WTG_Israel

ADVANCE COMMENTS “Ralph Moss’s report on CAM and cancer in Israel is extensive and enlightening. I thank him for his significant contribution and support of our activities in the Holy Land.” —Eran Ben-Arye, MD, Haifa, Israel “Ralph Moss’s report provides in-depth research on a subject never investigated before. In the course of his visit he reached most of the serious CAM-cancer practitioners in this country. He has shown that CAM can be practiced in a serious way and add greatly to the treatment of cancer patients. ” —Joseph Brenner, MD, Tel Aviv, Israel “In this report, the story of CAM in Israel is told in a powerful, comprehensive and interesting way by a keen outside observer. I am impressed by Moss’s systematic and informative coverage, including relevant background information, a vast number of facts, and a balanced description of a large variety of CAM activities. Moss has done a great job.” —Jacob Shoham, MD, PhD, Ramat-Gan, Israel “Ralph Moss provides an in-depth report on CAM and cancer in Israel. His detailed encounter with the various experts is an important and much needed guide for both health providers and patients who are interested in this thriving field.” —Isaac Eliaz, MD, Santa Rosa, Calif.

Moss / CAM and Cancer in Israel

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CAM AND CANCER IN ISRAEL

© 2010 by Ralph W. Moss, PhD (Including photos) All rights reserved

Figure 1 Israeli Flag Atop Masada


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Table of Contents Historical Context ........................................................................................5 Science in Israel ...........................................................................................7 Further Considerations On CAM In Israel ....................................................8 Historical Roots of CAM in Israel ................................................................9 Popularity of CAM.....................................................................................10 CAM and Family Medicine ........................................................................11 CAM and Nurse Midwives .........................................................................12 CAM And Medical Coverage .....................................................................12 CAM in the Military...................................................................................15 Relative Strength of CAM in Israel.............................................................15 CAM and HMO Health Services ................................................................16 Eran Ben-Arye (Haifa) ...............................................................................16 Gil Bar-Sela (Haifa) ...................................................................................18 Jacob Shoham And KaMaH .......................................................................21 Hadassah University Hospital, Ein Kerem (Jerusalem) ...............................25 Medical Marijuana .....................................................................................29 Shimon Slavin and the CTCI ......................................................................29 Joseph Brenner, Tel Aviv ...........................................................................36 Conclusions................................................................................................39 Appendix A: CAM Treatment Resources ...................................................42 Appendix B: Co-sponsors of the 2010 Jerusalem International Conference on Integrative Medicine ........................................................49 Appendix C: Peer-reviewed Articles on CAM in Israel...............................50 References..................................................................................................61


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Table of Figures Figure 1 Israeli Flag Atop Masada....................................................................... 2 Figure 2 Hyssop................................................................................................ 10 Figure 3 Moshe Frenkel .................................................................................... 13 Figure 4 Eran Ben-Arye with Middle Eastern Herbs.......................................... 17 Figure 5 Gil Bar-Sela ........................................................................................ 19 Figure 6 Jacob Shoham ..................................................................................... 22 Figure 7 Martine Toledano, Reuven Or, Ruth Radiano,

and Gisele Obadia-Aferiat ......................................................................... 25 Figure 8 Reflexology at Hadassah University Hospital...................................... 27 Figure 9 Shimon Slavin..................................................................................... 31 Figure 10 Joseph Brenner.................................................................................. 37 Acknowledgements: The author wishes to thank Reliable Cancer Therapies (RCT) (www.reliablecancertherapies.com) for their financial support of this site visit to Israeli cancer clinics. Moshe Frenkel, MD, of Zichron Ya’akov, originally suggested this project to me when he was still the head of CAM at the University of Texas M.D. Anderson Cancer Center, Houston. He served as my host during my Israeli journey and introduced me to most of the physicians I interviewed. I also wish to thank the following for reading and commenting on advance versions of this report: Tibor Bakacs, MD, PhD, DSc; Gil Bar-Sela, MD; Eran Ben-Arye, MD; Isaac Eliaz, MD; Martine Toledano, MD; Jacob Shoham, MD and Shimon Slavin, MD. Their help was invaluable. All opinions, including any remaining errors and omissions, are the author’s sole responsibility.


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This is a report on the use of complementary and alternative medicine (CAM) in the state of Israel, particularly for the treatment for cancer. I will focus on four questions:

1. What is being done for cancer in Israel, in an alternative or complementary way, that is not be done elsewhere? 2. What are some of the most promising findings or discoveries? 3. How does the Israeli medical establishment’s attitude towards CAM differ from that in other countries, particularly in the US? 4. If the situation in Israel is unique, why is that so?

To investigate these questions I visited Israel in July 2010. A non-profit organization that provides information on evidence-based cancer therapies supported this fact-finding mission. I visited a total of 15 hospitals, clinics and laboratories in Tel Aviv, Haifa and Jerusalem, as well in some smaller localities. The types of facilities that I visited included CAM research and practices in:

1. Accredited universities 2. Major hospitals 3. Independent private practices 4. HMO networks 5. Research facilities

I came away deeply impressed by the degree of CAM’s integration into the standard medical system in Israel. As the Israeli epidemiologist Liat Lerner-Geva, MD, PhD, has stated: “Assimilation of complementary medicine into the health system of Israel is one of the highest in the world.”1

Historical Context Israel is a land steeped in history; it is therefore logical to put the use of CAM (specifically for cancer) into a broad historical context. The territory that is now the state of Israel was for a millennium or more the ancestral homeland of the Jewish people. In 70 CE,* after decades of political and military conflict, the Romans destroyed the Second Temple in Jerusalem. Eventually the Emperor Hadrian barred Jews from Jerusalem and most of what was then the Roman colony of Judea. Thus began 2,000 years of forced exile of

* CE, which stands for Common Era, is a designation for the world’s most common year numbering system. It corresponds to AD (Anno Domini), just as “BCE” equates with BC (Before Christ). According to two scholars, the terms CE and BCE “are meant, in deference to non-Christians, to soften the explicit theological claims made by the older Latin terminology, while at the same time providing continuity with earlier generations of mostly western Christian historical research” (Irvin, DT and Sunquist, SW. History of the World Christian Movement, Maryknoll, NY: Orbis, 2001, p. xi.).


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the Jews in the so-called Diaspora.† During this time the great majority of Jews settled in diverse parts of the world. In Europe, they settled first in Spain and in Germany and later in the Hapsburg Empire and the Russian-dominated parts of Eastern Europe. A long period of anti-Semitic discrimination, persecution and pogroms culminated in the Nazi-led Holocaust, the murder of six million Jews in concentration camps as well as by other means. In 1948 came the creation of the state of Israel, and the well-known tumultuous political developments and conflicts that have followed. Israel is the only country in the world with a majority Jewish population: 5,726,000 out of a total population of 7,587,000 (or 75.5 percent).2 Despite many wars and conflicts, and the burden of a huge military budget, the country has thrived. Israel is now the only country in the Middle East to approximate a Western degree of affluence. According to the World Bank, its gross national income is now over USD $200 billion. (It was less than $27 billion in 1980) and the per capita income is $26,175 (2009), which is greater than Slovenia, Portugal or South Korea.3 During their long period of exile, the Jewish people were generally scorned, persecuted and barred from most spheres of gainful employment. For various reasons, one field in which Jews were generally allowed to earn a living was in medicine. Even in the Middle Ages, Jewish physicians were highly regarded by those who were otherwise vehemently anti-Semitic. For instance, every ruler of Castille (Spain) had Jewish physicians, including Ferdinand and Isabella4 (who nonetheless in 1492 expelled all Jews from Spain). Many members of the nobility insisted on being treated by Jewish physician even when Christian doctors were available. In modern times, despite frequently being discriminated against in admission to medical school, Jews managed to maintain their tradition for excellence in medicine (as well as many other fields of scholarship). One way of estimating the extent of their accomplishments is by looking at the winners of the Nobel Prize. This provides a metric of different peoples’ achievements vis-à-vis the world population in general. Thus, between 1901 and 2009, there were 829 Nobel prizes awarded and Jews (i.e., individuals defined by having at least one Jewish parent) received 180 of these, or 21.7 percent of the total. In physiology and medicine, Jews won 27 percent of the total. Jewish achievement in this regard is all the more remarkable when one considers that globally the Jewish community is just 13.2 million, or just two-tenths of one percent (0.00218) of the world population. This general trend continues, as two of the 2010 Nobel laureates (Peter A. Diamond and André Geim) are also Jewish. There is nothing unique in this regard about the Nobel Prizes. Jews have similarly won 32 percent of Japan’s Kyoto Prizes for advanced technology, 40 percent of the Wolf Prizes for medicine, 33

† Jews had already settled in various parts of the ancient world, such as at Rome, Alexandria and Babylon, but after this period were forced to do so and were denied a homeland to which they could return.


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percent of the Lasker Awards, and 38 percent of the U.S. National Medals for Science.5 Israel is a young country, which only began building most of its world-class research establishments since gaining independence in 1948. So far nine Israelis have won Nobel Prizes. In 2009, Ada Yonath, an Israeli-born and educated scientist, won the prize for chemistry, the first Israeli woman to do so.

Science in Israel Although a young country, Israel’s accomplishments in complementary and alternative medicine (CAM) are formidable. CAM requires not just excellent in medical practice but also an innovative attitude towards radically different treatment ideas. Israel is such an innovative place that it has been called “the start-up nation,” because of the myriad new companies spawned by its universities and medical schools.6 In complementary medicine, Israelis are also known for inventing, or testing, numerous innovative medical products and procedures. We might mention several of these:

1. The homeopathic preparation Traumeel, which was first subjected to a randomized controlled trial (RCT) by Menachem Oberbaum, MD, et al. of Shaare Zedek Medical Center, Jerusalem. This positive study was published in the scientific journal of the American Cancer Society, Cancer.7

2. The 3rd generation photosensitizer Tookad (which means “the warmth

of light” in Hebrew), which was developed at the Weizmann Institute by Profs. Avram Scherz and Yoram Salomon.8

3. Punisyn, a mixture of aqueous and lipid pomegranate extracts, which

has demonstrated activity against both breast9 and prostate10 cancer, developed by the “medical punicologist” Ephraim Lansky, MD (www.rimonest.com)

4. The cytotoxic effects of homeopathic remedies on breast cancer cells

was pioneered by the Israeli physician Moshe Frenkel, MD, formerly of M.D. Anderson Cancer Center, Houston, and his colleagues.11

5. The discovery at Hadassah University Hospital of the benzoquinone

HU-331, which is ultimately derived from the marijuana plant, and is a less toxic alternative to the standard cancer drug doxorubicin.12

6. Novocure, a novel apparatus that deliver alternating electrical field, is

being employed with promising results in the treatment of brain tumors. It was developed by Prof. Yoram Palti and his colleagues at the Technion, the Israel Institute of Technology in Haifa.13


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7. Scientists at the Integrated Cancer Prevention Center of the Tel Aviv Sourasky Medical Center have invented a dietary supplement called Coltect for the prevention of colorectal cancer. Coltect contains curcumin, green tea and selenomethionine. Experimentally, it causes a 40-70 percent reduction in precancerous lesions in the colon.14 It is also being tested for ulcerative colitis.15

At the same time, a high level of innovation and scholarship marks Israeli participation in CAM. Israel scientists are not only inventive but are quick to grasp the importance of new developments and find ways to put them into practice.

