺟﻞ ﺗﺰوﻳﺪ اﻟﻄﺤﻴﻦ ﺑﻬﺎ ، ﻣﻊ اﻟﻤﺤﺎﻓﻄﺔ اﻟﻌﺠﻴﻦ. ﻗﻲ ﺣﺎﻟﺔ اﺳﺮاﺋﻴﻞ وﻗﺪ ﺗﺤﺘﺎج ﻟﻤﻀﺎﻋﻔﺘﻬﺎ. ﻫﺬا ﻋﻠﻰ اﺣﺘﺮام اﻟﺘﻘﺎﻟﻴﺪ اﻟﺪﻳﻨﻴﺔ ﻋﻨﺪ اﻟﻤﺴﻠﻤﻴﻦ اﻟﺘﻌﺪﻳﻞ ﻣﻤﻜﻦ ﻋﻠﻰ اﻟﺘﺮﻛﻴﺒﺔ اﻟﻔﻠﺴﻄﻴﻨﻴﺔ, واﻟﻴﻬﻮد. اﻟﺘﺮﻛﻴﺒﺔ ﺗﻨﺎﺳﺐ اﻻﺳﺮاﺋﻴﻠﻴﻦ ﻗﺪ ﻳﺆدي اﻟﻲ زﻳﺎدة اﻟﻜﻠﻔﺔ ﻳﻤﻘﺪار (٠٫١٥) ﺑﻨﻔﺲ اﻟﺸﻜﻞ ﻓﺈﻧﻪ ﻳﺘﻢ اﻟﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ واﻟﻔﻠﺴﻄﻴﻨﻴﻦ: دوﻻر ﻟﻠﻄﻦ أو ٦٪ ﻋﻠﻰ اﻟﻜﻠﻔﺔ اﻟﺪارﺟﺔ وﻫﻮ اﻟﻘﻴﻤﺔ اﻟﻐﺬاﺋﻴﺔ اﻟﻜﺎﻣﻠﺔ ﻟﻠﻘﻤﺢ ﺑﻌﺪ ﻃﺤﻨﻪ ﻣﻦ ﺑﺎﻟﺮﻏﻢﻣﻦأناﻟﺤﺎﺟﺎت اﻟﺘﻐﺬوﻳﺔﻟﻠﻔﻠﺴﻄﻴﻨﻴﻦ ﺷﻴﺊ ﻣﺠﺪي. ﻓﻲ اﻟﺘﺮﻛﻴﺒﺔ اﻟﻔﻠﺴﻄﻴﻨﻴﺔ ﻟﻢ ﻳﺘﻢ ﺧﻼل اﺿﺎﻓﺔ ﻓﻴﺘﺎﻣﻴﻨﺎت ، ﻳﻨﺎﺳﺘﻴﻦ وb٢-B١ واﻟﻔﻠﺴﻄﻴﻨﻴﻦ ﻣﺨﺘﻠﻔﺔ ﻓﺈن اﻟﺘﺮﻛﻴﺒﺔ اﻟﻤﺼﻤﻤﺔ اﻋﺘﻤﺎد اﺿﺎﻓﺔ اﻟﻜﺎﻟﺴﻴﻮم ﺑﺴﺒﺐ اﻟﺤﺎﺟﺔ ﻟﻮﺟﻮد وﻗﺪ ﺗﻢ ﻣﻨﻊ ﺣﺪوث أﻣﺮاض ﺑﺮي ﺑﺮي واﻟﺒﻴﻼﻏﺮا واﻟﻤﻘﺒﻮﻟﺔ ﻣﻦ اﻟﺴﻠﻄﺔ اﻟﻔﻠﺴﻄﻴﻨﻴﺔ ﺗﻌﺘﺒﺮ أﻣﻨﺔ ﻣﺰود ﻣﺤﻠﻲ ﻟﻜﺎﻟﺴﻴﻮم ﻣﻌﻘﻮل اﻟﻜﻠﻔﺔ. ﻓﻲ اﻟﻮﻻﻳﺎت اﻟﻤﺘﺤﺪة ﺧﻼل اﻷرﺑﻌﻨﻴﺎت ﻟﻜﻼ اﻟﻤﺠﺘﻤﻌﻴﻦ وﻳﻤﻜﻦ ﺑﺘﻌﺪﻳﻼت ﺑﺴﻴﻄﺔ اذا ﻗﺮرت اﻟﺴﻠﻄﺎت اﻻﺳﺮاﺋﻴﻠﻴﺔ اﺿﺎﻓﺔ ﻣﻦ ﺧﻼل ﻫﺬا اﻻﺟﺮاء. ﻛﻤﺎ أن ﺗﺸﻴﻠﻲ ﻗﺪ أن ﺗﺼﺒﺢ ﻓﺎﻋﻠﺔ ﻟﻜﻼ اﻟﻄﺮﻓﻴﻦ. أن اﺳﺘﻬﻼك اﻟﻜﺎﻟﺴﻴﻮم اﻟﻰ ﻃﺤﻴﻦ اﻟﻘﻤﺢ ﻓﻬﺬا ﻗﺪ ﻳﺴﺎﻋﺪ اﺳﺘﻄﺎﻋﺖ اﻟﺴﻴﻄﺮة أو اﻟﺤﺪ ﻣﻦ ﻓﻘﺮ اﻟﺪم ﻧﺎﻗﺺ ﻃﺤﻴﻦ اﻟﻘﻤﺢ ﻓﻲ اﺳﺮاﺋﻴﻞ ﻳﺼﻞ اﻟﻰ ﻧﺼﻒ اﻟﻤﺴﺘﻬﻠﻚ اﻟﻔﻠﺴﻄﻴﻨﻲ ّاﻳﻀﺎ. اﻟﺤﺪﻳﺪ ﺑﻮاﺳﻄﺔ ﺗﺰوﻳﺪ ﻃﺤﻴﻦ اﻟﻘﻤﺢ ﺑﺎﻟﺤﺪﻳﺪ اﺳﺘﻬﻼﻛﺔ ﻋﻨﺪ اﻟﻔﺴﻠﻄﻴﻨﻴﻦ ّﺗﻘﺮﻳﺒﺎ ﺑﺎﺧﺘﺼﺎر, ﻓﺈن ﺗﻌﺰﻳﺰ اﻟﻄﺤﻴﻦ واﺛﺮاءة ﻫﻮ ﻣﺴﺘﻌﻤﻠﻴﻦ ﻛﺒﺮﻳﺘﺎت اﻟﺤﺪﻳﺪ. ﺗﻮﻓﺮ اﻟﺘﺮﻛﻴﺒﺔ ﻣﻦ ٠-٥٠ ٪ ﻣﻦ اﻟﺤﺎﺟﺎت ﻣﺒﺎدرة ﺟﻴﺪة واﻟﺘﻲ ﺳﺘﻔﻴﺪ ﺗﻌﺰﻳﺰ اﻟﺼﺤﺔ ﻣﺆﺧﺮا ﻓﺈن ﻫﺬا اﻟﺒﻠﺪ وﻛﺬﻟﻚ اﻟﻮﻻﻳﺎت اﻟﻐﺬاﺋﻴﺔ اﻟﻴﻮﻣﻴﺔ ﺑﺎﻟﺮﻏﻢ ﻣﻦ أن اﻟﻤﺤﺘﻮي ﻟﻠﻤﺠﺘﻤﻊ اﻟﻔﻠﺴﻄﻴﻨﻲ واﻻﺳﺮاﺋﻴﻠﻲ, وﻗﺪ اﻟﻤﺘﺤﺪة وﻛﻨﺪا ﻗﺪ أﻋﻠﻨﺖ أﻧﻬﺎ اﺳﺘﻄﺎﻋﺖ اﻟﻐﺬاﺋﻲ ﻟﻸﻃﻌﻤﺔ ﻓﻲ اﻟﻤﺠﺘﻤﺎﻋﺎت اﻻﺳﺮاﺋﻴﻠﺔ ﺗﺼﺒﺢ ﺣﺎﺟﺔ ﻣﺸﺘﺮﻛﺔ ﺗﻔﺘﺢ اﻷﻓﺎق ﻟﺤﻮار وﻓﻬﻢ ﺗﺨﻔﻴﻒ ﺣﺪوث اﺿﻄﺮاﺑﺎت اﻟﻘﻨﺎة اﻟﻌﺼﺒﻴﺔ ﻓﻲ أﻓﻀﻞ ﻣﻨﻪ ﻓﻲ اﻟﻤﺠﺘﻤﺎﻋﺎت اﻟﻔﻠﺴﻄﻴﻨﻴﺔ ﻓﺈن وﺗﻌﺎون ﺑﻴﻦ اﻟﻄﺮﻓﻴﻦ. ﺣﺪﻳﺜﻲ اﻟﻮﻻدة ﻣﻦ ﺧﻼل ﺗﺰوﻳﺪ اﻟﻨﺴﺎء ﺑﻄﺤﻴﻦ اﻟﻔﺮق ﻳﺘﻢ ﺗﻌﻮﻳﻀﺔ ﻣﻦ ﺧﻼل ﺗﻌﺰﻳﺰ اﻟﻄﺤﻴﻦ. ﻣﻌﺰز ﺑﺤﺎﻣﺾ اﻟﻔﻮﻟﻴﻚ. رﺑﻤﺎ أن ﻣﻌﻈﻢ اﻻﺳﺮاﺋﻴﻠﻴﻦ ﻟﻦ ﻳﻜﻮﻧﻮا ﺑﺤﺎﺟﺔ ﺗﻘﻮﻳﺔ واﺛﺮاء اﻟﻄﺤﻴﻦ: ﻟﺨﺪﻣﺔ ﺣﺎﺟﺎت ﻣﺸﺘﺮﻛﺔ ﺑﻘﻠﻢ: د. ﻋﻤﺮ داري

