Who would have thought that medical education could help bridge the divide between Israelis, Jordanians, and Palestinians? As CISEPO (Canada International Scientific Exchange Program), a Canadian-registered, nongovernmental organization, has proved, CME can do more than improve health outcomes in this war-torn region of the world. It can bring together doctors and help them see each other as people, neighbors, and even friends.

The impetus for the project began in 1995, one year after the signing of the Jordanian-Israeli Peace Treaty, when CISEPO received a personal invitation from the private office of the late King Hussein to conduct a medical education program with Jordan and its Israeli and Palestinian neighbors.

The choice of CISEPO made sense, since the group had been active in the Middle East since the 1970s, when surgeons from the University of Toronto's department of otolaryngology and the affiliated Mount Sinai Hospital ear, nose, and throat department traveled to Israel to conduct CME courses and to train local fellows. CISEPO began similar programs in the Arab world in the 1980s.

Shortly after King Hussein reached out, CISEPO received similar invitations from the Israeli Ministries of Health and Foreign Affairs and the Palestinian Ministry of Health, with the idea of creating a Canadian-led initiative to facilitate cross-border educational activities around common regional healthcare concerns. And so, a historic moment came to pass. The very first educational exchange program was born to cross-train physicians from Israel, Jordan, and Palestine.

“When I first crossed into Jordan and brought three Israeli colleagues with me to meet their peers for the first time, the moment can only be described as electric,” says Arnold M. Noyek, MD, CISEPO's chair and director of international continuing education, Faculty of Medicine, University of Toronto. He also serves as director, Peter A. Silverman Centre for International Health at Mount Sinai Hospital; and he is a professor for the departments of otolaryngology, medical imaging, and public health sciences at the University of Toronto. “There was a tremendous energy and a strong sense of commitment. I was inspired by the spirit and courage of these Arab and Israeli pioneers who were crossing a great divide as enthusiastic visitors and gracious hosts. They were overcoming a very nay-saying and dangerous environment to shine a ray of hope into a dark corner and build a model for future generations.”

These first tentative steps would set in motion a wave of energy and enthusiasm that has resulted in a far-reaching program consisting of CME courses throughout the region, student exchange programs with Canada, ongoing research, and tangible services to support the people of all three Middle Eastern cultures. New training, research, and education facilities have been built, and the Middle East Association for the Management of Hearing Loss is now established and supports ongoing initiatives. The outcomes of these programs have even affected public health policy in creating universal hearing-loss detection programs for newborns.

Hearing Each Other

From the beginning, the early detection and habilitation of hereditary sensorineural hearing loss and impaired hearing in newborns, infants, and children was identified as an ideal first topic for joint medication education, as it addressed a common health concern for the region. Due to the cultural prevalence of marriage among first cousins, this region of the world experiences a 6 to 10 times greater incidence of this genetic hearing loss than Western nations. A CME program was set up by local teams, working together with Canadian faculty and local experts from the CISEPO network.

“Health problems don't know boundaries,” says Abi Sriharan, scholar in residence, Peter A. Silverman Centre for International Health at the University of Toronto; and volunteer coordinator, CISEPO education programs. “These neighbors share common health issues and needs. Cross border training was needed to help solve a common health challenge.”

To help quantify the extent of the public health problem, a pilot test was put in place after the initial CME courses to learn more about the prevalence of hearing loss in the region. The Canadian International Development Agency — an agency similar to USAID — awarded a grant to start the pilot universal hearing screening and habilitation program.

During this pilot phase, 8,000 Jordanian, 8,000 Israeli, and 1,000 Palestinian newborns were screened. Jordan had the highest rate of hearing loss, and public health officials were eager to do something about it. Based on the data from the pilot study, the Jordanian Minister of Health proposed that all children be screened at birth for hearing loss. Between April 2001 and June 2004 more than 17,000 Israeli, Jordanian, and Palestinian children were screened for hearing loss; and the next step will involve testing 130,000 Jordanian infants, with Israeli and Palestinian involvement to connect deaf children and their families to community-based services.

