Oncology and Diplomacy in the Middle East

A Conversation With Michael Silbermann, DMD, PhD

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Michael Silbermann, DMD, PhD

Michael Silbermann, DMD, PhD

The Middle East is a vast region comprised largely of developing nations with complicated sociopolitical challenges, violent internecine disputes, and deeply fragmented health-care systems. Not surprisingly, the region’s suboptimal health care contributes to the late diagnosis and poor survival of people with cancer.

In 1996, in conjunction with leaders in the United States, Michael ­Silbermann, DMD, PhD, spearheaded a bold initiative called the Middle East Cancer Consortium, whose charter was to foster collaboration and address the region’s unmet cancer care needs. To gain insight into the Middle East Cancer Consortium and other cancer care–related issues in the Middle East, The ASCO Post recently spoke with Dr. Silbermann, Executive Director of the Middle East Cancer Consortium.

Childhood Tragedies

Please tell the readers a bit about your early background.

My parents emigrated from Germany to Acre, a small town in Palestine in 1934, right after the Nazi Party took over the German government. They didn’t speak a word of Arabic or Hebrew, but they made a good life for themselves. My father was a dental surgeon, opened a clinic, and began treating Arab patients. Despite the rudimentary living conditions—water in the old quarter of Acre was supplied by a Roman aqueduct built 1,800 years ago, which functioned sporadically—my parents were happy.

I was born on January 19, 1935, and several months later, the Arab-Jewish riots broke out in Palestine. One night, a pharmacist friend of my father came by our house to warn us that a local mob was bent on slaughtering us. My father packed up as much as he could, and we fled for our lives, landing in Nahariya, a settlement established by Jews who had escaped Nazi Germany. However, more rioting broke out, and we wandered again to a new home in the Haifa Bay area.

Soon, World War II erupted, and the ensuing years were quite difficult. The Germans bombed the oil refineries and the harbor, and there were massive encampments of British troops surrounding our town. Members of our family were still in Europe, and many perished in the Nazi death camps.

One of the most traumatic episodes in my childhood was during Israel’s War of Independence in 1948, hearing that 43 of our friends were ambushed and killed in a convoy on their way to aid an isolated Jewish community. All of these swirling events and tragedies had a profound effect on my childhood and during high school, I became very engaged in fostering programs to help bridge the gap between Jews and Arabs.

‘An Offer I Could Not Refuse’

Please describe your medical school ­experience.

As you may know, military service in Israel is obligatory. So, in 1955, after completing my service in the Israel Defense Forces, I moved to Jerusalem to study dental medicine at the Hebrew University-Hadassah Faculty of Dental Medicine. I graduated in 1961 and went to Boston, Massachusetts, for specialty training in maxillofacial surgery at Boston City Hospital.

During one grand round, while serving as a chief resident, I asked my chief resident why when applying the same protocol in the OR on 10 patients it works well for 9 but doesn’t work for the tenth? He said, ‘If you’re so curious, go find out.’ So Tufts University applied for and won a National Institutes of Health Young Scientist’s Career Award and I used that stipend to attend a PhD program in basic sciences at Tufts University Medical School in Boston.

As I was finishing my PhD program, I was approached and offered a position to help build a new and unique medical school at the Technion – Israel Institute of Technology in Haifa. Opening a new medical school in my home town in Israel was simply an offer I could not refuse.

It was an exciting and challenging time. After serving for 20 years as Chair of the Department of Anatomy and Cell Biology in the Technion Medical School and 10 years as Director of the Laboratory for Musculoskeletal Research, I was elected the Dean of the school and following my term in office, I was loaned by the Technion to the Israeli Ministry of Health, where I was appointed Chief Scientist of the Israel Ministry of Health in Jerusalem, beginning in January 1993.

Diplomacy Through Cancer Care

What led to the birth of the Middle East Cancer Consortium?

In September 1993, President Bill Clinton signed the Oslo Peace Accord in the White House. Our late Prime Minister, Yitzhak Rabin was there with the late PLO Chairman Yasser Arafat. Following an additional visit to Washington, DC with the Israeli Minister of Health, in the fall of 1995, my minister called me and said that President Clinton had related a story about his youth, which was quite difficult at times. He was very close to his mother, who died of cancer, and before she died, she asked her son to please use his great influence to do something to help people with cancer. President Clinton’s idea was to establish a Middle East Cancer Consortium, which would promote cancer care in the region and at the same time promote better understanding between the Arabs and Israelis—in other words, diplomacy through cancer care, a brilliant idea.

President Clinton shared the idea with his Secretary of Health and Human Services (HHS), Donna Shalala, who in turn approached Harold Varmus, MD, who was then Director of the National Institutes of Health. Dr. Varmus noted that the National Cancer Institute (NCI) was interested in working with the Middle East, so the NCI director, Richard Klausner, MD, flew to Israel to meet me. We had a very productive set of meetings, and he said, “OK, Dr. Silbermann, you are going to design and lead a Middle East Cancer Consortium.”