ﺧﻄﻮات ﻧﺤﻮ ﺗﻌﺰﻳﺰ اﻟﻄﺤﻴﻦ: ﻟﺘﻨﺎول ﻛﻤﻴﺎت اﺿﺎﻓﻴﺔ ﻣﻦ ﻓﻴﺘﺎﻣﻴﻦ A,D ﻣﻦ ﺑﺪأت اﻟﺴﻠﻄﺔ اﻟﻔﻠﺴﻄﻴﻨﻴﺔ ﺑﺪﻋﻢ ﻓﻨﻲ وﻣﺎﻟﻲ ﺧﻼل اﻟﻄﺤﻴﻦ اﻟﻤﻌﺰز وﻟﻜﻦ ﺑﺴﺒﺐ ﺗﺪﻧﻲ ﻣﻦ اﻟﻮﻛﺎﻟﺔ اﻷﻣﺮﻳﻜﻴﺔ ﻟﻠﺘﻨﻤﻴﺔ ، ﺑﺘﻨﻔﻴﺬ ﺧﻄﺔ اﻟﻜﻤﻴﺔ اﻟﻤﻀﺎﻓﺔ ﻣﻦ ﻫﺬﻳﻦ اﻟﻔﻴﺘﺎﻣﻴﻦ ﻓﺈن ﻹﺛﺮاء وﺗﻌﺰﻳﺰ ﻃﺤﻴﻦ اﻟﻘﻤﺢ وذﻟﻚ ﻣﻦأﺟﻞ ﺗﺰوﻳﺪ ﺗﻨﺎوﻟﻬﻤﺎ اﻟﻄﺤﻴﻦ اﻟﻤﻌﺰز ﺳﻴﻜﻮن ّآﻣﻨﺎ. اﻟﻤﺠﺘﻤﻌﺎت اﻟﻔﻠﺴﻄﻨﻴﺔ ﺑﺎﻟﻤﻐﺬﻳﺎت اﻷﺳﺎﺳﻴﺔ، ﻓﻲاﻟﺘﺮﻛﻴﺒﺔاﻟﻔﻠﺴﻄﻴﻨﻴﺔاﻟﺤﺪاﻷدﻧﻲﻟﺤﺎﻣﺾ وﺗﻢ ﺗﺼﻤﻴﻢ اﻟﺘﺮﻛﻴﺒﺔ ﺑﺤﻴﺚ ﺗﻤﻨﻊ أي أﺿﺎﻓﺔ اﻟﻔﻮﻟﻴﻚ ﻫﻮ ١ ﻣﻠﻐﺮام/ ﻛﻴﻠﻮ ﻏﺮام ( ﻣﺘﻮﺳﻂ وﻟﺪ اﻟﺪﻛﺘﻮر ﻋﻤﺮ داري ﻓﻲ ﻏﻮاﺗﻴﻤﺎﻻ ﻷب ﻏﻴﺮ ﺿﺮورﻳﺔ ﺗﺆدي اﻟﻰ ﺗﻨﺎول ﻛﻤﻴﺎت زاﺋﺪة ﻣﻦ ١,٥ ﻣﻠﻐﺮام / ﻛﻴﻠﻮ ﻏﺮام ) ﻣﻤﺎ ﻳﻌﻨﻲ أن ﺗﻨﺎول ﻓﻠﺴﻄﻴﻨﻲ. ﻳﻌﻤﻞ ﻟﺪى اﻟﻤﺆﺳﺴﺔ اﻟﻌﺎﻟﻤﻴﺔ ﺣﺎﻣﺾ اﻟﻔﻮﻟﻴﻚ أو اﻟﺤﺪﻳﺪ أو اﻟﺰﻧﻚ أو ﻓﻴﺘﺎﻣﻴﻦ ﻛﻤﻴﺔ أﺿﺎﻓﻴﺔ ﻣﻨﻪ ﻟﻦ ﺗﺰﻳﺪ ﻋﻠﻰ ١٠٠-٣٠٠ ﻟﻠﻌﻠﻮم واﻟﺘﻜﻨﻮﻟﻮﺟﻴﺎ (ISIT) ﻛﻤﺴﺘﺸﺎر A أو ﻓﻴﺘﺎﻣﻴﻦ D ﻟﻼﺷﺨﺎص اﻟﻠﺬﻳﻦ ﻳﺴﺘﻬﻠﻜﻮن ﻣﻴﻜﺮ وﻏﺮام ﻳﻮﻣﻴﺎ ﻋﻨﺪ ﺗﻨﺎول ١٠٠- ﻣﻴﻜﺮ ﺗﺤﺼﻴﻦ اﻷﻏﺬﻳﺔ ل (MOST) وﻫﻮ ﺑﺮﻧﺎﻣﺞ ّﻳﻮﻣﻴﺎ ﺣﻮاﻟﻲ ٤٠٠ ﻏﻢ ﻣﻦ اﻟﻄﺤﻴﻦ. وﻏﺮام ﻳﻮﻣﻴﺎ ﻋﻨﺪ ﺗﻨﺎول ١٠٠- ٣٠٠ ﻣﻴﻜﺮو اﻷﻏﺬﻳﺔ اﻟﺪﻗﻴﻘﺔ ، ﻣﺸﺮوع ل. (USAID) اﻟﺘﺮﻛﻴﺒﺔ اﻟﻤﻌﺘﻤﺪة ﺳﺘﻮﻓﺮ ٤٠-١٠٠٪ ﻣﻦ ﻏﺮام ﻳﻮﻣﻴﺄ ﻋﻨﺪ ﺗﻨﺎول ١٠٠-٢٠٠ ﻏﻢ ﻣﻦ وﻋﻤﻞ ﻛﻤﺴﺘﺸﺎر ﺧﺒﻴﺮ ﻓﻲ اﻟﺘﺤﺼﻴﻦ اﻟﻐﺬاﺋﻲ اﻟﺤﺎﺟﺎت اﻟﻐﺬاﺋﻴﺔ اﻟﻴﻮﻣﻴﺔ ﻟﻬﺬا اﻟﻔﻴﺘﺎﻣﻴﻨﺎت اﻟﻄﺤﻴﻦ اﻟﻤﻌﺰز ﻳﻮﻣﻴﺎ. واﻷﻏﺬﻳﺔ اﻟﺪﻗﻴﻘﺔ ﻟﻜﻞ ﻣﻦ إﺿﺎﻓﺔ ،اﻟﻰ ﻓﻴﺘﺎﻣﻴﻨﺎت B١. B٢, B٦, Pan American Health Organization, ,B١٢ واﻟﻴﻨﺎﺳﻴﻦ ﻷي ﺷﺨﺺ ﻳﺴﺘﻬﻠﻚ ﺑﻤﺘﻮﺳﻂ اﻟﺘﺮﻛﻴﺒﺔ اﻟﻤﻌﺪﻟﺔ ﻟﺘﻐﻄﻴﺔ ﺣﺎﺟﺎﺗﻨﺎ : GAIN, the Micronutrient Initiative ٢٠٠-٤٠٠ ﻏﻢ ﻃﺤﻴﻦ ّﻳﻮﻣﻴﺎ. وﻳﺘﻮﻗﻊ أﻧﻪ ﺗﻔﻴﺪ اﻟﺨﺒﺮات ﻓﻲ ﻛﻞ ﻣﻦ اﻟﻮﻻﻳﺎت اﻟﻤﺘﺤﺪة (MI), وﻛﺬﻟﻚ ﻓﻲ CDC ﻓﻲ اﻟﻮﻻت اﻟﻤﺘﺤﺪة ﻋﻨﺪ اﺣﺘﻤﺎل ﺗﻨﻔﻴﺬ ﺗﻌﺰﻳﺰ اﻟﻄﺤﻴﻦ ﻓﺈن ٨٠٪ وﻛﻨﺪا أن ﺗﻨﺎول ٢٠٠ ﻣﻴﻜﺮوﻏﺮام اﺿﺎﻓﻴﺔ ﻣﻦ اﻷﻣﺮﻳﻜﻴﺔ. 22 bridges April-May 2005 How to... Wheat Flour Enrichment and Fortification: Serving Mutual Needs Ilya Melnikov photos: ﺗﻘﻮﻳﺔ واﺛﺮاء اﻟﻄﺤﻴﻦ: ﻟﺨﺪﻣﺔ ﺣﺎﺟﺎت ﻣﺸﺘﺮﻛﺔ ﺑﻘﻠﻢ: د. ﻋﻤﺮ داري

