900,000 people in Israel are diagnosed as pre-diabetic. Every year about 6% of pre-diabetics become diabetics" * Personalized-social medicine that is implemented at the Faculty of Medicine of Bar-Ilan University in the Galilee is the key to reducing health disparities and morbidity in the periphery
The "Literature of the Galilee named after Russell Berry" project is a comprehensive project in the field of public health that focuses on diabetes and operates in the Galilee region. The project, which originated in the Faculty of Medicine of Bar-Ilan University in the Galilee, aims to reduce the incidence of diabetes and improve its treatment with an integrative multidisciplinary approach. The project leaders see before their eyes the connection between the periphery and morbidity, the diabetic patients and the people defined as pre-diabetic, the medical teams in the community and hospitals, the research teams and the local authorities.
According to Prof. Naim Shahada, one of the top endocrinologists in Israel and the chairman of the project, this is a global epidemic, which is felt even more strongly in Israel. "There are 460 million diabetics in the world, of which 600,000 are in Israel. In 2040, the number of diabetes patients is expected to reach 600 million in the world and one million in Israel. 900,000 people in Israel are diagnosed as pre-diabetic. Every year about 6% of pre-diabetics become diabetics."
The number of diabetics and people in a pre-diabetic state is higher in the north of the country, and in the periphery in general compared to the center, but paradoxically the number of doctors available to them is smaller. Diabetic patients in the Galilee are less balanced, suffer more complications and the mortality rate among them is high compared to the diabetic population in the center of the country. In addition, the diabetic patients in the periphery are spread over a large geographical area, which makes it even more difficult to receive treatment.
"These data emphasize the importance of the Galilee literature project in its specific location, says Dr. Sion Spitzer, an expert on reducing health disparities and implementing processes and the deputy chairman of the project. "The connection between the social situation and the high rate of diabetes in the Galilee is already known and known, and also from a global perspective, similar things are seen. The disparities in the extent of morbidity between the center and the periphery arise from the combination of medical characteristics and social characteristics (for example literacy, education, income), and they affect health by the very lifestyle of the person. We cannot separate the health perspective from the social understanding of where a person grows up and where he lives. Today in the world the integration between the clinical situation and the social situation is the main way to understand the origin of the gaps".
Diabetes as a case study for gaps between center and periphery
Diabetes is not the only health condition that draws the gaps between center and periphery. However, explains Dr. Spitzer, diabetes is a case study among chronic diseases because it is highly dependent on a person's lifestyle. "If we manage to find a suitable model for the treatment of diabetes and its prevention, it will be applicable to many other chronic diseases. Today, diabetes is seen as an epidemic caused mainly by lifestyles." As evidence, there are populations that do not suffer from diabetes, but when they change their lifestyles, there is a jump in morbidity. An example of this is the Ethiopian community which before its arrival in Israel had no cases of diabetes, but now many of its people are dealing with the disease following the exposure to Western culture and the changes in diet, employment, social status and social organization that have occurred as a result.
"The big challenge, which is international, in health disparities is our ability to find a way to reduce disparities in a way that will hold water and last over time," says Dr. Spitzer. "A distinction must be made between disparities, which are the objective numbers we measure (for example, between the number of patients in the periphery and the number in Israel), and between the unfairness that does not allow a person to reach his health potential due to his social status, which is a barrier. Therefore, from the concept of reducing gaps in order to reduce the gaps, we in the field of diabetes must create in the Galilee fair promoting infrastructures through personalized-social medicine."