A range of educational options were developed to support the program. Physicians and other hearing-loss health professionals can come to Toronto to receive training, or they can participate in one of the ongoing regional CME programs. To date, more than 2,500 participants have come to work and study together through the CISEPO program.

Emotional Obstacles

It wasn't easy to gain support for the CISEPO programs. Physicians had to overcome strong cultural resistance. “When we first approached the deans council and told them about the CISEPO program, the council was not respectful about this idea,” says Ziad Elnasser, MD, PhD, CISEPO director in Jordan; and deputy director, pathology and microbiology department, Faculty of Medicine, King Abdulla University Hospital. “They even accused me of being a traitor. I really suffered during this time, but I stood up for the program because I believed in it. We had a peace treaty with the Israelis — adopted by the Royal Court and the Parliament. Those who were accusing me were accusing the government and the peace process. I reminded them that we needed to do this for the sake of our country and the sake of our whole region.”

The deans council eventually approved the program, and Elnasser was declared the director of CISEPO in Jordan. His persistence paid off, and now his university is a central participant in the program.

“Many students from my school of applied medical sciences have joined Israeli and Palestinian students at the University of Toronto School of Medicine,” he says. “They returned [home] with very good impressions, and made presentations about their experiences. I feel it has been a good experience, in spite of a hard beginning.”

Medicine, Not Politics

One factor contributing to CISEPO's success is its program development and funding model. All courses are evidence-based and grounded in science, not politics. The project is only funded through NGO grants — CISEPO will not accept pharmaceutical company funding in order to avoid commercial conflict of interest. The Office of CME, Faculty of Medicine, University of Toronto; and the International CE Directorate provide staff support. All activities are free to participants.

The planning process ensures that programs include input from all of the local partners. Planning committees, set up during each CME course, identify major areas of need for education in order to create ongoing programs. Each CME program has several co-directors, who assure consensus as the multicultural teams, which include medical faculty from all participating nations, develop content. Accreditation is provided by the Office of CME, Faculty of Medicine at the University of Toronto.

Wherever possible, participants avoid discussing politics and focus on the healthcare issues that bring them together. “People follow guidelines that keep the programs focused on content, not politics,” says Noyek, CISEPO's chair. “So far, we have been lucky enough to have great facilitators. In the end, they are all doctors, professors, and healthcare providers. They are all taking a risk for a common goal.”

While the challenges are great, so are the rewards. “I remember the incredible transformation of the first meeting I attended,” says Dave Davis, MD, associate dean of CME, Faculty of Medicine, University of Toronto. “There were several doctors in the room from Israel, Jordan, and Palestine. In the beginning, they were sitting in three separate clusters. The questions would only go back and forth from the lecturer to the clusters. But as we broke for lunch, the doctors started to talk a bit. After lunch, a doctor would ask a question, and an actual dialogue opened up, cross-culturally, between physicians … Palestinian to Israeli to Jordanian. At the end of the day, you couldn't tell who was from which country. These were people now, interacting about day-to-day problems with patient management. It was incredible.”

Keep Hope Alive

CISEPO's ultimate hope is that the cooperative exchange of academic and scientific ideas and the relationship-building, trust, and confidence that the program fosters among participating nations will transcend politics and set a strong example for cooperation and peace-building in the region.

“Overcoming the political differences and focusing on professional issues was difficult,” says Yehudah Roth, MD, chairman, department of otolaryngology — head and neck surgery, Edith Wolfson Medical Center in Holon, Israel; and deputy director, CISEPO, Israel. “But I have met excellent, high-quality professionals, and have learned a lot from them. I had the honor to consult with the late Dr. Al Omari, a leading Jordanian surgeon, an experienced physician, and a key member of the CISEPO network.”

