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Introduction

This workshop on foodborne disease and public health was one in a series of cooperative exchanges between Iranian and U.S. scientists working in these fields. The workshop began with welcoming remarks by several speakers: Michael Doyle, co-chair of the Food and Nutrition Board of the Institute of Medicine (IOM); Glenn Schweitzer, director of the Office of Eastern Europe and Eurasia of the National Research Council (NRC); Linda Meyers, director of the Food and Nutrition Board; and Mohammad Reza Zali of Shaheed Beheshti University of Medical Sciences. This chapter summarizes their descriptions of the objectives of the workshop and also provides background information about the National Academies, the IOM, and U.S.–Iranian cooperation on foodborne disease and public health. In addition, this chapter contains background information on the Iranian health care system that was abstracted from later presentations by Ali Ardalan and Mohammad Reza Zali.

SPECIFIC OBJECTIVES

One specific objective of the workshop was the publication of a summary that would be of interest to specialists in both Iran and the United States. The workshop initially was intended to address issues relating to the prevention of foodborne disease. Given the stated objective and the variety of interests of participants and of the institutions and organizations represented, the workshop planning committee decided to cover a broad range of topics during the meeting. These topics included food-



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1 Introduction T his workshop on foodborne disease and public health was one in a series of cooperative exchanges between Iranian and U.S. scien- tists working in these fields. The workshop began with welcoming remarks by several speakers: Michael Doyle, co-chair of the Food and Nutrition Board of the Institute of Medicine (IOM); Glenn Schweitzer, director of the Office of Eastern Europe and Eurasia of the National Research Council (NRC); Linda Meyers, director of the Food and Nutri- tion Board; and Mohammad Reza Zali of Shaheed Beheshti University of Medical Sciences. This chapter summarizes their descriptions of the objec- tives of the workshop and also provides background information about the National Academies, the IOM, and U.S.–Iranian cooperation on food- borne disease and public health. In addition, this chapter contains back- ground information on the Iranian health care system that was abstracted from later presentations by Ali Ardalan and Mohammad Reza Zali. SPECIFIC OBJECTIVES One specific objective of the workshop was the publication of a sum- mary that would be of interest to specialists in both Iran and the United States. The workshop initially was intended to address issues relating to the prevention of foodborne disease. Given the stated objective and the variety of interests of participants and of the institutions and organiza- tions represented, the workshop planning committee decided to cover a broad range of topics during the meeting. These topics included food- 

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 FoodBoRnE dISEASE And PUBlIC HEAltH borne disease surveillance; issues in microbiology, including laboratory testing and the intestinal microflora; the application of risk-assessment methods to food microbiology; selected aspects of cancer; potential associ- ations of chronic diseases with the gastrointestinal microbiota; approaches to medical training and medical-research training; and potentially fruitful forms of further Iranian–U.S. scientific collaboration. A second specific objective was to help the Iranian guests make last- ing contacts with Americans working in the same field. To maximize the effectiveness of the workshop, Schweitzer urged all present to ask questions and make comments and suggestions. In particular, he invited participants to help generate a list of suggestions for future collaborative activities. BACKgROUND The National Academies and the Institute of Medicine Presenters: glenn Schweitzer and linda d. meyers The National Academies, originally established by the U.S. Congress as the National Academy of Sciences nearly 150 years ago, assist the federal government on questions involving science, engineering, and medicine. The National Academies now comprise four organizations (the National Academy of Sciences, the National Academy of Engineering, the IOM, and the NRC). Besides the many employees of the National Acad- emies, elected members and other experts volunteer their services in the preparation of reports of the National Academies. Many of these reports provide advice for the U.S. government. The international programs of the National Academies work to: (1) improve communication among scientists, engineers, and medical specialists; and (2) promote peace and prosperity and equality around the world. The IOM was established in 1970 and has approximately 1,600 elected members. The IOM program is organized into nine areas—population health and public health practice; health sciences policy; health care ser- vices; global health; food and nutrition; children, youth, and families; African Science Academy development; military and veterans health and medical follow-up; and health policy educational programs and fellow- ships. Each of these program areas has an advisory board of experts who volunteer their time. The foodborne disease and public health workshop that is the subject of this report was a collaborative effort between the IOM’s Food and Nutrition Board and the NRC’s Policy and Global Affairs Division. The National Academies and the IOM probably are best known for