Further Considerations On CAM In Israel Israel is the size of the state of New Jersey and one can drive from Kiryat Shemonah in the north to Eilat in the south in less than six hours. This compactness is combined with an astonishing degree of diversity in the population. This confounds any preconceived idea of “Jewishness.” Virtually all the nations and languages of the world are represented, and sometimes all seem to be speaking at once! While I was in Israel I met not just Ashkenazim and Sephardim (some of whose ancestors had been there since the expulsion of the Jews from medieval Spain), but also Jews from North Africa, sub-Saharan Africa, including Ethiopia, France, Great Britain, Australia, Canada, Iran, China, and of course Russia and many other parts of the former Soviet Union. I also met Israeli Arabs and Bedouins, Christians, and Druse, as well as “guest workers” from Thailand and the Philippines. Israel could be called a microcosm of humanity. Superficially at least, medicine in Israel is practiced much as in the US. Israel’s four medical schools‡ and various postgraduate programs mainly utilize American textbooks and journals. A high percentage of Israeli medical school graduates participate in fellowship programs in the US and many Americans come to Israel for education or training. According to my host, Moshe Frenkel, MD, American influence has been formalized in various ways. Three of the four Israeli medical schools have collaborative agreements with US medical schools. These attract US students to obtain their MD degrees in Israel and then return to the US for

‡ These are (1) Ben Gurion University of the Negev (founded 1974), (2) Joyce & Irving Goldman Medical School at the Technion in Haifa (found 1969), (3) Hebrew University of Jerusalem, Hadassah Medical School in Jerusalem (founded 1949) and (4) Tel Aviv University, Sackler Faculty of Medicine (founded 1963). They all follow the six-year European curriculum model, except for Tel Aviv, which in 2009 in addition to the 6 year program introduced the American style four-year curriculum. A new fifth medical school is scheduled to open in 2011 in Zfat. In addition, there is on paper at least a Palestinian Faculty of Medicine in Nablus in cooperation with An-Najah University, Nablus; Al-Quds University, Jerusalem, and Al-Azhar University, Gaza.


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postgraduate training and practice. Similarly, almost every Israeli doctor I met trained in the US…usually at top institutions such as Memorial Sloan-Kettering Cancer Center, the University of Texas M.D. Anderson Cancer Center, Roswell Park Memorial Institute, Brown University, the University of Maryland, etc. I also met Israeli doctors who were American or Canadian in origin but had immigrated to Israel, often for religious or nationalistic reasons.

Historical Roots of CAM in Israel There are interesting points of similarity between modern-day CAM treatments and ancient medical and religious practices of the Jewish people. For instance, the Torah (i.e., the first five books of the Hebrew Bible) enjoins Jewish men to put on ‘tefillin’ each day. Wearing tefillin is a prayer ritual during which two small leather boxes, attached to leather straps, are placed on the biceps of the weaker arm and on a particular location on the head. The biceps strap is wound on the arm in a carefully prescribed fashion while the head strap is tied in a knot, which is then placed at the base of the skull. The overall purpose of tefillin is to raise spiritual awareness. It is astonishing to learn that the tefillin and wraps actually “form a potent acupuncture point formula focused on the Governing vessel (Du Mai) and aimed at elevating the spirit and clearing the mind.”16 In a fascinating article on this topic, the New York acupuncturist Steven Schram, PhD, states:

“If someone handed an acupuncturist the above point formula and asked what was being treated, there is little doubt that mental…issues would be a strong part of the pattern. What is surprising is that such a point formula would be found in a non-Chinese procedure that has been continuously practiced for many thousands of years. It may be that the originators of the tefillin ritual had some inkling of its special effects, even though they may have lacked the depth and specific knowledge we have today.”17

There are also points of similarity between ancient food and herbal prescriptions and rational hygienic practices. The Biblical injunctions against consuming scavenger animals (Leviticus 11:31) or utilizing bowls or vessels in which animals have died (Leviticus 11:31-32) have long been interpreted as a way of preventing animal-borne diseases. (According to WebMD, there are at least 39 serious diseases people catch directly from animals.18) The Bible similarly enjoins inspection of the lungs of slaughtered animals, a practice that would help prevent the spread of tuberculosis. The ban on consuming unconscious animals would further prevent the consumption of sick animals. And the prohibition against consuming pigs (Leviticus 11:3-8) –“of their flesh ye shall not eat” (KJV) --would have similarly prevented the transmission of the roundworm, Trichinella spiralis, and other parasites. Even to this day, trichinosis (also known as trichinellosis) is exceedingly rare in Israel19 and is mostly seen among Thai immigrant workers.20


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The ancient Hebrews were also familiar with the cultivation of herbs for various purposes, including healing. In 1 Kings 21:2 Ahab proposed planting a “garden of herbs” (KJV). In particular, the herb hyssop (Hyssopus spp.) is often referred to as an herb of purification, because it is a purgative cathartic herb. (“Purge me with hyssop and I shall be clean,” Psalms 51:7) It is said to expel phlegm from the respiratory tract.

Figure 2 Hyssop Frankincense (Boswellia spp.), ketoret in Hebrew, was not strictly speaking a medicinal herb, but was an ingredient in the incense offered up twice daily in the ancient Temple. According to the Gospel of Matthew, one of the three Magi who visited the infant Jesus in the manger brought a gift of frankincense. Frankincense is now being explored as a treatment for colon21, bladder, prostate22 and brain cancer,23 as well as for cerebral metastases.24 So, in a sense, the use of “CAM” in Israel has ancient roots.

Popularity of CAM In Israel, as in the US and Europe, CAM has become popular with the general patient population. Estimates of CAM use has been measured at 32.4 percent among cancer patients in Haifa,25 36 percent of patients seen in primary care clinics26 and 50 percent among patients with chronic diseases.27 CAM use appears to be increasing rapidly. In fact, Prof. Amir Shmueli of Hebrew University Medical School found that CAM use in Israel doubled between 1993 and 2007.28 In a study conducted in 2003 at Meyer Children’s Hospital in Haifa, it was found that CAM was used by 61 percent of patients, with an average of three different treatments per patient. Usage was higher among those who had previously used CAM (85 percent), had a higher educational status (79 percent), and came from secular families (71 percent). Patients with a higher socioeconomic status tended to use chemical-biological remedies as well as homeopathy, where those with a


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lower status mainly used traditional Arab treatments. Significantly, a beneficial effect was reported by 69 percent of CAM users, which is a high rate of satisfaction. Most pediatric cancer patients, regardless of ethnic origin, used CAM without informing their physicians.29 According to Frenkel, Israelis in general are looking for additional options, especially when conventional practices do not produce a clear-cut solution. Nowadays, he adds, there is greater openness among family physicians, while there is a growing number who actually and actively refer patients to CAM. There is much less resistance among the other physicians, while the availability and easy access of the therapists is another factor favoring use of CAM.30 This interest in CAM is not limited to the Jewish portion of the population. In 2005-2006, Eran Ben-Arye and colleagues conducted a survey of CAM usage in northern Israel. The respondents were 58 percent Arab, 41.6 percent Jewish. Women were more likely to use CAM. He reported: “Arab women reported less CAM use than Jewish women but were more interested in experiencing CAM, had a higher degree of confidence in CAM efficacy and safety, and more frequently supported the integration of CAM practitioners in primary care clinics.”31

CAM and Family Medicine Family medicine doctors often practice CAM in Israel. In fact, Israel is considered to be a world leader in this sort of primary care. This contrasts sharply with the situation in the United States. From 1979 to 2007, family medicine declined by 40 percent as a residency choice in the US. By contrast, in Israel family medicine continues to be seen as a field that offers job flexibility, good work hours, and clear societal benefit.”32 The number of medical students entering family medicine in Israel remained stable from 1980 to 1995 and, according to my informants, remains a highly desirable career path. One reason for this is that the gap between the salaries of family physicians and medical specialists is not nearly as great in Israel as it is in the US.33 The department of family medicine in Haifa is a leading academic center in Israel for integrative family practice and CAM. The department is affiliated with the Haifa and Western Galilee district of Clalit Health center and the Rappaport Faculty of Medicine in the Technion, Haifa. Since 1998, Drs. Eran Ben-Arye, Moshe Frenkel, Amnon Oren, and other family physicians have taught elective courses in CAM within the department residency program as well as CME courses. In 2002, this group formed the Complementary and Traditional Medicine Unit within the Department of Family Medicine. The courses were designed to expose family physicians to common CAM methods, to provide these physicians with an additional perspective that would allow them to better understand the doctor-patient relationship, and to provide sufficient information to enable physicians to provide their patients with informed, evidence-based, safe and balanced advice. The concentration of medical ‘talent’ in Haifa is truly impressive, and could form the basis for fruitful collaborative projects with researchers in Israel as well as other countries.


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CAM and Nurse Midwives Another focus of CAM practice is the nurse-midwife movement. A study at Shaare Zedek medical center found that a majority of Israel’s nurse-midwives use and recommend CAM to their patients. (238 nurse-midwives were identified, of whom 173 responded to the survey.) Most of them (87.3 percent) reported using some form of CAM (67.1 percent used or recommended massage, 48.6 percent herbal medicine, 42.2 percent meditation, etc.). As a group, they believe that CAM can be used to complement conventional medical therapies. The authors concluded: “Health care providers could benefit from education with regard to the efficacy and safety of CAM modalities during pregnancy and childbirth.”34

CAM And Medical Coverage Israel is one of the few countries to provide a wide array of CAM choice as part of its universal health coverage. This development is the official policy of both the public and private sectors. According to Frenkel, “The extent of CAM services provided to the general public is quite extensive, if not the most extensive CAM public system in the western world.”35 (Drs. Ben-Arye and Shoham believe that the public CAM system is working in parallel tracts but is not yet actually integrated into the conventional system.) The US and Israel share another demographic characteristic, says Frenkel, who, before returning to Israel, was Medical Director of the Integrative Medicine Program at the University of Texas M.D. Anderson Cancer Center in Houston, TX: both countries contain a large number of immigrants from diverse countries and cultures around the world. This multi-ethnicity, he claims, is one of the reasons that CAM is so popular in both countries.


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Figure 3 Moshe Frenkel Another important consideration is that, historically, health care in Israel is based on the principle of ‘socialized’ medicine. I repeatedly found, among physicians at least, a suspicion of medical treatments that benefited the doctors who provided them. (Sometimes this hostility was mingled with concerns over quality or other factors.) According to Frenkel, however, there are an increasing number of health services that are provided on a fee-for-service basis (such as that of Joseph Brenner, MD, or Shimon Slavin, MD, below). The cost of some of these may be covered by additional health insurance policies. But, in Israel, health care services on the whole are provided by four major health maintenance organizations (HMOs) that provide for the health care needs of the general population under a National Health Insurance Law passed in January 1995. This law assures that every citizen receive the basic and necessary health care. This system provides extensive medical coverage through a large network comprising over 20 hospitals, as well as many clinics and mother-and-child care centers. The quality of this medical care can be gauged by the present life expectancy at birth of 82.8 years for women and 78.5 for men, or a cumulative total of 80.7. This is the eighth highest in the world; the US, by comparison, is 38th!36 The infant mortality rate of 4.7 per 1000 live births is lower than in the US, UK, Belgium, etc.37


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In addition, the use of CAM is expanding.§ Due to public demand and as part of the competition to attract patients, says Frenkel, “all the HMOs made a strategic decision in the mid-1990s to sponsor to some extent CAM outpatient clinics.” These services are partially covered by optional supplementary insurance policies as well as self-pay. By the year 2000, 45% of the population had purchased the supplementary insurance, which covers CAM and some additional services not covered by the National Health Insurance Law. As a result, somewhere between 42 and 60 percent of general practitioners have reported referring patients to non-conventional practitioners.38 In 1998, it was estimated that there about 10,000 students in Israel who were participating in a variety of CAM training programs with about 45,000 graduates from a variety of CAM schools. This includes immigrants from other countries, particularly the former Soviet Union. There are a few hundred graduates per year from all schools of alternative and/or complementary practices. Recently the Gertner Institute for Epidemiology and Health Policy Research in Israel has begun a systematic national research network in the field of complementary medicine in Israel, perhaps the first such network in the world.39 According to various estimates there are between 50 and 100 schools in Israel providing training in the various branches of CAM, with courses ranging from a few months to 4 years duration. There is an extraordinary level of involvement with CAM in Israel, probably equal to or greater than any other country in the world. The actual number of people making their living from CAM is of course much smaller, as a country of 7.5 million can hardly support tens of thousands of alternative practitioners. However, according to Frenkel, there are about 7,000 non-physicians actively practicing CAM in Israel at any one time, in addition to 700 physicians who practice CAM and conventional practice. Accordingly, there is nearly one practitioner actively practices per 1,000 population. These practitioners generally operate in private clinics on a fee-for-service basis. They may also operate in CAM outpatient clinics sponsored by the HMOs as well as at some public hospitals. According to new data that was presented in the Jerusalem International Conference on Complementary Medicine, 19-22 October 2010,40 it is estimate that there are 3 million visits to CAM practitioners in 2009, for a 25 percent increase over the previous year.41 As mentioned, all of the four HMOs as well as some of the public hospitals have expanded their services and number of CAM clinics. Consequently, in the past few years it has been estimated that there are close to 100 regional CAM outpatient clinics covering the whole state of Israel with an average of about one CAM clinic to every 60,000 people. § This situation is unlike in Germany, where government support has been shrinking for the past decade, and some CAM-oriented hospitals, such as the Leonardis Klinik in Bad Heilbrunn, have been forced to close their doors.