The high morbidity rate of diabetes in the Galilee as well as the social-health disparities have been well known for many years. Why, then, only now has the venture matured? Dr. Spitzer illuminates the challenge of translating value into pragmatic action. Although the connection between morbidity and the environment is known and proven, health systems do not have the power to touch social factors such as unemployment and low education level that are outside their scope. The health systems and government offices operate in a way that makes it difficult for them to be included. "It was clear to us that we needed to create a model that brings together all the players around the table," says Dr. Spitzer. "This was the biggest challenge in establishing the library. The focus cannot be only on the patient. Maybe the patient lives in a place where there is no accessible walking path, maybe he lives in an area where the price of fruits and vegetables is high and he cannot get healthy food. Therefore, the view is also on the community and society. For this reason, the library intervenes at the level of the local authority. We think about how to balance those who already have diabetes, but look at what makes it difficult for them, for example if they don't have money for medicine. With the help of research on assimilation and reduction of health gaps, we can do a 'scale-up', replicate the model and expand it to other settlements in the Galilee."
The Galilee - a microcosm for human diversity
It is important to note that not only morbidity makes the Galilee unique - the region is a microcosm of human diversity, where diverse ethnic communities of Muslim Arabs, Christian Arabs, Maronite Christians, Druze, Bedouin, ultra-Orthodox Jewish communities, Circassians and others live. Many of these communities are culturally and ethnically homogenous and relatively closed, which constitutes a very valuable source for research in the field of genetics and medicine as well as for research in public health, whose insights are expected to make a significant contribution to diabetes research beyond the borders of the Galilee.
The residents of the Galilee will benefit from the fruits of the project already in its early stages for several reasons, the most important of which are the strategic concept of learning while moving, and the second is the desire to reduce the time gap known in the medical world between the completion of research and its implementation in the field - this is a long period of time of 17 years on average. From a strategic point of view, the project will begin to operate in a few selected settlements - Nazareth, Nof HaGalil, Shafaram, Sakhnin and Safed - and the partners in it will be the health funds, the local authorities, the Faculty of Medicine in Bar-Ilan and other factors. The partners will monitor themselves along the way, compare data and achievements between the different settlements and apply the conclusions while expanding to other parts of the Galilee.
How will the gap between research and application be narrowed? Dr. Spitzer explains that the gap will be narrowed by the fact that the research is not done at the front door of the academy, but in the real world. "From the first day we make adjustments to the model with the help of all the relevant players and the presence in the field. That way we can understand what works and what doesn't." According to her, the application gap is usually due to two factors: one is technical, for example designing a drug that is convenient and safe to use after an effective active substance has been found; The second factor is human. For example, many studies show that a person who is in a support group will enjoy better diabetes control. But these are results produced in a controlled bubble, which has no reference to the space in which man exists. One of the main elements in the worldview of the Galilee literature is the reference to the environment in which the person lives, with all its components, including the possibility that there is no support group in his area, or that participation in such a group is culturally unacceptable.
The residents of the Galilee will not only benefit from the learning while moving and the goal of reducing gaps between research and application. Its very existence will attract new doctors to the area, which it lacks so much. The project's leadership team - which, along with Dr. Spitzer and Prof. Shahada, also includes Prof. Karl Skortsky, Dean of the Faculty of Medicine in Galilee, and Prof. Haim Futterman, Assistant Dean for Research and Director of the Research Institute at the Galilee Medical Center - are residents of the area (more on this in the Faculty of Medicine Bar-Ilan is already proud of the high rate of graduates who choose to live and work in the Galilee after graduation). Not only medical professionals, but also researchers are expected to be located in research institutions in the Galilee following the project, and as Prof. Haim Futterman says, the very presence of researchers contributes to improving the quality of the work of doctors.
A secondary benefit of the project that will benefit all residents of the region, even those who are not on the "diabetes spectrum", is the cross-system collaborations that the project produces. Actually it wouldn't be the first time. The corona crisis proved to health, medical and administrative personnel that such cooperation is possible and that it can be brought to an applied level in a short time. Home visits, testing stations, vaccination centers, a hotline and the mobilization of volunteers, including many medical students, operated effectively at the height of the crisis and are a source of inspiration for the Galilee Literature project as well. Collaborations involving various authorities and factors are at the core of the concept of the Galilee literature, and today we know beyond any doubt that they are possible, starting at the level of information sharing, for the way of creating infrastructure for a healthy lifestyle and education, and ending with the care of the individual.