اﻟﺘﻐﺬﻳﺔ اﻟﺠﻴﺪة ﺿﺮورة ﻟﺨﻄﺮ ﻓﻘﺮ اﻟﺪم ﺑﻴﻦ أﻓﺮادﻫﺎ وﻛﺬﻟﻚ ﻟﺨﻄﺮ ﻣﻦ ﺧﻼل ﺗﺰوﻳﺪﻫﺎ ﺑﻔﻴﺘﺎﻣﻴﻨﺎي A,D، ﻛﻤﺎ أﺳﺎﺳﻴﺔ ﻟﻠﺘﻤﺘﻊ ﺑﺤﻴﺎة ﺻﺤﻴﺔ اﻟﻜﺴﺎح وﻫﺸﺎﺷﺔ اﻟﻌﻈﺎم، وﻻ ﺿﻄﺮاﺑﺎت أن اﻟﻘﻴﻤﺔ اﻟﻐﺬاﺋﻴﺔ ﻟﻠﺤﻠﻴﺐ ﻣﻨﺰوع اﻟﺪﺳﻢ ﺗﻌﺘﺒﺮ وﻣﻨﺘﺠﺔ. اﻟﺘﻐﺬﻳﺔ اﻟﺠﻴﺪة اﻟﻨﻤﻮ. وﻋﺪم اﻟﻜﻔﺎﻳﺔ اﻟﻨﻔﺴﻴﺔ واﻟﻮﻇﻴﻔﻴﺔ. ﺗﻌﺪ ﻛﺎﻣﻠﺔ ﻣﻦ ﺧﻼل إﺿﺎﻓﺔ اﻟﻔﻴﺘﺎﻣﻴﻨﺎت اﻟﺘﻲ ﺗﻌﺘﻤﺪ ﻋﻠﻰ ﻧﻈﺎم ﻏﺬاﺋﻲ ﻣﺘﻮازن وﻣﻨﻮع. وﻣﻊ إﺿﺎﻓﺔ اﻟﻰ ﻋﺪم اﻟﻘﺪرة ﻋﻠﻰ اﻻﺳﺘﺠﺎﺑﺔ اﻟﺠﻴﺪة ﻳﻔﻘﺪﻫﺎ اﻟﺤﻠﻴﺐ ﻋﻨﺪ ازاﻟﺔ اﻟﺪﻫﻮن ﻣﻨﻪ. ﻛﻤﺎ ذﻟﻚ ﻓﺈن ﻫﺬﻩ اﻟﻀﺮورات ﻻ ﺗﺘﺤﻘﻖ ﻓﻲ اﻟﺒﻼد ﺿﺪ اﻷﻣﺮاض واﻟﺨﻤﺞ. أن ﻓﻴﺘﺎﻣﻴﻦ C أﺻﺒﺢ ﻳﻀﺎف اﻟﻰ ﻋﺼﺎﺋﺮ اﻟﻔﻮاﻛﺔ اﻟﻤﺘﻘﺪﻣﺔ أو اﻟﻨﺎﻣﻴﺔ ﻋﻠﻰ ﺣﺪ ﺳﻮاء ﺑﺴﺐ ﺗﺼﺒﺢ اﻟﺼﻮرة أﻛﺜﺮ ﺳﻮءا ﻓﻲ اﻟﻤﺠﺘﻤﻌﺎت ﻟﺘﻌﺰﻳﺰ ﻣﺤﺘﻮاﻫﺎ اﻟﻄﺒﻴﻌﻲ ﻣﻦ ﻫﺬا اﻟﻔﻴﺘﺎﻣﻴﻦ. اﻟﻘﻴﻮد اﻟﺘﻐﺬوﻳﺔ اﻟﻤﺮﺗﺒﻄﺔ ﺑﺎﻟﻌﻤﺮ أو ﻷﺳﺒﺎب اﻷﻓﻘﺮ ﺣﻴﺚ اﻟﻮﺻﻮل ﻟﻸﻃﻌﻤﺔ اﻟﻤﻐﺬﻳﺔ ﻛﻤﺎ ان اﻟﻤﻠﺢ أﺻﺒﺢ ﻣﺼﺪرا ﻟﻠﻴﻮد ﻣﻦ ﺧﻼل دﻳﻨﻴﺔ ، أو اﺗﻔﺎﻗﻴﺔ أو ﺳﻴﺎﺳﻴﺔ أو اﻗﺘﺼﺎدﻳﺔ. ﻛﺎﻟﺤﻠﻴﺐ واﻟﺒﻴﺾ واﻟﻠﺤﻮم ﻳﻜﻮن ﻣﺤﺪودا ﺗﺰوﻳﺪ اﻟﻤﻠﺢ ﺑﻬﺬا اﻟﻤﻌﺪن اﻟﺬي ﻳﺤﻮﻳﺔ ﺑﺸﻜﻞ ﻳﻌﺘﻤﺪ اﻻﻧﺴﺎن ﻓﻲ ﺣﻤﻴﺘﻪ ﺑﺸﻜﻞ رﺋﻴﺴﻲ ﻛﻤﺎ ﻫﻮ اﻟﺤﺎل ﻓﻲ اﻟﻤﺠﺘﻤﻊ اﻟﻔﻠﺴﻄﻴﻨﻲ ﻓﻲ ال ﻃﺒﻴﻌﻲ. ﻋﻠﻰ اﻟﺴﻜﺎﻛﺮ واﻟﻔﻮاﻛﻪ واﻟﺰﻳﻮت واﻟﺪﻫﻮن ﻇﺮوف اﻟﺤﺎﻟﻴﺔ. وﻛﺬﻟﻚ اﻷﻃﻌﻤﺔ اﻟﻨﺸﻮﻳﺔ واﻟﺘﻲ ﺗﻐﻄﻲ اﻟﺤﺎﺟﺔ ﺧﻼل اﻟﻘﺮن اﻟﻤﺎﺿﻲ ﻗﺎﻣﺖ اﻟﻌﺪﻳﺪ ﻣﻦ اﻟﺪول ﻟﻤﺎذا ﻃﺤﻴﻦ اﻟﻘﻤﺢ؟ اﻟﻰ اﻟﻄﺎﻗﺔ ، وﻟﻜﻨﻬﺎ ﺗﻌﺘﺒﺮ ﻣﺼﺪر ﻣﻔﻴﺪ ﺑﺎﻟﺘﻨﺒﻪ ﻟﻀﺮورة اﻟﻘﻴﺎم ﺑﺘﻄﻮﻳﺮ اﻟﻘﻴﻤﺔ اﻟﻐﺬاﺋﻴﺔ ﻳﺘﻤﺘﻊ ﻃﺤﻴﻦ اﻟﻘﻤﺢ ﺑﺨﺼﺎﺋﺺ ﺗﺠﻌﻠﺔ ﻟﻠﻔﻴﺘﺎﻣﻴﻨﺎت اﻷﺳﺎﺳﻴﺔ واﻟﻤﻌﺎدن. ﻟﺒﻌﺾ اﻷﻃﻌﻤﺔ ﻣﻦ ﺧﻼل اﺿﺎﻓﺔ اﻟﻤﻐﺬﻳﺎت ﻧﺎﻗﻞ أﺳﺎﺳﻲ ﻟﺘﺰوﻳﺪ اﻻﻧﺴﺎن ﺑﺎﻟﻔﺘﻴﺘﺎﻣﻴﻨﺎت ﻧﺘﻴﺠﺔ ﻟﺬﻟﻚ ﻓﺈن اﻻﻧﺴﺎن ﻳﻌﺎﻧﻲ ﺑﺎﺳﺘﻤﺮار اﻟﺮﻳﺌﺴﻴﺔ اﻟﻴﻬﺎ (اﻟﻔﻴﺘﺎﻣﻴﻨﺎت واﻟﻤﻌﺎدن). واﻟﻤﻌﺎدن اﻟﻤﺘﻌﺪدة ﺑﻄﺮﻳﻘﺔ آﻣﻨﻪ وﻓﻌﺎﻟﻪ. ﻣﻦ ﺗﺄﺛﻴﺮات ﻧﻘﺺ ﻓﻲ اﻟﻔﻴﺘﺎﻣﻴﻨﺎت واﻟﻤﻌﺎدن. ﻫﻜﺬا أﺻﺒﺤﺖ اﻟﺪﻫﻮن اﻟﻨﺒﺎﺗﻴﺔ ﻣﻜﺎﻓﺌﺔ ﻧﺪﻣﺞ ﻃﺤﻴﻦ اﻟﻘﻤﺢ ّﻋﺎدة ﻓﻲ ﻣﺼﺎﻧﻊ ﻣﺤﺪودة أن اﻟﻤﺠﺘﻤﻌﺎت اﻟﻐﻨﻴﺔ وﻛﺬﻟﻚ اﻟﻔﻘﻴﺮة ﻣﻌﺮﺿﺔ ﺗﻐﺬوﻳﺎ. وﻣﺮﻛﺰﻳﺔ وﻳﺴﺘﻬﻠﻚ ﺑﻜﻤﻴﺎت ﻛﺒﻴﺮة وﺑﺸﻜﻞ April-May 2005 bridges 23 Happening in Health Helping Palestinian Children at Tel-Hashomer Hospital For over a year, Jewish and Arab volunteers have been visiting the wards of Tel-Hashomer Children’s Hospital. Their aim is to help Pal- estinian families from Gaza and the West Bank whose children are hospi- talized.