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CAM in the Military Public support for CAM is not limited to the civilian sector but is also characteristic of the Israeli Ministry of Defense, which sends military veterans to a large CAM clinic that is affiliated with the Sheba Medical Center in Tel Hashomer.42 The broad public’s interest in CAM has also affected academia. The interest in CAM among health care providers is also quite high. As a result, there are a relatively large number of publications on this topic in the medical literature. Frenkel reports that there were 100 abstracts of scientific articles in PubMed written by Israeli authors between 1994-2004. This compared to 700 for the US, 200 for the UK, 120 for Canada and 85 for Germany.

Relative Strength of CAM in Israel If we search using country names plus four representative search terms, acupuncture, herbalism, homeopathy and reflexology, we can get a more exact picture of the relative strengths of CAM research:

Table 1 Research on Select CAM Topics in Five Countries

Israel US UK Canada Germany Acupuncture 88 1,061 283 192 365 Herbalism 213 939 166 215 183 Homeopathy 42 225 313 39 317 Reflexology 65 691 186 183 213 Source: PubMed, September 2010 If we consider that the US population is 42 times greater than Israel’s we get some idea of the extent of research on this topic. When it comes to homeopathy, for instance, the US would have to produce 1,764 papers (not 225) in order to match Israel’s output. Put another way, Israel is outperforming the US in this topic by a factor of 8:1. These sort of facts and numbers, says Frenkel, “make Israel an interesting place to study CAM integration in the conventional setting.” He himself recently returned from a six-year stint at the University of Texas to practice CAM in Israel. “Since the conventional medical system is closely related to the US in terms of medical education and clinical care,” he adds, “ it would be quite appealing to study the lessons learned in these practices with their extensive experience compared to the limited integration that is currently happening in the US health care system.”

I shall now give a brief description of the facilities I visited on this trip.


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CAM and HMO Health Services One cannot understand CAM use in Israel without understanding something about the basic structure of providing health care in that country. In January 1995, a national health insurance law went into effect. This created a compulsory health care system that was based around four non-governmental, non-profit service providers (i.e., HMOs). Every citizen in Israel pays in proportion to his or her income, and each is thereby entitled to the same quality and range of medical services. All of these organizations are deeply involved with providing CAM. Three of them (Clalit, Maccabi-Tivi and Meuhedet) cosponsored the 2010 Jerusalem International Conference on Integrative Medicine (see Appendix C), while the fourth, the Leumit Health Fund, promises potential clients “extensive complementary medicine services with an unlimited number of visits at low subsi[di]zed rates.”43 The largest of the HMOs is Clalit Health Service (CHS).44 According to webometrics.info, Clalit is the 172nd best hospital system in the world. Clalit dates from 1911, when 150 immigrants pooled their resources to form a mutual aid health society. With the founding of the state of Israel in 1948 Clalit greatly expanded, especially in new immigrant neighborhoods. Clalit now covers health services for more than half of the Israeli population (3.8 million people) from every ethnic and demographic group. Clalit has 14 hospitals and 1,200 primary and specialized clinics. It is the only health fund with a countrywide network of state-of-the-art pharmacies, dental clinics, laboratories, diagnostic imaging and specialist centers. It also provides the largest CAM public service in Israel. Clalit has a particularly strong involvement with CAM. It operates 40 CAM clinics around the whole country, with 400 CAM practitioners providing over 1,000,000 treatments per year. Maccabi Health Services, the second largest HMO, has a similar system, which provides an additional 700,000 treatments per year.

Eran Ben-Arye (Haifa) A Haifa researcher of note with whom I met was Eran Ben-Arye, MD. Ben-Arye is an expert in complementary therapies and on the general topic of physician-patient relations and of the attitude of health personnel towards CAM. Since 2001, he has been the author of 40 PubMed-listed articles on complementary medicine (with a total of 47 manuscripts accepted or published in peer-reviewed journals). Many of these are coauthored with Moshe Frenkel (who lives in a nearby town and has close links to Haifa) and Elad Schiff, MD.


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Figure 4 Eran Ben-Arye with Middle Eastern Herbs Ben-Arye led the first course in Israel in integrative medicine for oncologists in 2002. He has dual training in complementary medicine and family medicine. He has also had an exceptional education in CAM. He did a fellowship with Brian Berman, MD, at the University of Maryland’s pioneering CAM department. Ben-Arye taught the course on CAM for fourth year medical students. He has studied homeopathy and Ayurvedic medicine. He did studies on herbal medicine at Hadassah University Hospital in Jerusalem. He studied the so-called French school of homeopathy, using low dilutions. He finds homeopathy to be a very practical type of treatment to use with his patients. He also studied Anthroposophical medicine in Arlesheim. In his clinic in Haifa, Ben-Arye uses an interesting combination of herbal medicine, Chinese medicine (including acupuncture), homeopathy, folk and traditional remedies, dietary/nutritional therapy (including nutritional supplements), chiropractic, movement/manual healing therapies (including massage, reflexology, yoga, and Alexander and Feldenkrais techniques), mind-body techniques (including meditation, guided imagery, and relaxation), energy and healing therapies, and other naturopathic therapies (ibid.). In 2002, Ben-Arye was first author of one of the few randomized controlled trials on the use of wheat grass juice, for distal ulcerative colitis. Twenty-one patients


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completed this study, and full information was available on 19 of them. Treatment with wheat grass juice was associated with significant reductions in overall disease activity as well as severity of rectal bleeding. There were no serious side effects associated with this treatment. The healing effect was ascribed to its antioxidant potential.45 Since 2007, Ben-Arye has been the chairperson of the Israel Society for Complementary Medicine (ISCM) of the Israel Medical Association. The ISCM has more than 150 members (2/3 are physicians and the other researchers, health care providers active in integrative practices). Ben-Arye and his colleagues in the ISCM board lead international collaborations with leading academic centers in the US (called the Consortium), as well as in Europe and the Middle East. In 2008, Ben-Arye founded the Integrative Oncology Program (IOP) within the Clalit Oncology Service (COS) of the Haifa and Western-Galilee district of Clalit Health Organization, the largest Health Maintenance Organization (HMO) in Israel. The IOP offer a research-based free of charge service to patients during chemotherapy and in advanced disease state and is based on a multi-disciplinary team that include Ben-Arye with a multi-disciplinary team of social worker, occupational therapists, physiotherapists, nutritional specialist, and spiritual support therapist. The COS envisions this service as an integral part of the mission aiming to promote patients’ well being during chemotherapy and in advanced disease. Structured referral from the oncologist, nurse or social worker is mandatory. The IOP activities are based on a registry protocol research approved by Helsinki committee (a.k.a., the institutional review board). Ben-Arye sees complementary medicine as a way to improve medicine as a whole, to change things at their roots. All the CAM treatments done in his program is free-of-charge. This is especially important for reassuring people in Israel, who (because of the long history of ‘socialized’ medicine) tend to be suspicious of fee-for-service medicine. This is labor-intensive work. There is a one-hour intake process to evaluate their needs. Patients are then enrolled in a clinical trial. Most patients come to 10 to 20 CAM sessions. The treatment is always tailored to the individual patient.

Gil Bar-Sela (Haifa) I visited Gil Bar-Sela, MD, an integrative oncologist at the Rambam Health Care Campus in Haifa. Bar-Sela is a graduate of the Ben Gurion University Faculty of Medicine in Beer Sheva, who obtained his oncology training at Rambam Medical Center in Haifa. In addition, he has trained in complementary medicine at two outstanding European centers: the world-famous Anthroposophical center in Dornach, Switzerland and at the Witte Herdeke University, the only accredited private university in Germany. Bar-Sela is also associated with the Harduf kibbutz, which is located in the Lower Galilee, not far from Haifa. This kibbutz, which pioneered organic food in Israel,


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was established in 1982 by followers of Rudolf Steiner. The name Harduf means “oleander” (coincidentally, oleander is used in some countries as an experimental cancer medicine). The Kibbutz members live according to Steiner’s anthroposophy philosophy. Harduf has several well-known health centers: Beit Elisha, for the rehabilitation of adults with special needs; Tuvia, for young people who have been removed from their homes and need a foster family; and Hiram, which helps young people who are suffering from emotional problems.46

Figure 5 Gil Bar-Sela During 2006 Bar-Sela worked in research at the Radiation Oncology Branch of the National Cancer Institute - NCI, Bethesda, Maryland. He is currently a senior physician in the oncology department and leads the supportive care center in the division. Gil’s main research and clinical interests are the basic research of epigenomics and the clinical field of integrative medicine in oncology treatment.47 As part of his work, Bar-Sela provides what he calls supportive oncology services to his patients. He has a nurse who covers the booking of patients in the outpatient department. As a regular oncologist the meeting time for each patient is very brief. But the supportive clinic allowed complementary medicine


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consultation with more time, between 40 minutes and 1 hour for each patient. He always sees each patient with a nurse. If he is seeing someone who is not his oncology patient he tries not to contradict the recommendations of the other oncologist. The first thing to determine is what the symptoms are. He also wants to know if the patient is using any non-conventional treatments. He usually starts with Anthroposophical medicine. They are using Iscador (mistletoe) in the hospital with IRB (Helsinki) permission. In his private clinic he has seen some tumor regression and decline in patients’ tumor markers using mistletoe without any conventional medicine. The Rambam Health Care Campus (HCC) in Bat Galim, Haifa, was founded in 1938 and is the largest medical center in northern Israel. Rambam serves as a referral medical center, which treats 75,000 in patients each year. An additional 500,000 are treated as outpatients. The Technion’s medical school is located next to the hospital. At Rambam HCC, all the CAM treatments done in the supportive oncology center are free of charge as part of the oncology division’s services. These include art and music therapy, reiki, shiatsu, reflexology, oil anointing, guided imagination, healing, the nutrition clinic and spiritual care. Bar-Sela comments that in Israel CAM is closely integrated into the various cancer centers. This allows patients to get both conventional and complementary safely, a major consideration. The situation in Israel, he says, is unique because there is more freedom for the doctors and less regulations than in the US; nonetheless, the various unconventional treatments are given at the big centers and not in small clinics (as often happens in the US). A great deal of research is done in Israel. “Personally, the research I am doing now with mistletoe in non-small cell lung cancer (NSCLC) failed to recruit a sufficient number of patients in Germany because of the requirement that it be randomized. In addition, the ongoing studies here using wheat grass juices in conjunction with chemotherapy, curcumin (a turmeric extract) with the standard drug gemcitabine, mistletoe extracts in ascites, and so forth, are all unique.” Bar-Sela consults for patients from abroad, mainly from East Europe, the US and South Africa. He mainly tries to help them via email and by giving them directions for medications and referrals to physicians working in their respective countries. In the next five years, Bar-Sela said, there will be a floor for CAM at Rambam in the new oncology building. The problem is that the hospital administration must first building an emergency 500-bed underground hospital under the proposed new hospital building. I was told that this was a result of a rocket attack on downtown Haifa in 2006. Although Haifa seemed peaceful enough, the prospect of rockets or worse coming from the northern border is ever-present.