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 IntRodUCtIon their committee reports—reports written by balanced, expert commit- tees. Such reports undergo a rigorous peer review process and include evidence-based recommendations. In the area of food safety, the IOM has published committee reports on a number of topics, including the safety of genetically engineered foods (NRC, 2004), seafood safety (IOM, 2007), and the safety of new ingredients in infant formula (IOM, 2004). In another vein, the IOM and the Food and Nutrition Board have produced several reports on the prevention of obesity in children. Other types of activities sponsored by the National Academies and the IOM include workshops, roundtables, symposia, and fellowships. Iranian–U.S. Collaboration on Public Health Presenter: mohammad Reza Zali In 1999 a new scientific relationship between the United States and Iran began with a visit to Iran by a delegation from the National Acad- emy of Sciences. During that visit representatives from the two countries agreed that mutual cooperation and education could lead to greater prog- ress for both nations and also serve as the basis for future collaboration. At a subsequent workshop on education held in Italy, participants agreed that, given its importance as an international health issue, foodborne dis- ease would be a suitable subject for an Iranian–U.S. collaboration. Then, at a 2003 meeting in France, a delegation of U.S. and Iranian experts developed plans for a workshop on that subject. 00 Workshop In October 2004 the Research Center for Gastroenterology and Liver Disease of Shaheed Beheshti University in Tehran hosted an Iranian–U.S. workshop on surveillance systems for foodborne diseases. Its purpose was to initiate contacts between Iranian and U.S. experts in order to exchange information about activities in the two countries related to such surveillance systems and also to set up a program for future cooperation. In addition to the Iranian and U.S. experts, representatives from the World Health Organization and the Food and Agriculture Organization partici- pated in the workshop. Participants identified three aspects of foodborne diseases for Iran and the United States to investigate more intensively: surveillance research, international trade, and risk assessment. After the workshop, the U.S. participants visited several production, research, and clinical facilities in the greater Tehran area and continued discussions with their counterparts at those facilities. The next year, in 2005, William E. Keene, a senior epidemiologist from the Oregon Department of Human

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 FoodBoRnE dISEASE And PUBlIC HEAltH Services, and Glenn Schweitzer visited health centers and primary health care units in Iran to increase communication about health care between the two nations. Proceedings from the 2004 workshop were published in 2006 (NRC, 2006). One result of the 2004 workshop was the establishment of a labora- tory for the identification, isolation, and culture of relevant bacterial food- borne pathogens at the Research Center for Gastroenterology and Liver Disease, where the workshop had been held. Later, the Center expanded to include work on various viruses and parasites. Thanks to the teamwork and cooperation of colleagues, the laboratory is now a major center for the evaluation of foodborne diseases and a reference laboratory for the investigation of illness outbreaks. The Health Care System in Iran Presenters: Ali Ardalan and mohammed Reza Zali In Iran, a private health care system works in parallel with the public health care system, but a large majority of the population relies on the public health care delivery system. In the public sector, the Ministry of Health and Medical Education is responsible for health services delivery, medical education, and medical research. Figure 1-1 shows the organi- zations that fall under the aegis of the Ministry of Health and Medical Education. Notably, the medical education system and the public health service delivery system are integrated. The structure of the Iranian primary health care system is depicted in Figure 1-2. Each of the urban health centers has many satellite units (called health posts) that provide primary health care. The urban health centers also each work with several rural health centers. These centers, in turn, have satellite units (called health houses) that provide primary health care services to surrounding villages. Trained community-health volunteers are an important part of the system. Each volunteer covers 30 to 50 households. Health houses and health posts collect and maintain information on the health of those they serve. The health houses and posts send reports to the health center above them, which, in turn, reports up the line. The health-information system that keeps track of all these data includes such elements as household folders, vital horoscopes (up-to-the- hour accounts of births, deaths, and family-planning activities), log books, and report forms, as well as health network information software. 1 This content was abstracted from later presentations by Ardalan and Zali.

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Ministry of Health and Medical Education Medical Sciences Blood Transfusion Universities: 55 Organization Office of Pasteur Institute of International Iran Collaborations Councils and Board of Trustees Deputy of Human Deputy for Food Deputy of Research Deputy of Education Deputy of Health Resource and and Drug and Technology and Student Affairs Development Landscape view FIgURE 1-1 Organization of the health care system in Iran. SOURCE: M. Zali, Shaheed Beheshti University of Medical Sciences. 

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 FoodBoRnE dISEASE And PUBlIC HEAltH Province Health Centers District Health Centers Urban Health Centers Health Posts Rural Health Centers Health Houses FIgURE 1-2 Structure of the primary health care system in Iran. fig 1-2The Current Workshop Presenter: mohammad Reza Zali With its ongoing modernization, the availability of university and agricultural resources within the country, and a population of more than 70 million people, Iran is evaluating its current status with regard to the control of foodborne diseases and is seeking input from its U.S. colleagues. In addition, the Iranian representatives to the current workshop have a special interest in addressing such conditions as post-infectious irritable bowel syndrome, post-diarrhea arthritis, and post-infectious inflamma- tory bowel disease—health problems that are increasing in frequency in Iran and that may be linked to the consumption of unsafe food. Mohammed Reza Zali expressed the hope that this workshop’s pre- sentations, productive discussions, and the exchange of views on food- borne diseases and on applications of modern technology and science would advance prevention efforts in both countries.