Because of the policy of “closures,” Ilya Melnikov “encirclements” and the occupation in

general, these families and their sick photo: children are detached from their own environment. Sometimes children in grave condition arrive at the hospi- International Master tal only with a grandparent, because their parents were forbidden to enter of Public Health Israel, or because they must look af- ter other children at home. Many of by Elliot Berry students from more than 80 countries them have no personal items, be- and Shulamit Amir have participated in this unique ex- cause of the difficulties involved in The International Master of Pub- perience, including 33 from Gaza and crossing the checkpoints. Sometimes lic Health Program (IMPH) at the the West Bank and some from East women come to the hospital soon af- Hebrew University-Hadassah Braun Jerusalem. Ahlam Kastiro, a former ter giving birth, without a change of School of Public Health and Commu- student of the program from Palestine clothes, washing items or other hygi- nity Medicine welcomed its first class says, “The Palestinian population is enic materials. They sometimes ar- in 1970, building on the experiences considered a developing region in a rive after hours on the roads, cross- acquired during the previous10 years transition state. Some are rich and the ing through checkpoints, and with a of teaching the Israeli MPH course. others are poor and public health is a newborn baby in serious condition. The aim of the program is to pro- new emerging field. Being in this pro- The volunteers do their best to pro- vide public health knowledge, ex- gram gave me a wide range of tools vide the children’s relatives with a perience and skills for current and that I can use to detect, identify and helpful and listening ear, and help future public health practitioners, solve problems facing a small region them cope by mediating with the bu- mainly from the developing regions or even whole countries.” reaucracy. They visit those children of the world. The 12-month program “The program provided me not who are alone, with no accompanying includes compulsory core courses, only with academic opportunities, relatives. They bring the parents basic elective courses selected by each but also the chance to form relation- needs – food, diapers for the children, student, workshops and an individ- ships with students from all over the washing items, phone-cards to stay in ual research project. Epidemiology, world and most importantly, Pales- contact with home, and so on. statistics, nutrition, administration, tinian students with whom I main- None of the above is provided by communicable diseases, economics tain contact with professionally and the hospital, and without this help and sociology are some of the core as close friends,” shares Shiri Ouri- the parents must sometime live off disciplines as well as an intensive an, former student of the program their children’s left-over food, be- workshop in Community Oriented from Tel-Aviv. cause of the high cost of living in Is- Primary Care (COPC). Other cours- The vision for a new Middle East rael and the length of the children’s es include AIDS, aging, demography, includes building a bridge of cooper- stay in hospital. maternal and child health, and pub- ation in the field of public health. We Since it began, the project has been lic health dentistry. hope to continue our commitment in self-funded in cooperation with Phy- The student body consists prima- establishing public health teaching sicians for Human Rights - Israel. rily of physicians (approximately and research in our region – for bac- For more information contact Shaula: 75%), nurses, dentists, educators and teria know no borders and water and 052-2936917 or Judith 052-2958886 other health professionals. Over 550 sanitation are a problem for all.