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Jacob Shoham And KaMaH On a very hot day in July I met Jacob Shoham, MD, PhD, at his office at Bar Ilan University in Ramat Gan, to the east of Tel Aviv proper. Bar Ilan is Israel’s largest and fastest growing university. The University is unusual in many respects, one of which is that it has an overtly religious orientation. At its Web site it states: The University regards the sacred principles of Judaism as the manifestation of the Jewish people’s uniqueness….” At the same time, it proclaims its promotion of “tolerance and coexistence between religious and secular, and Arab and Jewish students.” This is not an idle boast. In keeping with these principles, this university is simultaneously a magnet for both the orthodox Jewish community and the Israeli Arab population. Indeed, I was surprised to see a considerable number of Arab students, male and female, strolling on campus.** Shoham has been active in the cancer field for 40 years. He serves as the international editor of the peer-reviewed journal, Integrative Cancer Therapies. Shoham reminded me that we met in 2000 in a very unlikely setting: a clinic in Tijuana, that specializes in administering and teaching the controversial Gerson dietary approach to cancer. At the time, Shoham was studiously taking notes and I hardly registered his presence. In retrospect, I think it is remarkable that such a distinguished physician/scientist would take the time and trouble to visit an obscure cancer clinic in Tijuana. Very few others have, and I think this incident speaks volumes about the man and his character. Shoham earned his medical degree from Hebrew University-Hadassah Medical School and his doctorate at the famed Weizmann Institute in Rehovath in 1970, working with Leo Sachs, MD, winner of both the Wolf Prize for medicine and the Israel Prize.48 Hebrew University and Weizmann are two of the top academic centers in Israel (equivalent to Harvard and M.I.T. in the United States). In an earlier phase of his career, Shoham conducted in-depth research on the role of the thymus and factors secreted by it in T-cell development, including exploration of their clinical relevance in cancer and other diseases. He also studied experimental and clinical aspects of interferon activities, including collaborative studies with Michel Revel’s group at the Weizmann Institute.

** At most of the CAM facilities I visited Jewish doctors went out of their way to affirm their commitment to both treat Arab patients and collaborate, whenever possible, with Arab physicians, although they were frank about the difficulties involved in implementing such cooperation.


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Figure 6 Jacob Shoham Photo courtesy Jacob Shoham Shoham is board certified in internal medicine in both Israel and the U.S. He accomplished a medical oncology fellowship at Roswell Park Memorial Institute, Buffalo, NY, one of the most venerable cancer centers in the U.S. In addition, he has also completed studies in Nutritional Medicine, Medical Ecology, Clinical Immunology, Chinese and Western Herbal Medicine, Psycho-oncology, medical hypnosis and Mind-Body Medicine. His research focus is in cancer and immunology. While serving as a fellow in medical oncology at Roswell Park Memorial Institute in the 1970s he became disillusioned with the exclusive focus on conventional medicine. “We were bringing people to the door of death,” he told me. “People died of the treatment.” He decided that he couldn’t do this anymore. When he returned to Israel he went to work as a senior physician in internal medicine at the Chaim Sheba Medical Center in Tel Hashomer. This functions as Israel’s national medical center in many fields. In 1985, Shoham lost his first wife to breast cancer, which was discovered when it was already in stage IV. This needless to say gave him a new perspective on cancer and what patients endure. He says that his main mission is to understand cancer better and implement this understanding to clinical practice.. The medical status quo won’t yield big


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solutions, he says. He sees the struggle as one of complex systems vs. the prevailing reductionism in most of science. The science of complex systems is a new, vital phase in modern science which better reflects the real world. It has the potential of opening a new era in medicine, particularly when dealing with chronic diseases. Human beings and their health problems can be better viewed from this perspective. When dealing with cancer, this disease should be conceived as a new system (‘neo-plasm’), created within the hierarchy of body’s normal systems and displays features of a complex, adaptive and dynamic system. The patient and his cancer are intimately interacting systems. Treatment should be directed to both. This view has implications to all aspects of cancer medicine – diagnosis, follow-up, prognosis and treatment, as well as to cancer experimental and clinical research. The molecular and reductionist approach to cancer is over emphasized, he says. It should be balanced by a complexity science approach. After serving as a senior physician at the Sheba Medical Center he became Vice-President of R&D at Interpharm, an Israeli pharmaceutical company. He was a member of the Israeli National Committee for Biomedical Research Policy. He is currently developing the conceptual and practical foundations of Health-Promoting Medicine in addition to his clinical work in his private clinic, emphasizing recruitment of inner healing forces, and his research at Bar-Ilan University on cancer therapies. Shoham is also Chairman of the “KaMaH” Association's Executive Committee and serves as the Center's Medical and Scientific Director. Although he currently serves as an emeritus professor at The Mina & Everard Goodman Faculty of Life Sciences,49 most of his energy is presently used in promoting the formation KaMaH, the Israel Center for Health Promoting Therapies. KaMaH’s aim is to enable individuals suffering from severe health problems to recover and heal, by using what Shoham calls Health Promoting Medicine The organization’s motto is taken from “The Physician’s Prayer” of Moses Maimonides (1135-1202 CE): “In the patient let me always see the human being.” Shoham interprets this to mean the following:

1. Let me approach the patient with respect, empathy, compassion, and hope. 2. Let me see his enormous capacity to take responsibility, to heal himself, to

transform and to grow. 3. Let me see the patient as a unique whole.

Although Shoham is the driving force, the idea of KaMaH has attracted prominent physicians, therapists and scientists in Israel. KaMaH is at present Shoham’s dream. He projects that the clinic will be in the hills surrounding Jerusalem. He wants international patients to come there for (a) health promotion, (b) combating of disease and (c) to provide motivation to patients to cope more efficiently with their disease and by doing so live longer and healthier lives. One of Shoham’s mentors is Lawrence LeShan, who is famous for his promotion of mind-body medicine in cancer.50


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KaMaH is striving to institute a new approach to medicine, which views the patient as an integrated whole, identifies internal healing powers that are related to various dimensions of an individual's life – the physical, emotional, spiritual and social-environmental – and mobilizes them in order to facilitate health rehabilitation.. The aim is to create a compassionate climate of health care delivery, in a healing environment, which will encourage and facilitate these processes. The KaMaH association is determined to establish a scientific basis for approaching severe disease conditions through treatment of the whole individual. KaMaH's treatment programs combine disease-specific, non-toxic therapies and health-building resources, as carefully integrated means of overcoming the disease and regaining health. These systematic and individualized programs are based on principles derived from the science of complex systems, employing means developed from a variety of medical disciplines – modern medicine, modern biology, biochemistry, physiology and immunology, nutritional and environmental medicine, traditional medicines – Chinese, Ayurvedic, and native American, psychological counseling, and several other disciplines. KaMaH is not a hospital. It is an outpatient clinic that provides medical treatments that systematically integrate non-medical mans of promoting healing and recovery. The current focus is on cancer, employing science-based means to outsmart the cancer process, by using an indirect attack strategy on the cancer process, in addition to or instead of the prevailing direct means of treatment, while fortifying inner defense mechanisms. The program cultivates a life-affirming outlook by encouraging patients to view the disease as a turning point in their lives and reassess their beliefs, values, priorities and meaning in life. The aim is to heal life and not only disease, by guiding the patient on a path of personal growth and fulfillment. KaMaH will convey, through its services, a message of humanistic medicine that may balance the growing inclination in contemporary medicine towards medical technology.

The fact that KaMaH is non-profit is very important in the Israeli context. It removes the suspicion that the motive behind such a venture is selfish or exploitative. In this way KaMaH can preserve its focus on professional concerns without having to address pressures applied by investors seeking yields on their investment. The focus of contemporary medical R&D on profit-bearing themes has led to the atrophy of R&D that investigates the potential inherent in treatments that have not been labeled as having a profit potential. These are, among others, the therapeutic directions that the KaMaH will try to develop and prove their value.

The Israeli Ministry of Health has endorsed the Center's establishment and attaches importance to its plans – namely, to make practical and controlled use of non-medical means for coping with chronic and complex medical problems and to scientifically examine their contribution to health promotion and rehabilitation, an enhanced quality of life and increased life expectancy. This KaMaH project seems most worthy of support.


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Hadassah University Hospital, Ein Kerem (Jerusalem) One of the big surprises of this visit was Hadassah University Hospital in Ein Kerem, in the far southwestern suburbs of Jerusalem. First, for clarification, there are two Hadassah Hospital. The original facility is located on Mt. Scopus, overlooking northeast Jerusalem. Hadassah, the Women’s Zionist Organization of America built this in the 1930s. Hadassah was and is one of the largest Jewish organizations in the world, with some 300,000 members. In 1948, the invading Jordanian army blockaded the road to Mt. Scopus. As a result, in 1960-1961, Hadassah built another hospital in Ein Kerem, an 800-bed tertiary care facility further from the “front line” of what is now northeastern Jerusalem. This is where the medical school is located and also where I visited the complementary medicine team. Mt. Scopus was, of course, part of Jerusalem eventually recaptured by the Israelis in the Six Day War of 1967 and now primarily serves the Arab population of East Jerusalem.

Figure 7 Martine Toledano, Reuven Or, Ruth Radiano, and Gisele Obadia-Aferiat Hadassah Hospital is ranked #1 in Israel and #158 in the world, according to the Web site, webometrics.info.51 It is the leading medical center in the entire Middle East (its closest competitor is the Hadad Medical Corporation in Doha, Qatar.) To put this in perspective, its world ranking puts it ahead of L’Institut Curie in Paris, the 22 Shriner’s Hospitals for Children, and Dana-Farber Cancer Center in Boston. Hadassah offers state-of-the-art treatment, with excellent physicians and advanced medical and surgical staff and equipment. It participates in numerous clinical trials and has a strong relationship to US medicine. (It is actually a hybrid Israeli-American institution and is a member of the American Hospital Association.52 One meets many American and Canadian physicians there.) In 1990, Hadassah became one of the first hospitals in Israel to open a complementary and alternative medicine (CAM) clinic. To put this in perspective, this was before the founding of the Office of Alternative Medicine at the US


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National Institutes of Health, now the National Center for Complementary and Alternative Medicine. There was a certain irony to this, as Hadassah has a reputation as Israel’s most high tech hospital. This clinic offers both traditional and complementary medicine, with a unique way of approaching patients’ needs and providing optimal treatment that draws on both traditions. This was the brainchild of Martine Toledano, M.D., Director of Integrative Medicine of Hadassah Medical Center, Jerusalem and head of research discipline and Director of Acupuncture studies Hebrew University, Jerusalem. The CAM clinic operates entirely within the framework of the Medical Center. This allows for a close contact between staff and patients, and also allows access to the advanced laboratory and imaging facilities of the hospital. At present, more hundreds of patients use the clinic’s services monthly. Martine Toledano Martine Toledano, MD, is the heart and soul of the CAM program at Hadassah (and the pioneer of integrative medicine in Israel as a whole). She has a charismatic personality, and combines a profound knowledge and enthusiasm for CAM with a realistic recognition of its strengths and weaknesses. “What’s important is recognizing your limits,” says Toledano. “Sometimes, conventional therapy is the best way. A choking child needs an Emergency Room, for example. A cancer patient needs chemotherapy.” Hematopoietic stem cell transplantation (HSCT) must receive pre-transplant conditioning. This involved high doses of combined chemo-radiotherapy. After the transplant, the side effects of this treatment can be further increased by neutropenia-associated infections, gastrointestinal mucositis and graft-vs.-host disease (GVHD). In addition to the physician symptoms, patients understandably suffer various negative emotional responses such as stress, anxiety and far. The staff decided to use reflexology (a special kind of foot massage) in order to try and relieve these symptoms. The medical and nursing teams hold a conference to decide on integrating reflexology into the conventional treatment plan. Patients then receive individualized reflexology sessions twice per week from licensed professionals.