I told Dr. Klausner that building the science end of the consortium was certainly something I would relish, but the international legal aspects of such a vast undertaking were a bit daunting. Dr. Klausner simply told me to come to Washington and attend a meeting with the legal department of the Department of State, and they will draw up an international agreement. So I did, and it proved to be a fascinating experience. All the participating heads of state signed the charter at the 1996 World Health Assembly meeting in Geneva.

In December 1993, I joined the first Israeli delegation of Doctors Without Borders, which visited Palestinian medical professionals in Cairo, Egypt. Dr. Fathi Arafat, at the time head of the Palestinian Red Crescent, hosted the delegation at his home, which facilitated a fruitful dialogue between the two parties. Ever since, former HHS Secretary Donna Shalala, currently President and CEO of the Clinton Foundation, has supported the Consortium and served as its inspiration.

Creative Collaboration Between Sworn Enemies

Please tell the readers how you negotiated the difficult political dynamics in the Middle East.

First off, the fact that Jordanians, Egyptians, and Palestinians signed the agreement did not make them instantly close friends with Israel. It took a lot of hard work, good will, mutual respect, and patience at the grass-roots level. The original agreement was signed by the United States, Israel, Jordan, Egypt, Palestine, Cyprus, and Turkey. Although these nations are the full members, in all of our activities, we have engaged the participation of about 20 countries in the Middle East.

There is an incredible amount of sensitivity involved in our meetings. However, when you are dealing with cancer, it overcomes the most difficult political conflicts.
— Michael ­Silbermann, DMD, PhD

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Remember, Israel has no diplomatic relationship with about 80% of the countries with which we work. There is an incredible amount ofsensitivity involved in our meetings. However, when you are dealing with alleviating the suffering of patients with cancer and their families, it overcomes the most difficult political conflicts. It is an interesting phenomenon. We’ve put together a publication, and it was not too far back when many of our working partners stated they’d never have their name in print next to an Israeli. Equally impressive is having a Turk and a Cypriot sitting down at the same table, something that no one would have believed possible. So I’m very proud that the Middle East Cancer Consortium has done what the political process still struggles and fails with: creative collaboration between sworn enemies.

Cancer Registries and Palliative Care

Please share a Middle East Cancer Consortium initiative that you feel has enhanced cancer care in the region.

First was the establishment of a network of cancer registries, because we simply had no way to gauge the actual burden of disease from country to country. The project began in 1997 with the establishment of a regional network of cancer registries documenting the incidence of various cancers and stage of the disease at diagnosis. This framework enabled the Middle East Cancer Consortium to build a consensus among its members in developing standards that enable comparisons of cancer incidence in the Middle East. Except for patients with cancer in Israel, we found that about 70% of patients with cancer in the region present with stage III or IV disease on their first physician encounter.

Second, the Middle East Cancer Consortium followed up the regional registry project with a region-wide response to the initial registry information, aimed at developing a formal capacity for palliative care services in the region. To do so effectively, the Middle East Cancer Consortium established a baseline of information on palliative care services in its six partnership jurisdictions, examining barriers to the delivery of palliative care that might exist and promoting solutions.

Palliative care needs are very underserved in the Middle East. Most problematic is pain control, which is partly due to a cultural taboo about opioids in the Middle East extending from North Africa through the Eastern Mediterranean countries, to the Gulf States, and to Central Asia.

In many Arab nations, cancer is still a stigmatized disease; people simply don’t talk about it. Remarkably, in some areas, even doctors are forbidden to discuss the diagnosis with their patients. And when people are in late-stage disease, they refuse morphine and suffer silently. So we have a huge challenge ahead in educating people about palliative care.

Right to Free Health Care

Please describe the health-care system in Israel.

When I was Chief Scientist of the Israel Ministry of Health, I was part of the team that was involved in creating a new health-care bill into law. In effect, it stated that every Israeli citizen has the right to free health-care services. In cancer, this means that a patient receives high-quality care for free, except for some of the very expensive newer targeted biologics, which come with a certain extra cost. The system works, and we have outcomes comparable to those in the United States.

In fact, Palestinian children with cancer come from Gaza or the West Bank into Israel, and we treat them, exactly as we treat any Israeli child (with a survival rate of 82%), for free. Unfortunately, when they return to their towns and develop an ancillary symptom such as fever, the primary care doctors refuse to treat them, as they are not familiar with the oncology treatment they received in Israel. But this is just one more hurdle we have to confront, and I’m positive that in time we will work things out.

I’m proud to have been part of the team that put the Israeli system in place. It’s a good system and treats all our citizens fairly.

A Sense of Hope

Would you like to share any closing thoughts?

Despite the ongoing geopolitical conflicts in the Middle East, the past 18 years have left the Middle East Cancer Consortium with a sense of hope and optimism for better medical and nursing education and improved services for patients with cancer at the primary, secondary, and tertiary levels, including both curable treatments and palliative care.

It is our profound conviction that health issues offer original ways that lead to a new dialogue for mutual understanding. Our goal is to make cancer palliation a shared objective for neighboring populations. Our experience shows that even in settings of political animosity and differences, this sort of humanitarian cooperation in the extended oncology community is possible and positive. ■

Disclosure: Dr. Silbermann reported no potential conflicts of interest.