24 bridges April-May 2005 Disability Is a Challenge, Not a Burden Dissemination and Information Department – PRCS

The Palestine Red Crescent Soci- Additionally, Fayeq Hussein, PRCS ety (PRCS) held a conference titled, Deputy General Director, gave a pres- “Disability Is a Challenge, Not a Bur- entation titled, “Rehabilitation and den”, from February 12 – 14, 2005 in Development”. In his speech, Rabah the city of Al-Bireh. Representatives Jaber, Head of PRCS Rehabilitation from forty-two organizations partic- Department, presented the achieve- ipated in the three day event com- ments of the PRCS rehabilitation de- prising Palestinian ministries, local partment during 2000 to 2004. He and international institutions includ- noted that the number of beneficiar- ing PAZ – Spain (Asamblea de Co- habilitation services to the Pales- ies - including those with develop- operacíon por la Paz), the Spanish tinian people, particularly children, mental delays, slow learners, mental Red Cross, the Norwegian Red Cross both in Palestine and the Diaspora, retardation, cerebral palsy, physi- and G.V.C – Italy (Italian Volunteer in order to boost their self-esteem cal disability, hearing impairments Group). and increase their independence. and deafness, and multi disabilities During the opening session, PRCS Dr. Rihab Al Esawi, Ministry of – from the PRCS rehabilitation serv- President, Younis Al Khatib, pro- Social Affairs, Dr. Jihad Zakarneh, ices reached 87,174 people between vided a historical perspective of the Ministry of Education and Mr. Arsan 2000 – 2004. concept of disability in Palestine Ibrahim, Chief of the National Cen- Participants included people with and the challenges of overcoming tral Committee for Rehabilitation, disabilities, their parents and the stereotypes. Furthermore, Al-Khat- praised the PRCS for its role in ad- PRCS rehabilitation staff, discussed ib stressed the significance of the dressing the needs of people with- different issues related to rehabilita- role that the community must play disability, and stressed the impor- tion. At the conclusion of the con- to promote integration of those with tance of working on their integration ference participants presented their special needs. He added that one of by giving them the opportunities to recommendations and working pa- the PRCS’ priorities is providing re- develop their abilities. pers were submitted for ratification. The Day after Disengagement

Physicians for Human Rights-Isra- that medical services continue to

el (PHR-Israel) released a new posi- Nir Kafri be purchased from various sources, tion paper which warns of the health while simultaneously improving the

consequences following disengage- photo: infrastructure of the medical system ment unless a process of planning until it at least reaches the standard and coordination for the provision level of Jordan. This will most likely of external medical services to resi- take about 10 years, at the cost of ap- dents of the Gaza Strip begins imme- proximately $250 million a year. diately. Israel is asked to begin working The position paper entitled, “The forced to travel to the West Bank, immediately on a set of regulations Day After”, states that Israel will East Jerusalem, Israel and abroad to which would enable the thousands still be required to allow Palestinian receive certain life saving treatments of people who must leave Gaza each patients to receive life-saving treat- and complex diagnosis. Some serv- year for medical treatment to exit ment in Israel and abroad, even af- ices are simply non-existent in Gaza, and receive the treatment outside of ter disengagement, and explains the such as catheterization and cardiac the Strip. Also, plans must be made legal rationale. Also, Israel must re- surgery, burn treatment, pediatric for the rehabilitation of the Palestin- habilitate the Palestinian health care cardiology, radiotherapy, and MRI ian health care system. Israel’s re- system over the next decade, in or- facilities. PHR-Israel points out that sponsibility for Palestinian patients der to raise the standards to at least no preparations are known to have does not end with disengagement. those of Jordan. been made to enable Palestinians For more information contact Maskit Due to the limited facilities and needing to leave the Strip for medi- Bendel, author of the position paper, services of the Palestinian health cal treatment after disengagement. +972-54-7700477. The position paper care system, residents of Gaza are The position paper recommends is online at www.phr.org.il

April-May 2005 bridges 25 Happening in Health Child Nutrition in Israel and Palestine – Seeking Joint Initiatives A Conversation with Osman Galal

“Micronutrient deficiencies are not extreme cases, infant and maternal their proposals and set timelines and only a health problem,” stated Dr. deaths as well as blindness in chil- teams for publication of the working Osman Galal, active participant in dren, weak immune systems, low IQ group reports as well as fundraising the Child Nutrition Conference held and low intellectual functioning. efforts. this past February at Ben-Gurion Uni- “We cannot ignore, that cognitive Tufts University, USA also devel- versity, Beer Sheva, Israel. Dr. Galal, and physical impacts of nutrition will oped an important collection of peer- Professor of Community Health Sci- have a strong impact on productiv- reviewed literature relevant to Pales- ences in the School of Public Health ity. The importance of productivity of tinian and Israeli communities about at UCLA, USA, and Director of the the child and therefore of the com- food security and MNDs and is avail- School's International Health Pro- munity in the future has a direct im- able at http://nutrition.tufts.edu/ gram is referring to the fact that mi- pact on the economic development,” conferences/childhood. cronutrient deficiencies and food said Dr. Galal who began his obser- “If we are looking at trends over security are complex issues which vations in Egypt, where he was born. the past five years, we are seeing

affect not only the health status of photo: the population, but also the econom-

ic status and social development of Osama Silwadi a country. The members of the two day con- ference held in Beer-Sheva under the auspices of Al-Quds University, Ben- Gurion University and Tufts Univer- sity representing Palestine, Israel and the United States, respectively, aimed to identify ways in which joint initia- tives could be made in order to col- laboratively improve the nutrition status of children in both Israel and Palestine. “The appropriate development of the child starts from the nutritional status of the mother at conception The World Bank has estimated that not only the continuation of existing and the nutritional status of the child iodine deficiency, in combination MNDS, but also the emergence of de- continues to be a primary cause of with vitamin A deficiency and iron ficiencies in zinc, folic acid and Vita- proper development until puberty,” deficiency may lower the economic min E appearing which will impact explained Dr. Galal. “In recent years, wealth of a nation by as much as 5% our children first and hardest. We we have expanded our attention every year. (1) must take care of our children,” in- from physical growth indicators to On the second day of the event, sisted Dr. Galal. cognitive growth and its relationship following the presentations of nu- The American, Israeli and Pales- to nutrition,”states Dr. Galal. And tritional status, participants, who tinian scientists and academics at in fact, the conference held in Beer- are top leaders in nutrition and ex- the conference enjoyed working to- Sheva presented nutritional summa- perts from various NGOs in their re- gether and did so effectively. “The ries of both Israel and Palestine and spective countries, joined working obstacle in collaboration has usually highlighted both the physical and groups about food security, micro- been at the political level,” claimed cognitive impacts issues of food se- nutrient deficiencies and behavioral Dr. Galal. curity and MNDs have on our chil- change and communications in order References dren which include complications in to develop draft reports for collabo- 1. Network for Sustained Elimination of Iodine Deficiency. Available at www.sph.emory.edu/ pregnancy, low birth weight and, in rative projects. The groups presented iodinenetwork

26 bridges April-May 2005 Student Page photo: C. Gaggero/WHO/PAHO

lic health program at Hebrew Uni- versity has broadened my university Study Break experience immensely especially dur- ing such tense times. I have become from the Conflict aware of problems other countries have to face in order to develop and by Noa Cedar protect its people. While security is high on our agenda, here, there are magine you’ve finished attend- think and act differently. Instead of other issues that are essential - health ing classes for the day. You opening up to new social experienc- education, communicable disease know you have fours hours of es and building dynamic interesting control and a keen understanding of research to do at the library and relationships, students protect them- population behavior. at least two hours to study for an selves by socializing only with peo- I am learning the importance of Iexam tomorrow. You’ve planned out ple with whom they feel safe. This these topics mostly by meeting oth- exactly how you’re going to organize limits opportunities for mutual coop- er students from all over the world your time and then, “PIGUA” – a ter- eration and enrichment. who feel a tremendous responsibility rorist attack. A suicide bomber blew However, like everyone, I per- towards their own countries. These up a bus in the center of Jerusalem. severe. I am pursuing my field of students are studying public health Instantly everything changes; people interest which is maternal and child so they can contribute to their home- are on their cell phones checking on health. I am particularly interested in land which are mostly developing the safety of friends and relatives. working with women from the Jew- countries where infant mortality rates Radios are blaring. There is a new ish ultra orthodox and Arab popula- soar and infectious diseases are ram- reality. Research at the library? Study tions in Israel. Both of these groups pant This helps put my own worries for an exam? There’s no way to con- share a common factor in terms of into perspectives. There is a tremen- centrate on anything but the recent maternal and child health - they have dous feeling of camaraderie between events. high birth rates. Therefore, there is a us. These relationships have been an Studying among a population that great need for public health interven- inspiration to me and make the world is divided politically, ethnically, reli- tion. The Masters project I am pursu- smaller and safer for me. giously and nationally is not simple. ing is about home births - its cultural Walking through the corridors on a aspects, advantages and disadvantag- Noa Cedar was born in Jerusalem. Her normal day absent of terrorism, you es in both the Arab and ultra-ortho- background is in medical sciences. She is can feel the tension in the air. Peo- dox communities. currently studying at the Hebrew University ple not only dress differently, they Studying in the international pub- in the International MPH Program.