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Figure 8 Reflexology at Hadassah University Hospital Photo courtesy Department of Bone Marrow Transplantation, Hadassah University Hospital Reflexology has been shown to improve the patients’ quality of life by diminishing the side effects of chemotherapy, including nausea, vomiting, pain, anxiety and insomnia. It affects the whole cycle of activities of daily living. Along with mainstream care, and in addition to the usual MRI scans, organ transplantation and chemotherapy, the complementary department uses a variety of non-conventional treatments:

1. Acupuncture 2. Alexander method 3. Aromatherapy 4. Auricular therapy 5. Biofeedback 6. Craniosacral therapy 7. Homeopathy 8. Hypnosis 9. Meditation 10. Mesotherapy 11. Naturopathy 12. Osteopathy 13. Phytotherapy 14. Reflexology 15. Relaxation 16. Tai-chi 17. Yoga

“At a first consultation, we give a patient a full conventional medical examination,” Toledano told me that they take a medical history, and review the X-rays, CT-scans or biochemical test results and possibly request additional standard tests. But they also do less conventional studies, with the help of Chinese and/or homeopathic questionnaires, and so on. In fact, oncology was the first entry point for CAM at Hadassah. “Most of our patients look for other options at some point during their long and difficult


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treatment,” said Tamar Peretz, MD, head of Hadassah’s Sharett Institute of Oncology. “Some seek help in fighting their illness or in coping with therapy; others want ‘natural treatment’ together with conventional approaches. Not only are these patients entitled to every viable treatment option, but homeopathy and reflexology are known to markedly diminish side effects of chemotherapy in many patients.”53 Needless to say, such statements would be highly unusual coming from a leading academic oncologist in the US. “Today, scores of oncology patients come to our clinic for help in offsetting side-effects of treatment,” says Toledano. “And they do it knowing they have the full support of their oncologists.” Originally, the Complementary Medicine Unit was a kind of ‘stepchild’ of the medical center. Its mandate was to use “all treatments and therapies not included under conventional medicine.” Then, in 2008, because of the excellent relations between the CAM doctors and the regular staff, it was invited into main hospital. The service quickly took off, and was soon handling hundreds of cases per month. “People with intractable problems will understandably do or pay almost anything for hope or relief,” said Toledano. “If conventional medicine hasn’t helped them enough, many will look to complementary medicine.” She points out that in Israel, as in the US, patients frequently hide their CAM usage from their conventional doctors, because of fear of censure, rejection or denial of services. But this can result in dangerous or even disastrous drug interactions. There is also the problem of charlatanism, which has bedeviled the field of complementary medicine from its inception. But administering CAM within Hadassah itself, and adhering to the ethical and scientific standards of a modern medical center, these problems all but disappear. Recently, the unit was given permission to open and run clinics in many fields for which there is reliable evidence-based research that complementary medicine is effective. During the course of my visit, Toledano took me to the various clinics that are currently offering CAM to their patients. This included not just adult and pediatric oncology but gynecology, cardiology and the pain clinic. “The list of disciplines is growing all the time.” Conventional medicine tends to treat all patients with similar diagnoses the same. But in complementary medicine, the treatment tends to vary with the individual patient. It is customized medicine, just as, Toledano says, modern conventional medicine is. “If a woman comes to me with an intractable headache that responds neither to Voltaren (diclofenac) nor to pain-blocks, I have several choices,” she says. “If this patient sits and weeps and tells me she can no longer bear her headache because she’s already burdened by problems at work or at home, I may recommend a mind body technique such as yoga, hypnosis, meditation, or relaxation. If her headaches began after a car accident or strenuous exercise, I’ll recommend a mechanical response, such as osteopathy. If she has painful menstruation in addition to her aching head, I’ll think in terms of a poly-systemic problem, and start her on acupuncture, for example.”


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The unit is plagued by some of the same problems as CAM units in other countries—a lack of money for documenting and researching promising results. “We’ve reduced back pain so radically that patients no longer require surgery,” Toledano says. Several women with unexplained infertility have become pregnant following acupuncture in our unit, which means that complementary medicine offers solutions to problems that conventional medicine either could not handle, or ‘solved’ by performing more drastic procedures. These are exciting results and we’d like to investigate them in full.” Nonetheless, the Unit continues to grow. “It’s clear from both the demand for complementary medicine and its successes that some additional form of treatment is needed,” Toledano says. “Complementary medicine techniques add therapeutic tools to the doctor’s arsenal, often giving patients very great benefit at very low risk. Today, most doctors recognize there are many ways to help a patient, and understand that complementary medicine approaches are among those ways. My dream,” she adds, “is to see a new approach to patient care – known, perhaps, as integrative medicine – which embraces both conventional and non-conventional therapies.

Medical Marijuana Medical marijuana is being intensively researched in Israel. Much of this is due to the work of Raphael Mechoulam, PhD, a professor in Hadassah’s School of Pharmacy.54 The endogenous cannabinoid neurotransmitter, anandamide, was discovered in Mechoulam’s laboratory at Hadassah hospital in the 1990s.55 But Mechoulam has been researching the chemistry of cannabinoids (their isolation, structure elucidation and synthesis), as well as synthesis of novel agonists to cannabinoid receptors, since 1965. He then tests these novel compounds for action on suitable in vitro and animal models, with the financial support of the US National Institutes of Health (NIH). In fact, he is the author of over 360 scientific papers, over 75 of these on marijuana constituents and derivatives.56

Shimon Slavin and the CTCI Shimon Slavin, MD is one of the most accomplished physicians involved in basic science in Israel. Slavin’s work focuses on stem cell transplantation and innovative cellular therapies for treatment of malignant and non-malignant disorders, including the use of donor stem cells for induction of transplantation tolerance to foreign organs (i.e., allografts). He is also a specialist in the use of stem cells for regenerative medicine. Slavin is the author of four books and more than 500 scientific publications. A 1967 graduate of Hadassah-Hebrew University School of Medicine in Jerusalem, he is board certified in internal medicine (1970-1975) and took postdoctoral training in clinical immunology at Stanford University, Palo Alto, CA, and the


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Bone Marrow Transplant Center at the Fred Hutchinson Cancer Research Center, Seattle, WA. He is also board certified in clinical immunology and allergy and holds license to practice medicine in California and Illinois. Upon returning to Israel in 1978, he opened the first bone marrow transplantation (BMT) unit, which was subsequently recognized as Israel’s National BMT Center. Slavin became its first and long-term chairman. In 1980 Slavin established the first center for stem cell transplantation and cancer immunotherapy in Israel. He has attracted patients as well as doctors from around the world. Two years ago, he left his long-term post at Hadassah Hospital to establish a private clinic in Tel Aviv. (He retains an academic appointment at the Hebrew University School of Medicine.) His new clinic is called the International Center for Cell Therapy & Cancer Immunotherapy (CTCI). Although it is sometimes stated that his center is located “at the Tel Aviv Medical Center,”57 I discovered that this is a misnomer. CTCI is physically located adjacent to the Sourasky Medical Center and although its Clean Rooms and GMP Cell Processing Center are both located at the Sourasky-Tel Aviv, it has no official affiliation with that hospital. It is a private fee-for-service clinic. Slavin believes that the immune system may be the most promising tool for eradicating cancer. This include cancer stem cells, which are primarily resistant to all available anti-cancer agents and are widely believed to be the main cause of recurrent disease. Slavin says that the best and, in some cases, the only chance to eradicate all malignant cells is when the tumor has been reduced (via the conventional means of surgery, radiation and/or chemotherapy) to a state he calls “minimal residual disease.”


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Figure 9 Shimon Slavin Unfortunately, conventional oncologists and hematologists recommend no further treatment when patients show no evidence of disease (NED), although this is probably the best time to eradicate the invisible disease. After all, one million cancer cells is still only the size of the head of a pin. Therefore, many millions of cancer cells may be already on board but cause no symptom and remain invisible by any available diagnostic method. Every oncologist or hematologist can easily recognize their high risk cases, i.e., those that are unlikely to be cured by any of the conventional anti-cancer modalities. Unfortunately, most cancer specialists are not yet convinced that immunotherapy can be the answer for curing such cases. At the point of minimal residual disease, Slavin says, the immune system can be activated to wipe out these small but potentially dangerous nests of malignancy, including cancer stem cells. Slavin says that the activation of the patient’s own immune system may be sufficient for eradicating minimal residual disease. However, patients with more aggressive malignancy, or whose tumors are much larger, the use of foreign (allogeneic) lymphocytes may be required for induction of a much more effective warfare against cancer. This is because immunologically mismatched lymphocytes can kill cancer cell faster and more effectively.


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One method of activating a patient’s own immune system against cancer is to administer a drug that unblocks the immune system’s attack on cancer. Slavin believes that this can sometimes be done with a substance in the aspirin family. It has been shown that people who use aspirin or similar non-steroidal anti-inflammatory agents (NSAIDs) regularly have a diminished likelihood of developing cancers of various kinds. He has co-authored papers on the use of the common NSAID indomethacin (Indocid, Indocin, etc.) in inducing immunity in mice. This drug is typically used to diminish the symptoms of arthritis. But it has anticancer potential as well. When mice that normally failed to induce an immune response against metastatic breast cancer were given indomethacin in the drinking water they would resist a subsequent breast cancer challenge.

Indomethacin has potential as an adjuvant anticancer agent. Here is what the National Cancer Institute drug dictionary has to say about this drug:

“A synthetic nonsteroidal indole derivative with anti-inflammatory activity and chemopreventive properties. As a nonsteroidal anti-inflammatory drug (NSAID), indomethacin inhibits the enzyme cyclooxygenase, thereby preventing cyclooxygenase-mediated DNA adduct formation by heterocyclic aromatic amines. This agent also may inhibit the expression of multi-drug-resistant protein type 1, resulting in increased efficacies of some antineoplastic agents in treating multi-drug resistant tumors. In addition, indomethacin activates phosphatases that inhibit the migration and proliferation of cancer cells and down regulates survivin, which may result in tumor cell apoptosis.”58

In the US, indomethacin is available by prescription. One attractive fact about these drugs is that they are inexpensive. At the Israeli drug exporting Web site, www.israelpharm.com, 30 x 25 mg capsules of Indocid sell for $10 (plus s&h), which works out to 33¢ per capsule. The normal dose for treating arthritis is 2 or 3 x 25 mg capsules per day (~$1 per day). The maximum dose is 200 mg per day. Even at this high dose, the cost of the drug is $2 per day. Thus, for a drug with such promising anticancer activity this is a “bargain.” A similar drug, Celebrex (celecoxib) results in less gastric acidity and probably has a similar effect. (NB: These drugs are subject to an FDA ‘black box’ warning on the label, explaining the increased risk of cardiovascular disease in those who take the drug, especially for a prolonged period.59) Another treatment that Slavin sometimes recommends is a natural cytokine named interleukin-2 (IL-2). In a recombinant form, this is a standard immune therapy for a few types of malignancy, including melanoma and kidney cancer.60 It has been used experimentally to treat other cancer types as well. Slavin finds IL-2 to be useful in conjunction with cell therapy (q.v.) to improve the outcome of leukemia patients. He employs a combination of BMT, or stem cell transplantation, and IL-2. He can pre-treat lymphocytes (particularly T cells and natural killer, or NK, cells) with IL-2 in order to give them an enhanced ability to attack and destroy the remaining tumor cells. The treatment Slavin uses with IL-2 is different from the treatment provided by other centers because he uses IL-2 activated donor lymphocytes, not only patient’s own lymphocytes, and uses a