Roth's institution also learned from peers in Jordan. “A year ago, a group of leading otolaryngologists in Israel went to Jordan to learn how teachers there assess resident progress in conducting clinical examinations,” he says. “Several of their techniques were later adopted here.”

CISEPO's goals include introducing new topics and involving more regions of the world. Says Noyek: “Having accepted this challenge, we have a moral obligation to keep growing.”

For more information, visit www.cisepo.ca or contact Abi Sriharan at asriharan@mtsinai.on.ca.

Of Courage and Checkpoints

For meeting planners and participants in the Middle East, dealing with travel logistics such as visas and checkpoints poses serious challenges. Because the CISEPO (Canada International Scientific Exchange Program) CME project is supported by government ministries, the group must be careful to remain politically neutral. Sometimes organizers can help with checkpoint issues and sometimes they cannot.

“This past March, we held a conference in Jerusalem for 250 participants,” says Abi Sriharan, scholar in residence, Peter A. Silverman Centre for International Health at the University of Toronto; and volunteer coordinator, CISEPO education programs. “Our participants from Gaza had to leave their homes at 5 in the morning in order to arrive late that evening.”

Crossing the border from Israel into Jordan is easier, but the border closes at a certain time each day. If potential attendees can't get through in time, the group needs to step in and arrange transportation and lodging options.

Obtaining visas is another hurdle. One young Palestinian medical student lives in Ramalla, which has no Canadian embassy — so she was supposed to travel to Tel Aviv to get a Canadian visa, but she had no Israeli ID card to allow her to travel past the checkpoints. Luckily, CISEPO was able to work with the Canadian outpost in Ramalla to fill out the paperwork with the student. The papers were sent to the embassy in Tel Aviv via courier; a volunteer collected the visa from the embassy and brought it with a plane ticket to the student at the border. The young woman then flew out from Jordan to Canada. “The courage of these students is amazing,” says Sriharan.

A Decade of Bridging Barriers

  • IN 1994, the Jordanian-Israeli peace treaty is signed; part of the treaty encourages both countries to establish programs that involve cross-border collaborations, with the idea that these programs will encourage understanding and facilitate the peace process.

  • IN 1995, CISEPO (Canada International Scientific Exchange Program) is invited by the private office of the late King Hussein of Jordan to serve as a Canadian umbrella organization to foster cross-border health sector collaborative programs between Arabs and Israelis. Invitations and interest quickly follow from the Ministries of Health of Israel and Palestine.

  • IN 1996, CISEPO sponsors the first joint Arab and Israeli CME event in Amman, Jordan, on “Contemporary Otolaryngology in the Middle East.” Local planning sessions and committees are assigned to look into logical next steps.

  • IN 1998, the first cross-border Arab and Israeli professional association — the Middle East Association for Managing Hearing Loss — is formed, with His Royal Highness, Price Firas Raad of the Royal Court of Jordan, as MEHA patron.

  • IN 2001, CISEPO begins a series of telemedicine rounds between Canada and the Middle East; training programs begin in Canada.

  • SINCE 2001, ongoing programs keep the momentum going; topics have now expanded to include youth health, smoking cessation, and nutrition; videoconference programs also invite the participation of more countries around the world.

  • IN APRIL 28, 2004, CISEPO receives the Canadian Red Cross Power of Humanity Award, presented by Queen Noor of Jordan.

Unpredictable Attendance

“Trying to confirm attendance for our conferences is probably the most challenging aspect of our program,” says Abi Sriharan, scholar in residence, Peter A. Silverman Centre for International Health at the University of Toronto; and volunteer coordinator, CISEPO (Canada International Scientific Exchange Program) education programs. “Hotel arrangements, especially contracts, are extremely difficult because of the realities of visas and checkpoints in the region. Sometimes we have to pay attrition fees of up to 50 percent of the total room block because of attendees who could not make it past the checkpoints.” CISEPO tries to book properties that are willing to work with special attrition clauses. Planners also try to book through their local partners (universities and hospitals), who often have stronger relationships with area hotels.