April-May 2005 bridges 27 photos: Osama Silwadi

A Day in the Life Prof. Abdeen Treats His Students' Wounds by Lily Galili

very day at 7:30 AM hospital or from the hospital to the sharp, Prof. Hani Abdeen University is now quite an ordeal. leaves his apartment in The normally five minute drive, has Bet-Hanina, a neighbor- turned into a half hour detour on a hood on the outskirts of "good" day. "When you are both a EEast Jerusalem, to go to work. For clinician and an administrator, every Prof. Abdeen, 'work' means not only moment counts," says Prof. Abdeen. multiple positions, but also multiple “It doesn't even make me angry; it locations. Abdeen, 52, is the Head of just feels stupid." Internal Medicine at Augusta Victo- For Prof. Abdeen, the time lost is ria Hospital on Mt. Scopus, Dean of more than just a technicality. It's a real the Medical School of Al-Quds Uni- burden and constant source of griev- versity and Director of the Health ance. For instance, he had to short- Sciences Center at Al-Quds, which is en his time at the teaching rounds in certainly enough to keep him busy. the hospital to get to the university in The separation wall and never end- time. Still, this native born Jerusale- ing checkpoints make this endeavor mite is quite lucky. His Jerusalem ID even more complicated. What used and the yellow (Israeli) plates on his to be a short trip from home to the car, make this commute possible at all.

28 bridges April-May 2005 His students, on the other hand, are the very existence of Al-Quds medi- frustrated. The whole idea is to get us often less fortunate. Closures, check- cal school, just a mile away from frustrated, isn't it?" points and curfews constantly disrupt the medical campus of Hebrew Uni- That's exactly what Prof. Abdeen their carefully crafted curriculum. As versity, is a fact not known to most keeps telling his students. Unlike in a dean, their many problems become Israelis. any other medical school, at least one his one huge problem. "Imagine the The Palestinian state is still a dream of his five weekly sessions with stu- state of a student coming into the and the graduates of the first and only dents is dedicated to hearing their hard hospital having been harassed on the Palestinian medical school do not get feelings and bitterness. A student gets way," he says in a matter of fact voice. accreditation from Israel or from the delayed because of the checkpoints? “But also,” he admits, “it's a trigger World Health Organization (WHO). "Get up an hour earlier," suggests for creative thinking and solutions.” Prof. Abdeen, an expert in detours, Abdeen; a student complains about Some time ago, he was summoned to used his personal contacts in England the harsh treatment by soldiers on the a police post to release 12 of his stu- to convince the British Medical Coun- way to the campus? "Don't let them dents, detained from going from Al- cil to grant accreditation to his gradu- achieve their goal,” Prof. Abdeen tells Quds campus in the West Bank to ates on an individual basis. He then the students. “They want to keep you Augusta Victoria Hospital in Jerusa- tried his luck with the United States ignorant. They want you to stay sim- lem without a permit. What do you do and worked out a similar arrange- ple laborers. Try harder." when the age for permits is over 25, ment. Yet, the Jerusalem ID holders Quite often, these issues cross the but the students are much younger? among his students cannot work in line of theoretical analysis of medical Since then, he has managed to reach an Israeli kupat holim (Sick Funds) ethics and Hippocratic Oath to deal a special agreement with the author- around the corner. with real life dilemmas. Once, they ities, and decreased the age limit for Frustrating? "Of course," admits dealt with the question 'if a helicop- permits for medical students to 21. Prof. Abdeen, who is still extreme- ter with Israeli soldiers crashes near- "A lot of my time is devoted to silly ly proud of his pioneer project that by, do you treat them?" Most of the issues," he sums up his victory. One brought back Palestinian expatri- students said "yes, we do,” but then could say that Prof. Abdeen's daily ates to teach basic medical sciences. expressed a wish for the soldiers to routine is very different from the one Unlike the expatriates, students from disappear out of sight. Suicide bomb- of any other dean of a medical school. Gaza have no access to the campus in ings, become another ethical issue for He doesn't cope only with a complex Al-Quds. “The solution to this conun- medical students, trained to save lives. Most of them condemn the phenom- ena; some say that knowing the cir- cumstances, they could do the same. It saddens him, but does not really surprise him, that the students who enter medical school with liberal and moderate ideas, graduate more con- servative, to say the least. "It’s oppo- site of what is to be expected, but that's the truth,” says Prof. Abdeen. "I have a visual criterion. First year, about 30% of the female students wear a headscarf; upon graduation, 90% do." Despite all these unique difficulties, the school is a tremendous source of pride for Prof. Abdeen. Hospitals in Amman, for instance, are actively academic curriculum and an adminis- drum could be a nice topic for a real- searching for his graduates to staff trative work load; he also serves as a ity TV show," describes Prof. Abdeen their facilities. And, it’s important psychologist, social worker and medi- of the different methods developed to not to forget the Palestinian mother, ator between his students and the dif- cope with this situation. "They gradu- proud of her child, the doctor. At least ferent elements of occupation. ate without ever being at Al-Quds. We this is something Palestinians and This is not the way it was sup- monitor them from a distance. Since Israelis share in common. posed to be when the first Palestin- I predict the situation is just going to ian medical school opened in 1994, get worse, we are in the process of Lily Galili is a reporter who focuses soon after the Oslo Accords. Elev- establishing a distance learning tele- on social issues for the daily Hebrew en years and 120 graduates later, video system. We cannot afford to get newspaper, Ha'aretz.

April-May 2005 bridges 29 A Day in the Life Prof. Carmi Diagnoses Life During the Conflict by Abd el Raouf Arnaout

en years ago, a Palestin- ous diagnostic tests. “Now she is ian man from Gaza met probably thirteen or fourteen years Prof. Rivka Carmi, now old and she needs an operation that Dean of the Health Sci- can not be performed in Gaza and ences Faculty at Ben- this upsets me because I know that TGurion University, about his daugh- we can help her here," laments Prof. ter’s rare disease. Over the years, Carmi. Prof. Carmi developed a special rela- Just until two moths ago, the tionship with this family until the father was in touch with Prof. Car- current conflict disrupted it. mi. But for unknown reasons, she Prof. Carmi, 56 years old, recalls stopped hearing from him. “When I the days when the young, Palestin- call the number the father gave me ian girl was able to travel back and I get no answer. I don’t know what forth to her clinic to undergo vari- is happening with them; I am very