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short course of IL-2 administered subcutaneously to continue to activate donor lymphocytes after they have been infused to the patient. Furthermore, Slavin developed special approaches for targeting the killer cells (IL-2 activated donor T cells and NK cells) to the malignant cells by antibodies against antigens that are over-expressed on the tumor cells. Slavin likes to pose hypothetical situations in order to explain his treatment approach. For instance, he points out that normally a tumor transplanted from a cancer patient into a healthy stranger will not “take.” Within a few days the recipient’s normal immune system would energetically attack these unmatched tumor cells and wipe them out. This is similar to how a transplanted organ can be rejected by the host when there is a poor match between donor and host. Slavin’s idea was to use lymphocytes that are taken from the blood of a healthy person, activate them in the laboratory, and then administer them to the cancer patient. Since these lymphocytes of normal people are presumed to be able to destroy foreign tumors in their own body, he reasons that they can also kill tumor in another person’s body. These specially prepared cells are called “activated donor lymphocytes.”61 Slavin finds that this is a very effective way to wipe out a relatively small number of malignant cells often remaining in the body of a person who has been treated for cancer. Why not use this against large tumors? The reason is that the “activated donor lymphocytes” would have to remain for weeks and months in the body of the patient in order to do this. But the obvious difficulty is that the patient’s immune system senses the presence of these donor cells, identifies them as foreign, and kills them before they have a chance to destroy the tumor. Hence, donor lymphocytes can kill all cancer cells if the job can be accomplish within less than a week, while they circulate in the host. If longer time is required to eliminate large masses of tumor cells, the permanent survival of donor lymphocytes is required. This can be accomplished by prior transplantation of donor stem cells through a procedure called allogeneic stem cell transplantation. The engraftment of donor stem cells ensures durable engraftment of donor lymphocytes. And hen, following transplantation “donor lymphocyte infusion” (DLI) can be used to amplify the anti-cancer effects mediated by donor lymphocytes. This is accomplished with a rather elaborate procedure. First, the bulk of the cancer has to be eliminated (through surgery, radiation, chemotherapy, etc.) Second, the patient’s bone marrow is destroyed and then replaced by newly grafted bone marrow or blood stem cells from the donor. In this way, the patient becomes tolerant of the donor’s lymphocytes. At this point, the patient is ready for a transfusion of activated lymphocytes from the donor. These are the cells designed to finish off the last cancer cell. Slavin speaks movingly about one of the first cases treated with this new technology, a two-and-a-half year old toddler with leukemia who had gone through many forms of conventional treatment. This included radiation given at four times the lethal dose and treatment with some of the most poisonous drugs known to man. He survived the treatment, but unfortunately the cancer returned with visible tumor masses on his forehead and next to his trachea, threatening to


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close his airway. As a last desperate measure, once per week for six weeks the little boy was given an injection of blood from his sister. Amazingly, the tumor masses disappeared and the young boy was completely cured! He is in fact still alive and well, more than 24 years after the fact. This was the first patient ever to be cured by donor lymphocytes when all available anti-cancer modalities, including supra-lethal radiation and chemotherapy failed, thus proving the working hypothesis: activated lymphocytes can be more effective than any available anti-cancer treatment once used correctly. Since that time many thousands of patients (most of them with leukemias or lymphomas) have been treated in a similar fashion, sometimes using short-lived donor lymphocytes or else more long-lived donor lymphocytes after tolerance has been induced by stem-cell transplantation. In the abovementioned case, tolerance of the foreign blood was made possible because the boy underwent bone marrow transplantation (BMT), and so his immune system became tolerant of his sister’s blood. Her blood then did the work of killing off his cancer, a fine example of sisterly love! Today, because of improvements in technology, DLI can be performed without performing a BMT or finding an immunological match. In fact, Slavin says, mismatched, half matched donor lymphocytes are actually preferred because the greater the mismatch, the strong the anticancer effect of the donor lymphocytes. The cells that are most desirable are the donor’s “natural killer” (or NK) cells. This is because T-cells (a broad category of white blood cells) would attack all of the patient’s cells, including normal ones, in a potentially disastrous process called graft vs. host disease (GVHD). NK cells do not cause this problem, even if they are fully mismatched. Such an approach developed recently by Slavin, makes it possible, he says, to cure patients considered incurable using an innovative procedure for safer engraftment of donor stem cells. In this way, donor NK cells can be activated to become vicious cancer killer cells without also attacking patient’s normal tissues. Therefore, Slavin says one can separate out the harmful effects of GVHD from the beneficial type of graft-vs-tumor effects by first separating the NK cells from the T-cells and only then injecting the former into the body. The selection of NK cells is effected using antibodies that are bound to metal beads that specifically bind only to NK cells. These are then removed through the use of a special magnetic device called a CliniMACS® Cell Separation System (from the German company, Miltenyi Biotech). Alternately, they can remove the T-cells by using antibodies against the latter. Slavin himself recognizes the limits of DLI in patients with bulky and end stage disease. No one should mistake this as a cure for very advanced disease. However, he believes that the use of haploidentical stem cell transplantation with DLI from the mismatched donor using guided killer cells, may eventually provide a much more effective tool against cancer in its earlier or residual stages. In addition to these original methods, Slavin is also employing a number of other innovative treatments. For instance, he creates a vaccine against cancer using the


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patient’s surgically removed cells, modifying them slightly, and then reintroducing them into the body. Alternately, he uses cancer cells of the same histological type, but from a different patient, to create a vaccine to induce an immune response against the patient’s cancer cells. He also uses antibodies to target cancer cells. They are first bound to the surface of natural killer (NK) cells and then hone in on specific markers on the surface of the cancer cell. This brings the NK cell into close proximity to the cancer cell, leading to the elimination of the malignant cell. Lately, he told me, he has been experimenting with an antibody that can deliver both NK cells and T-cells to the tumor site. He is also working with an antibody that binds to a T-cell and a human melanoma cell. All of the antibodies removed from that cow’s blood would be capable of destroying human melanoma cells. In addition, this ability will be passed along to their offspring, thus ensuring an almost limitless supply of what Slavin calls “anticancer smart bombs.” This is being mass-produced in transgenic cows that have been cloned by a German scientist, Gottfried Brem, who is an expert on genetically modified animals. Slavin is also working with Newcastle Disease Virus (NDV) vaccine as a potential treatment for cancer. This is a treatment that has been intensively investigated at Hadassah Hospital.62 This virus, which causes a deadly lympho-proliferative disorder in poultry, is essentially apathogenic in humans (i.e., its worst side effect is conjunctivitis, or pink eye). But this virus sometimes attacks cancer cells selectively, which results in their replication inside cancer cells and ends in the death of the affected cell. At the same time, this process releases new viruses into the vicinity of the tumor. These viruses also pass through the blood-brain barrier and have been observed to cause remissions even in glioblastoma multiforme (a kind of stage IV brain tumor). While these observations are relatively well known, it has proven difficult to produce a pharmaceutical grade NDV and to get rigorous clinical trials in motion. Although immunotherapy has made great strides around the world, as a general rule it is only used when every other conventional treatment has failed. “This is too late for a cure to be expected,” says Slavin. “One can only anticipate more successful treatments if they were administered at an early stage of the disease against minimal tumor burden.” He says that prospective randomized clinical trials are urgently needed to prove the value of such procedures. Slavin says that this kind of treatment has been used successfully in thousands of patients. In a 2010 paper, Slavin, et al. discuss the feasibility of his approach, called IMAK (intentionally mismatched rIL-2 activated killer lymphocytes) in patients with advanced (chemotherapy-resistant) blood (hematological) cancers as well as metastatic solid tumors. According to Slavin, the procedure was successful in 5 out of 39 patients. These were all end-stage patients —“desperately sick patients, all comers, no exclusion.”63 The point of the paper is to show that the procedure is safe and to justify the application of a similar approach to patients who might be cured if treated at the stage of minimal residual disease (MRD). Slavin and his coauthors conclude that the procedure is in fact “feasible, safe and potentially effective,”64 especially when applied to earlier-stage patients.


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Joseph Brenner, Tel Aviv Joseph Brenner, MD, is arguably the best-known CAM practitioner in Israel. Being a pioneer in introducing CAM treatments (such as hyperthermia) in oncology in Israel, he has had a high profile controversy with the leaders of the medical board in Israel and as a consequence became a well-known figure in the news in Israel. But his struggle paid off. In 2010 he was invited to give a presentation on hyperthermia at a large conference in Jerusalem on complementary medicine co-sponsored by the Ministry of Health. Since the time of his struggle with the medical authorities, CAM units have become an integrated part of every oncology department in Israel. Despite his history, Brenner is not as anti-establishment as he may sound. Brenner is a board-certified head of the oncology department oncologist at the Edith Wolfson Medical Center in Holon, but also maintains a private CAM clinic in Tel Aviv. Born in Israel, he studied medicine at the University of Siena, Italy, for three years. In 1971, he received his medical degree from Tel-Aviv University in Israel.


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Figure 10 Joseph Brenner In the following five years Brenner completed a Residency Fellowship in Internal Medicine and Oncology at Sheba Medical Center, Tel Hashomer. For the following four years he received a fellowship in radiation oncology at Rhode Island Hospital in Providence, following this with a fellowship in medical oncology at Memorial Sloan Kettering Cancer Center (MSKCC), New York. After returning to Israel in 1982, he joined the medical oncology department at Wolfson. Despite (or because of) this long involvement with conventional oncology, Brenner has maintained a deep interest in CAM approaches to cancer. As a result, he has sought out training in such diverse fields as acupuncture, homeopathy, Reiki, applied kinesiology, dark field and oxidative test microscopy, German electro-acupuncture testing (EAV), nutrition and more. Brenner is the founder director of the New Hope clinic, an outpatient center for biologic and metabolic non-toxic medicine in oncology, in Tel-Aviv. At this Center, he implements the new techniques developed in Europe and the United States, such as superficial, regional, and whole body hyperthermia. He is more or less synonymous with the use of hyperthermia in Israel.


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In the past, Brenner has been closely associated with the late Prof. Luigi Di Bella, MD, of Modena, Italy, who treated more than 10,000 cancer patients with a unique method combining the drug somatostatin with high melatonin. He has also collaborated closely with Friedrich Douwes, MD, of the St. Georg Hospital in Bad Aibling, Germany. Brenner recently installed the Oncothermia 3000, the most advanced hyperthermia (also called oncothermia) equipment available, manufactured by a company in Budapest. He typically combines this with insulin potentiation therapy (IPT) and hyperthermia (which he believes to be a good combination) as well as high-dose vitamin C infusions. He also has started to use the controversial substance, GcMAF. He uses galvanotherapy externally, putting electrodes above and below the tumor. Brenner is well known for his battle with the Israeli Medical Association. He initiated a libel suit against the four top medical doctors in the IMA. He says he had no choice but to do this because his reputation would have been ruined if he had failed to respond to their insults and provocations. After seven years of litigation the case was essentially fought to a draw. In a sense, he has a kind of split personality. In the mornings he practices as a regular medical oncologist. In the afternoon he runs his personal clinic. The clinic, he says, is as busy as he wants it to be. After 15 years of administering hyperthermia he feels confident in the methodology and says he gets very good results. Due to this 15 years experience in hyperthermia treatments, Brenner is often invited to lecture in the most important hyperthermia conferences all over the world. As an oncologist, he knows what constitutes a result. For instance, he has recently seen a patient who had a CA 19-9 marker go down from 50,000 to under 1,000. He also had a patient whose bilirubin went from 7 to 0.8 using hyperthermia. But he has not published his results with this modality, at least not in peer-reviewed journals. Whole body hyperthermia at Brenner’s clinic costs $3-4,000 per session, and local-regional hyperthermia is $400 per treatment. An IV infusion of vitamin C is $400-500. Brenner says the costs of treatment at his clinic are similar to those in the European CAM clinics. That may be true for some clinics (such as St. Georg.) Most of the criticism I heard of Brenner on this trip had to do with the allegedly high cost of his treatment, which contrasts with most Israeli medicine that is covered by the insurance plans. Brenner gives whole body hyperthermia once per week for three weeks, and then the patient takes two months off. Surprisingly, he says that he does not generally like to use whole body hyperthermia. He considers it risky because if there are brain metastases, he says, you are in danger of killing the patient. He also cannot treat patients with whole body hyperthermia if they have high blood pressure, heart or lung conditions. He doesn’t sedate the patients and he takes their temperature to 40.5º C (104.9º F) not to 41.5º C (106.7º F), where there is definitely a need to sedate the patients. He keeps an anesthesiologist on hand when he does WBH.


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He tests markers after one month of treatment and CT scans after two months. He claims to be able to shrink or stabilize the tumor in 50-60 percent of cases using these more natural methods.

Conclusions It is now possible to answer the four questions raised at the beginning of this report.