30 bridges April-May 2005 she became the Head of the Genetics in the recent months give Prof. Carmi Institute in Soroka Medical Center hope. “I'm very happy to tell you that and five years ago she was elected to things are improving now and just be the Dean of the Faculty of Health recently I met two physicians from Sciences at Ben-Gurion University the West Bank. We will start cooper- and also serves as the Head of the ating on research projects together. Medical Deans Association in Israel. There are many similarities between For many years, cooperation our neighborhood in the Negev and between Palestinian and Israeli doc- their community in the West Bank. tors was part of Prof. Carmi’s daily For example, inter-marriage is a prob- life, but the eruption of the conflict lem among the Bedouin families in four and a half years ago ended eve- the Negev as well as communities in rything. Palestine, so we have common goals "Up until five years ago, we had both in research and in health serv- a lot of research cooperation which ices,” she explains. ended completely because of the Prof. Carmi hopes to see the medi- conflict. We also had medical rela- cal school in Al-Quds University in tions; we used to go to Gaza to give Jerusalem eventually recognized. consultations," she says. “Israel does not officially recognize Prof. Carmi believes that the lack Al-Quds University and because of of cooperation is a result of technical that, students don’t have the oppor- problems arising from the conflict. tunity to use the facilities in Israel. “The lack of cooperation is mainly We are trying hard to overcome this technical because whenever some- barrier but unfortunately this will thing huge happens, the atmosphere only get better when the conflict will is emotionally poor for research but be over and the Palestinian state will even on a daily basis when we don’t be established.” have something dramatic going, we For Prof. Carmi, leaders can make can’t move from one place to the decisions but it’s the people who other and this is very disturbing,” bring it to reality. “Leaders can she explains. sign agreements but if people don’t To try and maintain contact with cooperate nothing will happen. We her Palestinian colleagues, Prof. Car- may have it on paper but not on the mi spoke on the phone and commu- ground,” she claims. nicated via e-mail and sometimes Daily life doesn’t feel normal under met with them outside the country. the conditions of the conflict for Prof. A Day in the Life “You can call and write e-mails to Carmi who says, “The conflict is like a Prof. Carmi Diagnoses Life During the Conflict by Abd el Raouf Arnaout

worried,” said Prof. Carmi adding, “I a certain extent but cooperation is big cloud on our life; I feel it the most am not able to implement my capa- about meeting together and sitting when I travel out side Israel, where I bilities to help somebody else. This in the same room and talking about don’t have to hear what’s going on conflict has impaired my abilities to things in general and this was tech- the radio all the time and people are practice my profession.” nically not possible for a very long living normal lives. Only then I real- Born in the town of Zikhron Yaa- time,” Prof. Carmi explains. ize how much we are deeply occu- kov in Israel, Prof. Carmi excelled in For Prof. Carmi, both the Pales- pied and affected by this conflict.” her professional life. After graduat- tinians and Israelis are paying the ing from Hebrew University Hadas- price. “People cannot get the appro- Abd el Raouf Arnaout, born in East sah Medical School in Jerusalem, she priate treatment and in research we Jerusalem, is the political correspondent at moved to Beer Sheva in the Negev are not making as much progress as Al-Ayyam daily newspaper published from before going to the United States we could,” she says. the West Bank city of Ramallah. Since the for her training in medical genet- The new relations emerging establishment of the Palestinian Authority, ics. She moved back to Israel where between the Palestinians and Israelis he has covered Palestinian-Israeli relations.

April-May 2005 bridges 31 alnutrition means “badly nourished” but it is more than

a measure of what WHO Archive we eat, or fail to eat. Clinically, malnutrition is character- M photos: ized by inadequate intake of protein, energy, and micronutrients and by frequent infections or disease. Nutri- tional status is the result of the com- plex interaction between the food we eat, our overall state of health, and the environment in which we live – in short, food, health and caring, the three “pillars of well-being”.

Malnutrition: Casting Long Shadows Although often an invisible phe- nomenon, malnutrition casts long shadows, affecting close to 800 mil- lion people – 20% of all people in the developing world. • Malnutrition kills, maims, cripples and blinds on a massive scale world- wide. • Malnutrition affects one in every three people worldwide, afflicting all age groups and populations, espe- cially the poor and vulnerable. • Malnutrition plays a major role in half of the 10.4 million annual child deaths in the developing world; it WHO on Malnutrition: Consequences and Determinants World Health Organization Literature Review

continues to be a cause and conse- Determinants of ic transformations. In theory, there quence of disease and disability in Malnutrition is more than enough food for all. the children who survive. Poverty-driven hunger The problem is that food is neither • Malnutrition is not only medical; Compared with the relatively produced nor distributed equitably. it is also a social disorder rooted in recent past, today we live in a world All too frequently, the poor in fer- poverty and discrimination. of abundance. Improved health and tile developing countries stand by • Malnutrition has economic ripple increasing agricultural productivity watching with empty hands – and effects that can jeopardize develop- in the 20th century have catalyzed empty stomachs – while ample har- ment. unprecedented social and econom- vests and bumper crops are export-

32 bridges April-May 2005 ed for hard cash; short-term profits nutrition. As a result, healthier, more 1992 - The World Declaration and for a few, long-term losses for many. productive societies are a potential Plan of Action for Nutrition with Hunger is a question of mal-distribu- outcome. 9 goals and 9 action areas were tion and inequity – not a lack of food. endorsed in its entirety by the World That is why, despite abundance, hun- WHO Nutrition Timeline Health Assembly. ger hovers; despite progress, poverty 1948 – Article 2 of the Constitution 1995 – The Forty-eighth World persists. of the World Health Organization Health Assembly identified nutrition Development-driven obesity specifically includes the improve- as one of WHO’s priority program Simultaneously, “globesity” – a ment of nutrition among the declared areas. swelling global tidal wave of obes- functions of WHO. 1998 - Health-for-All in the Twenty- ity and diet-related diseases – 1978 – The Declaration of Alma Ata first Century includes malnutrition threatens to envelop us as globali- lists promotion of food and nutrition (stunting), and iodine and vitamin A zation changes the nature of the as one of the eight essential elements deficiencies, among its specific tar- world’s nutrition. Yet another form of primary health care. gets for the year 2000. of malnutrition, development-driv- 1981 – The Global Strategy for Health en obesity, is emerging among all for All features nutrition as one of its WHO Mandate age and socioeconomic groups, cornerstones, and three of its twelve Our vision is of a world where people especially in countries caught up monitoring indicators are nutrition- everywhere, at every age, enjoy a high in the swiftest societal transition. related. level of nutritional well being, free from As a result, diet-related diseases, 1990 - The World Summit for Chil- all forms of hunger and malnutrition. such as diabetes, cardiovascular dis- dren identified eight nutrition goals It is founded on the intrinsic value ease, hypertension, stroke, and can- for the year 2000. of human life and the dignity it com- cer – previously regarded as “rich mands, as reflected in the internation- men’s diseases” – are now escalating “Diet-related diseases, al human rights instruments adopted in developing countries, superim- over the last half century. Everyone, posed on precarious health systems such as diabetes, without distinction of age, sex or race, already buckling under the double cardiovascular has the right to nutritionally adequate weight of communicable and other disease, hypertension, and safe food and to be free from non-communicable diseases. hunger and malnutrition. It rests on stroke, and cancer – the conviction that hunger and mal- Downward Spiral previously regarded as nutrition are unacceptable in a world Malnutrition is the single most that has both the knowledge and the important risk factor for disease. “rich men’s diseases” resources to end this widespread, When poverty is added to the pic- – are now escalating in continuing human catastrophe. It ture, it produces a downward spiral developing countries” recognizes that hunger and malnu- that may end in death: trition are rooted in poverty, depri- • Poor people may eat and absorb vation and underdevelopment, and too little nutritious food, making are the result of inadequate access to them more disease-prone. the basic requirements for nutrition- • Inadequate or inappropriate food al well-being including safe and ade- leads to stunted development and/or quate food, care, health, education, premature death. and a clean environment. WHO, with • Nutrient-deficient diets provoke its health sector focus, has a major health problems; malnutrition responsibility for promoting healthy increases susceptibility to disease. nutrition for the entire world’s peo- • Disease decreases people’s ability ple, through collaborative support to to cultivate or purchase nutritious Member States, particularly in their foods. national nutrition programs, in part- This need not be so. Better nutri- “Everyone, without nership with other intergovernmen- tion is a prime entry point to end- distinction of age, sex tal and nongovernmental organi- ing the malnutrition maelstrom. Bet- or race, has the right to zations, and their related sectoral ter health means stronger immune approaches. systems which mean fewer illness- nutritionally adequate es. Healthy people feel stronger, and safe food and to Compiled by Mohammad Shahjahan can work better and may have more Sources: www.who.int/nut/nutrition2.htm earning opportunities to gradually be free from hunger www.who.int/nut/nutrition3.htm climb out of both poverty and mal- and malnutrition. “ www.who.int/nut/mandate.htm

April-May 2005 bridges 33 Readers’Readers’ ForumForum Primary Care Needs a Community Orientation by Jaime Gofin

here is a general agree- proposed and what is the expected • Promotion and facilitation of com- ment that primary care outcome? munity involvement (PC) is characterized 5. What measures are needed to con- • Intersectoral cooperation since by being the first con- tinue health surveillance of the com- health services cannot cope and deal tact between an individ- munity and to evaluate the effects with the health problems on its own. Tual and a health worker in a health what is being done? maintenance organization (HMO) The Community Oriented Primary What are the stages of COPC? or Mother and Child Clinic or other Care (COPC) approach is an illustra- 1. Definition of the target commu- health/medical service. In general, tion of community medicine and a nity and its characterization with PC is of universal accessibility and response to these 5 questions aim- regard to physical, demographic and the closest contact with members of ing at developing public health at the social features, services available and the community, even under a state of community level. It is considered to health status, as based on available conflict. Although there is awareness be a reflection of the Alma Ata rec- information; that preventive activities are indi- ommendations. Because of the com- 2. Prioritization of the identified health cated, services are heavily based on prehensive scope of the approach, problems using defined criteria, (e.g.: demand, mainly of a curative nature it is also considered as a strategy to relative importance of each problem, To achieve a community-orienta- reduce health disparities. The devel- feasibility and predictable effective- tion in primary health care it is ness of intervention, community necessary to introduce a commu- concern and interest); nity medicine approach, which is 3. A community diagnosis which much broader than merely having measures the distribution and medical services in the communi- determinants of the selected ty meaning that simply the phys- health condition; ical location of the service and 4. Implementation of a commu- providing health education in the nity health program that includes community are not enough. promotion, prevention, treatment and rehabilitation, considering Questions to Answer in photo: Osama Silwadi the social, cultural behavioral Community Medicine opment of this approach, whether as and economic components of health; The main components of commu- a re-orientation of an existing serv- 5. Surveillance of health and moni- nity medicine are an active assess- ice or as the creation of a new health toring of activities; ment of the health status and the service, requires the commitment 6. Evaluation of the impact of the subsequent provision of health care of the health practitioners to extend interventions; directed to the community as a whole their individual clinical practice to 7. A re-assessment to decide about (1). In operational terms, it requires the practice of community medicine. the continuation of the program and implementing activities that answer 5 The main components of COPC if new prioritization is needed. In this cardinal questions (2): include: way the systematic cyclic process is 1. What is the state of health of the • A defined total population (neigh- continued and sustainability may be community? borhood, place of work, members of assured. 2. What are the factors responsible an HMO) for this state of health? • A primary care clinic with multidis- Is community 3. What is being done about it by the ciplinary team with free access and medicine effective? health services and by the communi- outreach activities (to identify physi- The impact of COPC has been ty itself? cal and social determinants and local demonstrated with regard to reduc- 4. What more can be done, what is resources) tion of infant mortality and incidence

34 bridges April-May 2005 LettersLetters toto thethe EditorEditor of infectious diseases, increase in Dear Editor, the Ministry of Justice. New winds immunization coverage and improve- At the onset I would like to thank of equal rights for people with dis- ment of growth and development, you very much for all the effort you abilities blow in Israel. I encourage control of risk factors of chronic dis- put to produce bridges which is a Palestinian people with disabilities eases and changes in health behav- real excellent idea. My message does and the families to start a dialogue ior. A recent issue of the American not mean that I am against the whole - to exchange ideas and to establish Journal of Public Health, November content of the magazine. In contrast a new, big organization consisting of 2002 (vol. 92), has a series of eight I am completely with it but I do have our two communities. articles on COPC (with a total of 200 one main point. Henia Schwartz references) showing the impact of As far as I know, bridges is a pure School of Public Health, this approach in different countries public health magazine and looks at Jerusalem and health system contexts (Israel, the joint Palestinian/Israeli health [email protected] Spain, UK, US, among others) issues as a means to enhance both The COPC approach generates basic sides' peace talks. However my main questions that have to be dealt with: point is that there should be no room Dear Editor, is it feasible to be responsible for a for the conflict related pictures (the It is only by chance that I came total defined population under the picture of the suicide bomb victim) across the second issue of this maga- current organization of health serv- and my suggestion is to keep it away zine and it is a pity. I feel that every ices? Are health professionals will- from bridges but if there is no way to doctor, nurse and other public health ing to assume this function? Some- keep it aside I believe that you have worker in Israel and the Palestinian times the statement is made that to consider putting one of the thou- Authority should know about this this approach is only applicable in sands pictures that shows the suffer- publication, get it read it and partici- “developing situations”. Is this state- ing Palestinians undergo as well. I pate in its development. Although ment relevant? Experience shows really wish that bridges would be the it is very difficult it seems to me that by the adoption of the principles place of fairness and equality and be that health care is the most suitable and the adaptation of the methods the root of the factual peace bridges bridging technique between the two to each particular local situation, the between the two people will be built notions. I would like to know how COPC approach has an impact on very soon. I can get the magazine on a regular a community's health. Why is this Hamada Al Bayari basis. method of delivery of care increas- UN Office for the Coordination Sincerely, ingly used in teaching but has not of Humanitarian Affairs Prof. Isaac Meller yet had a broader parallel applica- (OCHA) - Gaza Head of the National Unit of tion in practice? These questions are Orthopedic Oncology, Tel Aviv not rhetorical. The answers should Sourasky Medical Center be assessed for their value and rel- Best wishes and a call Photo: evance in each local situation. to organizations of people Please send your comments to with disabilities. UNDP/PAPP, George Azar [email protected] Dear Editor, I would like to express my deep Jaime Gofin, former Director of COPC appreciation to bridges. I was attract- programs at the School of Public Health and ed to read word by word and I have Community Medicine at Hadassah is the the feeling that bridges together Chairman of the Task Force on Integrating with sincere cooperation of Israeli Medicine and Public Health of the Network, and Palestinian health professionals Towards Unity for Health, a WHO related really helps to construct the bridge NGO and Adjunct Associate Professor of to peace. GWU in Washington, DC. I am a scientist and I am a woman bound to a wheelchair. I am active Forthcoming issues References in a number of Israeli organizations 1) Gofin J, Planning the teaching of Community of people with disabilities. I am also will feature: Health (COPC) in an MPH Program, Public Health Reviews 2002, 30;293-301. a member of the Advisory Commit- • Women's Health 2) Kark SL, The practice of community-oriented tee to the Commissioner for Equal health care. New York: Appleton-Century-Crofts, • Quality of Care 1981. Rights of Persons with Disabilities in • Mental Health

April-May 2005 bridges 35 WHO Office for West Bank and Gaza Old Nablus Road, Sheikh Jarrah, P.O. Box 54812, Jerusalem Tel: +972-2-5400595, Fax: +972-2-5810193 © World Health Organization, 2005 To contribute please send articles to [email protected] www.bridgesmagazine.org