1. What is being done for cancer in Israel, in an alternative or complementary way, that is not be done elsewhere? Most everything done in Israeli clinics is also done at other hospitals, clinics and private practices around the world. So the distinctiveness of Israel is not in what is being done but how it is done, i.e., in how well integrated complementary measures are with the conventional medical treatments. 2. What are some of the most promising findings or discoveries? Israeli doctors (and non-physician CAM practitioners) are finding new uses for acupuncture, homeopathy, reflexology, medical marijuana, and a host of other substances and techniques. The most promising discovery is actually that a full spectrum of CAM can be practiced in a conventional setting, even in the seemingly unpromising setting of an HMO. 3. How does the Israeli medical establishment’s attitude towards CAM differ from that in other countries, particularly in the US? One of the most surprising findings is that medical leaders in Israel are favorably inclined towards the idea of CAM and towards specific CAM approaches, such as acupuncture, homeopathy, medical marijuana and reflexology. 4. If the situation in Israel is unique, why is that so?

As I have said, what is unique is the degree to which CAM has been integrated and accepted by Israeli medical profession, including the top leadership. The establishment there seems to not have the same morbid fear of “quackery” that has historically marked CAM’s development in the United States.65 In some ways, such as its tolerant attitude towards homeopathy, Israel seems more European than American influenced. (Israel was in fact the first non-European country to be associated to the European Union’s Framework Programme for Research and Technical Development, the RTD. In some research contexts, Israel is in fact treated as a European country!66


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Doctors in Israel are quick to grasp the potential of new treatments and quick to commercialize these. Being highly pragmatic, they are less swayed by ideological considerations and able to see more clearly whether something has promise or not. Those things are then fairly explored and, if possible, developed. This behavior befits a country that has been called the “start-up nation.”

My visit to some of Israel’s complementary and alternative (CAM) doctors and clinics was full of surprises. The greatest of these was the degree to which CAM is integrated into the conventional health care system. This was most evident at Israel’s largest and most prestigious health organizations: Hadassah Hospital as well as its largest HMO, the Clalit system. At Hadassah this was largely due to the two decades of work by Martine Toledano, MD. There, step by careful step, CAM has entered the former bastions of conventional medicine (surgery, pediatric oncology, internal medicine, etc.) and earned the trust of medical colleagues in all of these disciplines. It was astonishing to see such CAM modalities as homeopathy, reflexology, and acupuncture, being so enthusiastically embraced as part of standard medicine. Another surprising development is the degree to which CAM has found a home in the major HMOs, including Clalit. There is a widespread perception in the US that managed care is necessarily antithetical to complementary medicine. In Israel, however, HMOs compete among themselves as to who can provide the most comprehensive CAM services! According to everyone I spoke to, this has led to an enormous expansion of CAM services that are available to the average patient. Finally, Israel is also seeing the rise of some interesting fee-for-service options. Most noteworthy are the two private Tel Aviv clinics of Joseph Brenner, MD and of Shimon Slavin, MD. Both have distinguished records as oncologists. The cost of these clinic services may be prohibitive for many Israelis (and the idea of fee-for-service treatment is still repugnant to many people brought up with a non-profit ethos concerning medical care). But it seems possible that these facilities might grow in number and importance, especially if they can attract international patients in the future. The KaMaH clinic, or a contemplated consortium of Haifa CAM doctors, might provide the ideal solution, by providing innovative cancer treatments, with an international appeal, but under the aegis of a strictly non-profit foundation. More to the point, I found a genuine openness to CAM among the various department heads and non-CAM doctors with whom I met. One of them even said that she saw CAM as not just interesting in its own right, but as the future of medicine. One can certainly find such sentiments expressed by CAM practitioners in the US, but I am unaware of any leaders of American conventional medicine who have ever publicly expressed this view. In this sense, Israel is a very forward-looking country, as well as an eminently pragmatic one: they are in favor of whatever works. In the field of CAM, Israel truly earns its sobriquet of the “start-up nation.”


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THE END


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Appendix A: CAM Treatment Resources Most Israeli CAM doctors are members of the Israeli Society for Complementary Medicine (http://www.cam.org.il/) Bar-Sela, Gil, MD, director Rambam Health Care Campus Integrated Oncology and Palliative Care Center Division of Oncology POB 9602 Haifa 31096 Israel Tel: +972-50-2061207 Hospital: +972-4-8543810 Fax: +972-4-8541810 E-mail: [email protected] Coworkers: Prof. Haim N., MD, Epelbaum R. MD Main research themes: Supportive oncology; Anthrophosophical medicine in integrative oncology; CAM; Stomach cancer No. of publications (integrative oncology): 8 Ben-Arye, Eran, MD, director The Complementary & Traditional Medicine Unit Department of Family Medicine, Rappaport Faculty of Medicine, Technion Institute of Technology; Clalit health services, Haifa and Western Galilee, Haifa 6 Hashahaf Street, Haifa 35013, Israel. Tel: +972-528709282 Fax: +972-4-851-3059 E-mail: [email protected] Coworkers: Oren A. MD, Frenkel M. MD, Karkabi K. MD, Lev E. MD, Keshet Y. PhD , Schiff E. MD Main research themes: Integrative family medicine; CAM medical education; Doctor-patient communication; Evidence- & Narrative-based medicine; Bio-Psycho-Social-Spiritual patient-centered approach; CAM and ethics; Traditional & Cross-cultural medicine; Integrative oncology; Herbal medicine No. of publications (peer-reviewed journals): 38 Ben-Arye Eran, MD, Director Integrative Oncology Program Haifa and Western Galilee Oncology Service, Lin Medical Center of Clalit Health Services Haifa, Israel Tel: +972-528709282 E-mail: [email protected] Coworkers: Lavie O. MD, Steiner M. MD, Schiff E. MD, Frenkel M. MD, Shalom T. PhD, Levi M. MD Main research themes: Evidence-based and


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narrative-based medicine; Family medicine; Doctor-patient communication; Bio-Psycho-Social-Spiritual patient-centered approach; Anthroposophic Herbal & medicine No. of publications: 11 articles, 2 book chapters An outstanding program in complementary/integrative medicine in northern Israel in family medicine and integrative oncology. Brenner, Joseph, MD New Hope Clinic 62 Hei Be-Iyar St. Kikar Hamedina Tel Aviv, Israel Mobile = +054-660-6864 Tel: +972-3-5467733 Private practitioner of hyperthermia, IPT, etc. Caspi, Opher, MD, PhD Director, Integrative Medicine Davidoff Comprehensive Cancer Center, Rabin Medical Center, Petach-Tikva, Israel E-mail: [email protected] Tel: +972-504065528 Coworkers: Baranovitch O. DOM, PhD, Lac, Argash O., Sheinman, N., ND Main research themes: patient care; decision-making; methodology; health policy; shiatsu and fatigue in breast CA; Integrative medicine outcomes & lung CA; TCM for peripheral neuropathy. Stress & GYN cancer No. of CAM-related publications: 6 Frenkel, Moshe, MD Integrative Oncology Consultant Tel: +972-52-3311255 Web: www.moshefrenkelmd.com Email: [email protected] Former Medical Director of The Integrative Medicine Program, M.D. Anderson Cancer Center, presently provides international consultations on the integration of homeopathy and complementary medicine in cancer care Gamus, Dorit, MD, PhD, Director Complementary Medicine Service Chaim Sheba Medical Center, Tel-Hashomer (Affiliation:Tel-Aviv University, Sackler School of Medicine) Tel: +972-35303956 E-mail: [email protected] Main fellow contributors: Siev-Ner I. MD, Perla D. MA, Lic. Acup, Kleinhauz M. MD, Mesinger A. Lic. Acup. Main research themest: Rehabilitation; Post-traumatic stress disorder; Dermatology; Pain; Palliative care/oncology; Gastroenterology; Gynecology/infertility; Hypnosis; Acupuncture; Reflexology No. of CAM related publications: 8


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Kaufman, Yakir, MD Neurology Services Sarah Herzog Memorial Hospital POB 3900, Jerusalem, Israel Tel: +972-2-531-6814 or +972-2 531980 Fax: +972-2-653-6075 E-mail: [email protected] or [email protected] Fellow contributors: Lichtenberg, P., Epstein, D., Heresco-Levy, U. Main research themes: Spiritual Well-being and Alzheimer's Disease; Shiatsu therapy & Schizophrenia; Placebo effect; Genetics of Personality Traits; Hypnosis Neurodegenerative Diseases; Orthomolecular therapy No. of CAM related publications: 18 Kuten, Abraham, MD Director, Division of Oncology Rambam – Health Care Campus POB 9602, Haifa 31096, Israel Email: [email protected] Tel: +972-4-8543003 Fax: +972-4-8543008 Mobile: +972-50-2062003 A major hospital with a CAM presence Lerner-Geva, Liat, MD, PhD CAM Research Network Gertner Institute for Epidemiology and Health Policy Research Chaim Sheba Medical Center, Tel Hashomer, 52621, Israel Phone: +972-35303505 E-mail: [email protected] Improving communication between MDs and CAM practitioners, collect data from CAM clinics, improve quality of treatment, follow-up, and provide the data to Israeli policy makers. with expert in cancer care in both Israel and the US Lev, Prof. Efraim, PhD School of Public Health Faculty of Social Welfare and Health Studies University of Haifa, Haifa 31905, Israel Phone: +972-4-8240949 Email: [email protected], [email protected] Expert on historical use of medicinal herbs in the Holy Land Obadia-Aferiat, Gisele, MD Integrative Medicine, Acupuncture, Homeopathy Director of Acupuncture Course-Hebrew University Hadassah University Hospital, Ein Kerem POB 12000, Jerusalem 91120, Israel Tel: +972-2-6777111


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Mobile: +972-52-3558640 Email: [email protected] Toledano’s deputy and an outstanding practitioner of acupuncture and homeopathy of the French school. Oberbaum, Menachem, MD, director Center for Integrative Complementary Medicine Shaare Zedek Medical Center E-mail: [email protected] Tel: +972-26666395 Coworkers: Samuels, N., MD, Singer, R., MD. Main research themes: pain; sepsis; intensive care; infertility; obstetrics: oncology; homeopathy. No. of CAM related publications: 22 articles, 9 book chapters Or, Reuven, MD Director, Department of Bone Marrow Transplantation Cancer Immunotherapy and Immunobiology Research Center Hadassah University Hospital, Ein Kerem P.O.B. 12000, Jerusalem 91120, Israel Tel: +972-2-6776561 Fax: +972-2-6777540 or +972-2-642-2731 Mobile: +972-52-3376992 Email: [email protected] Radiano, Ruth, RN, BSN, MPH, Head Nurse Dept. of Bone Marrow Transplantation and Cancer Immunotherapy Hadassah University Hospital, Ein Kerem P.O.B. 12000, Jerusalem, Israel 91120 Tel: +972-2-677-6680 Fax: +972-2-677-6693 Mobile: +972-50-787-4726 Email: [email protected] or [email protected] Reshef, Alon, MD Psychiatric service, Integrative psychiatry research unit Ha Emek Medical Center (affiliated with Technion medical school) Tel: +972-46494351 E-mail: [email protected] Fellow contributors: Tamar Eshel Bialer Main research themes: Mental reactions to acupuncture; Therapeutic relationships of TCM in psychoanalytic terms; Creating a model of dialogue between Western therapies and TCM No. of CAM related publications: 2 Schachter, Leora, MD Integrative Pain Medicine Center Maccabi HMO group


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E-mail: [email protected] Tel: +972-508800122 Fellow contributors: Faculty of the Meirav school of CAM Main research themes: mind-body aspect of pain management; CAM & pain perception Schiff, Elad, MD, director Department of CAM/Integrative Medicine Ethics & Law at the International Center for Health, Law & Ethics, Haifa University Tel: +972-506267243 E-mail: [email protected] Fellow contributors: Golan O. PhD, Wietchner N. Adv. Main research themes: Assessing and developing ethical frameworks for CAM research and utilization; doctor-patient-CAM practitioner communication; Development of ethical codes; Ethics of touch based therapies; Informed consent in CAM; Mind-Body Medicine; Integration of traditional systems of care. No. of CAM related publications: 7 Shoham, Boaz, and Levin, Avi, co-founders Efranat Phagogen, Bio Immune Therapeutics 3 Maharal St. Tel Aviv, Israel Tel: +972-3-522-1894 Fax: +972-3-522-2130 A serious effort to manufacture and clinically investigate Nobuto Yamamoto’s natural compound “GcMAF” in cancer patients. Shoham, Jacob, MD, PhD Medical oncologist, nutritional medicine, Chinese and Western herbal medicine, mind-body medicine 98 Hagefen St. Gimzo, 73130, Israel Tel: +972-8-9285043 Fax: +972-8-9285053 Email: [email protected] Integrative oncology Slavin, Shimon, MD Professor of Medicine International Center for Cell Therapy and Cancer Immunotherapy Ltd. 14 Weizman St., 20th floor Tel Aviv 64239 Israel Tel: +972-2-6777270 Tel: +972-54-9425456 Tel: +972-77-777-9255 Fax: + 972-77-777-9247 Email: [email protected]


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A private center located near Tel Aviv Sorasky Medical Center with an original program in deliberately partial mismatched stem cell transplantation as well as other innovative cancer treatments, such as Newcastle Disease Virus Vaccine therapy. Sterian, Chaya, Mrs., general director Zwang-Gonen, A., medical director Maccabi Tivi CAM in Maccabi HMO group, Tel Aviv Tel: 972-508802039 E-mail: [email protected] Coworkers: Y. Sandhaus, A. Shmueli, F. Wood, C. Shelhav Main research themes: integrative pediatrics- handling technique; Cost effectiveness of CAM; Community CAM –a research network The Yuri Shtern Holistic Center for Cancer Patients c/o the Yuri Shtern Foundation Clinic Coordinator: Hila Sivan Tel-Hai st. 14, The German Colony, Jerusalem Phone: +972-77-5181021 e-mail [email protected] The Center provides treatment for individuals suffering from cancer as well as for their families, at no charge, helping to ease the process and length of the illness. The Center's goals stem from the belief of its namestake, the late Knesset legislator, that alternative treatments benefit both the mind and the body and ease the psychological stress of battling cancer, thus increasing the chances of recovery. Toledano, Martine, MD Director of Integrative Medicine Head of Research Discipline Director of Acupuncture Course-Hebrew University Hadassah Integrative Research Center Hadassah University Hospital, Ein Kerem, P.O.B. 12000, Jerusalem 91120, Israel E-mail: [email protected] Tel: +972-2-6777111 Mobile: +972-507874747 Coworkers: Obadia-Aferiat, Kaplan A., Dema R., Baris-Ginat J. Main research themes: Integrative oncology, cardiology, women's health & pain research No. of CAM related publications: 3 Weintraub, Michael, MD Director, Department of Pediatric Hematology-Oncology Hadassah University Hospital, Ein Kerem P.O.B. 12000, Jerusalem 91120, Israel Tel: +972-2-6777408 Fax: +972-2-6777833


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Mobile: +972-50-7874025 Email: [email protected] Zajicek, Gershom, MD, director Hebrew University of Jerusalem E-mail: [email protected] Tel: +972-39784985 Main research themes: Induction of a prolonged cancer remission (dormancy); Mobilization of healing processes in cancer; Guided imagery and meditation


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Appendix B: Co-sponsors of the 2010 Jerusalem International Conference on Integrative Medicine Shaare Zedek Medical Center, Jerusalem E. Wolfson Medical Center, Holon The Tel-Aviv Sourasky Medical Center Israeli Chamber for Complementary Health Professions Lady Davis Carmel Medical Center, Haifa Hadassah Medical Organization, Jerusalem Israeli Association for Classical Homeopathy (IACH) Sarah Herzog Memorial Hospital. Jerusalem Bnai Zion Medical Center, Haifa The Lowenstein Rehabilitation Hospital, Raanana Israel Reflexology Association Asaf Harofeh Medical Center The Israeli Feldenkrais Guild Rambam Health Care Campus, Haifa Rabin Medical Center, Beilinson Hospital The Israeli Association of Traditional Chinese Medicine The Israeli Osteopathic Association Maccabi-Tivi, Complementary and Integrative Medicine Services - HMO Israeli Organization of Medicinal Plants Meuhedet Complementary medicine - Israeli Health Maintenance Organization (HMO) IPEC Therapist Association Reidman International College for Complementary Medicine, Tel Aviv School of Homeopathy in Broshim Campus, in Tel Aviv University Clalit Complementary Medicine services - HMO Israeli Yoga Teachers' Association Wingate Institute Israeli Massage and Bodywork Association Israeli Association for Lousky Method Therapists I.R.U - Israel Reiki Unity Practitioners Association of Structural Integration - Rolfing Israel Ministry of Health, Israel


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Appendix C: Peer-reviewed Articles on CAM in Israel

Abdul-Hai A, Ben-Yehuda A, Galsky H, Slavin S, Or R. Interleukin 2 regulation following semi-allogeneic bone marrow transplantation in mice. Cancer Immunol Immunother. 2006;55(11):1330-1336.

Abdul-Hai A, Weiss L, Slavin S, Or R. Improved survival following induction of GVHD following lipopolysaccharide immunization. Exp Hematol. 2006;34(4):549-553. Abrahamov A, Abrahamov A, Mechoulam R. An efficient new cannabinoid antiemetic in pediatric oncology. Life Sci. 1995;56(23-24):2097-2102. Ahn AC, Nahin RL, Calabrese C, et al. Applying principles from complex systems to studying the efficacy of CAM therapies. J Altern Complement Med. 2010;16(9):1015-1022.

Amar S, Tiben N, Karkabi K, Hermoni D. [The efficacy of a doctor-patient appointment in a primary care setting dedicated to preventive medicine]. Harefuah. 2001;140(8):689-693, 808, 807. Argash O, Caspi O. [Touching cancer: shiatsu as complementary treatment to support cancer patients]. Harefuah. 2008;147(8-9):707-711, 750, 749. Azaizeh H, Saad B, Cooper E, Said O. Traditional Arabic and Islamic medicine, a re-emerging health aid. eCAM [E-pub ahead of print: 13 June 2008].

Azaizeh H, Saad B, Khalil K, Said O. The state of the art of traditional Arab herbal medicine in the eastern region of the Mediterranean: a review. eCAM 2006;3:229–35. Bachrach U. Antiviral activity of oxidized polyamines. Amino Acids. 2007;33(2):267-272. Bar-Eli N, Giloh H, Schlesinger M, Zakay-Rones Z. Preferential cytotoxic effect of Newcastle disease virus on lymphoma cells. J. Cancer Res. Clin. Oncol. 1996;122(7):409-415.

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22 Pang X, Yi Z, Zhang X, et al. Acetyl-11-keto-beta-boswellic acid inhibits prostate tumor growth by suppressing vascular endothelial growth factor receptor 2-mediated angiogenesis. Cancer Res. 2009;69(14):5893-5900. 23 http://tinyurl.com/2gxhy4t (NB: link shortened and immortalized) 24 Flavin DF. A lipoxygenase inhibitor in breast cancer brain metastases. J Neurooncol. 2007;82(1):91-93. 25 Pud D, Kaner E, Morag A, Ben-Ami S, Yaffe A. Use of complementary and alternative medicine among cancer patients in Israel. Eur J Oncol Nurs. 2005;9(2):124-130. 26 Moshe? Giveon SM, Liberman N, Klang S, Kahan E. Are people who use ‘natural drugs’ aware of their potentially harmful side effects and reporting to family physician? Patient Educ Couns. 2004;53(1):5-11. 27 Moshe? Paltiel O, Avitzour M, et al. Determinants of the use of complementary therapies by patients with cancer. Journal of Clinical Oncology. May 1, 2001;19(9):2439-2448. 28 Shmueli A, Igudin I, Shuval J. Change and stability: use of complementary and alternative medicine in Israel: 1993, 2000 and 2007. Eur J Public Health. 2010. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20375024 [Accessed September 24, 2010]. 29 Weyl Ben Arush M, Geva H, Ofir R, et al. Prevalence and characteristics of complementary medicine used by pediatric cancer patients in a mixed western and middle-eastern population. J Pediatr Hematol Oncol. 2006;28:141-146. 30 Personal communication, October 18, 2010. 31 Ben-Arye E, Karkabi S, Shapira C, et al. Complementary medicine in the primary care setting: Results of a survey of gender and cultural patterns in Israel. Gend Med. 2009;6(2):384-397. 32 Sunkara, Vasu. Family medicine and medical student residency choice in Israel and the US: A cross-country comparison. Global Pulse (American Medical Student Association publication), 2009;5:2. 33 Ibid. 34 Samuels N, Zisk-Rony RY, Singer SR, et al. Use of and attitudes toward complementary and alternative medicine among nurse-midwives in Israel. Am J Obstet Gynecol. 2010;203(4):341.e1-7. 35 Private communication, August 5, 2010. 36 http://tinyurl.com/yvls29 37 http://tinyurl.com/7yhje 38 Giveon SM, Liberman N, Klang S, Kahan E. Are people who use "natural drugs" aware of their potentially harmful side effects and reporting to family physician? Patient Educ Couns. 2004;53:5-11. 39 http://www.gertnerinst.org.il/e/869/130.htm 40 http://www.mediconvention.com/en/ 41 Frenkel, op.cit. 42 http://eng.sheba.co.il/ 43 http://rbsmedical.com/?page_id=47 44 http://www.clalit.co.il/HE-IL/english 45 Ben-Arye E, Goldin E, Wengrower D, et al. Wheat grass juice in the treatment of active distal ulcerative colitis: a randomized double-blind placebo-controlled trial. Scand J Gastroenterol. 2002;37(4):444-449.


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46 Pinto, Goel. Pioneers of an organic lifestyle. Haaretz, May 24, 2007. 47 http://www.rambam.org.il/Home+Page/Biosketch/A+G/Bar+Sela+Gil.htm 48 Shoham J, Inbar M, Sachs L. Differential toxicity on normal and transformed cells in vitro and inhibition of tumour development in vivo by concanavalin A. Nature. 1970;227(5264):1244-1246. 49 http://www.biu.ac.il/faculty/shohamj/ 50 Leshan, Lawrence. Cancer As a Turning Point: A Handbook for People with Cancer, Their Families, and Health Professionals. New York: Dutton, 1989. 51 http://tinyurl.com/29m7uzd 52 http://www.hbl.co.il/hadassah.asp 53 http://tinyurl.com/233txza/ 54 http://pharmacy.huji.ac.il/eng/staff_win.asp?id=66 55 Devane WA, Hanus L, Breuer A, et al. Isolation and structure of a brain constituent that binds to the cannabinoid receptor. Science. 1992;258(5090):1946-1949. 56 Mechoulam R, Gaoni Y. Hashish. IV. The isolation and structure of cannabinolic cannabidiolic and cannabigerolic acids. Tetrahedron. 1965;21(5):1223-1229. 57 http://thefutureofthings.com/articles/1012/smart-bombing-cancer.html 58 http://www.cancer.gov/drugdictionary/?expand=I 59 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001050 60 Fyfe G, Fisher RI, Rosenberg SA, et al. Results of treatment of 255 patients with metastatic renal cell carcinoma who received high-dose recombinant interleukin-2 therapy. J. Clin. Oncol. 1995;13(3):688-696. 61 Slavin S, Or R, Dray L, et al. Targeted immunotherapy with intentionally mismatched rIL-2 activated donor lymphocytes in an attempt to eliminate minimal residual disease in patients with high-risk metastatic cancer. J Clin Oncol (Meeting Abstracts). 2007;25(18_suppl):21175. 62 Freeman AI, Zakay-Rones Z, Gomori JM, et al. Phase I/II trial of intravenous NDV-HUJ oncolytic virus in recurrent glioblastoma multiforme. Mol. Ther. 2006;13(1):221-228. 63 Personal communication, Nov. 4, 2010. 64 Slavin S, Ackerstein A, Or R, et al. Immunotherapy in high-risk chemotherapy-resistant patients with metastatic solid tumors and hematological malignancies using intentionally mismatched donor lymphocytes activated with rIL-2: a phase I study. Cancer Immunol Immunother. 2010 Oct;59(10):1511-9. Epub 2010 Jun 20. 65 Juhnke, Eric S. Quacks and Crusaders: The Fabulous Careers of John Brinkley, Norman Baker, and Harry Hoxsey. Lawrence: University of Kansas Press, 2002. 66 http://www.iserd.org.il/default.asp?id=924

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