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Ep.364: Prof. Arnon Afek, Sheba Medical Center

Cannabis Economy Podcast
Ep.364: Prof. Arnon Afek, Sheba Medical Center

Prof. Arnon Afek

Professor @ArnonAfek, on the ‘medicalization’ of cannabis “the most significant results we’ve seen in our clinical trial are the reduction of anxiety and violent outbursts.” A pathologist by profession. Professor Afek graduated from Hadassah Medical School and then served in the army as a medical officer. He was the head of the classification branch at the IDF, which is responsible for the medical classification of all the young people in Israel. When he retired from the army and started his career in the hospital system, he was the deputy director of Sheba Medical Center and went on to the Ministry of Health to serve as the Director of the Medical Affairs, which is equivalent to the Surgeon General in the States. He’s now back at Sheba.

Transcript:

Arnon Afek: My name is Arnon Afek. I'm 55 years old. I'm a physician. I'm a pathologist by profession. I graduated from Hadassah Medical School and then served for many years in the army as a medical officer. I was the head of the classification branch at the IDF, which is responsible for the medical classification of all the young people in Israel. Which is a unique opportunity, because we see the services in the armies and the opportunity and the right of the people. So in Israel, we accept into medical service people which in the USA would never been accepted. With severe asthma and even volunteer with very, very threatening diseases, but we accept them into the army because it's part of our culture and the way the Israeli think.

Seth Adler: Everybody must serve.

Arnon Afek: Everybody must serve. There are certain population which are exempt because of Orthodox religious or where they're being-

Seth Adler: Which is a new wrinkle as I understand it, right?

Arnon Afek: Well, it's something very old, but I mean it's part of the ... It started when Israel was established, but now because they're growing in numbers and they're becoming a central part in our society, we're trying to integrating them in the army and try to find the right way for them to serve, so they will comfortable, though the army, you know, is not the classical religious environment. They will respect them. And of course some of the Arab people, some of the Arab people do serve in the army, by the way. But some find it difficult because, you know, they are their brothers we are fighting against, so we try to respect them as well. So that was the first part of my career, then I retired from the army and started my career in the hospital system. I was the deputy director of Sheba Medical Center, then went to the Ministry of Health, I was the Director of the Medical Affairs, which is equivalent to the Surgeon General in the states-

Seth Adler: So, I wanna unpack those two things, if you don't mind, because we're here and Sheba and thank you for having me.

Arnon Afek: My pleasure.

Seth Adler: It's gargantuan, we were just talking about, this is the largest facility in Israel. But it seems like it must also rank pretty highly world wide. Can you give us a sense of the scope and the scale of the facility?

Arnon Afek: Yes. Well, Sheba Medical Center is Israel's largest hospital, it's Israel's main hospital, what we call the Hospital of the State, because it's a 1,800 bed hospital. It was founded by David Ben-Gurion, who was the first Prime Minister of Israel, and Chaim Sheba was at that time the Director General off the Ministry of Health and the Surgeon General of the IDF, Israel Defense Forces. And they established the main hospital, which has in scope first to treat people, but treat them in a very special way. We think about the '50s, not nowadays. So at that time they created the general hospital, which I direct right now, together with the rehabilitation hospital together, so if someone who's injured or sick can come out of the hospital in the most best functional way possible. So we not only treat them, we rehabilitate them.

Arnon Afek: So this is our first scope. Second we help many other hospitals, especially in the peripheral part of Israel. We have, for example, the Department of Cardiac Surgery in the small hospital in the north of Israel under our help. We help them also radiation oncology and support and so on, so we help all these people and places. And we have also an international assistant program, and we have many residents coming to us, we have a medical school. So we are quite a big hospital.

Seth Adler: Yeah, so and it would make sense then if you had a ... Well, important position at Sheba, that you would be tapped to be the Surgeon General as you say. You know. Equally.

Arnon Afek: You're right.

Seth Adler: Right.

Arnon Afek: I mean it goes both ways.

Seth Adler: Right.

Arnon Afek: Some of the people who were the directors at this hospital were before or afterwards Directors General of the Ministry of Health, and that's exactly what is my, I would say, position in the Ministry after I was chosen in Israel by the Minister of Health at that time. She asked me to become the Director General of the Ministry of Health. For us, it's a political appointment, though for me, I'm not a political person. For me, she took a professional, she wanted someone professional, she didn't want a politician. And when I told her "Minister German, look, I can help you with everything to do with the Israeli healthcare system, with the professional part, but I'm a very poor politicians. Don't ask me to go to the parliament and try to lobby the laws." She said to me "That's exactly what I'm looking for. Forget about the lobbying. I'll do the Knesset, you do the work."

Arnon Afek: My name is Arnon Afek. I'm 55 years old. I'm a physician. I'm a pathologist by profession. I graduated from Hadassah Medical School and then served for many years in the army as a medical officer. I was the head of the classification branch at the IDF, which is responsible for the medical classification of all the young people in Israel. Which is a unique opportunity, because we see the services in the armies and the opportunity and the right of the people. So in Israel, we accept into medical service people which in the USA would never been accepted. With severe asthma and even volunteer with very, very threatening diseases, but we accept them into the army because it's part of our culture and the way the Israeli think.

Seth Adler: Everybody must serve.

Arnon Afek: Everybody must serve. There are certain population which are exempt because of Orthodox religious or where they're being-

Seth Adler: Which is a new wrinkle as I understand it, right?

Arnon Afek: Well, it's something very old, but I mean it's part of the ... It started when Israel was established, but now because they're growing in numbers and they're becoming a central part in our society, we're trying to integrating them in the army and try to find the right way for them to serve, so they will comfortable, though the army, you know, is not the classical religious environment. They will respect them. And of course some of the Arab people, some of the Arab people do serve in the army, by the way. But some find it difficult because, you know, they are their brothers we are fighting against, so we try to respect them as well. So that was the first part of my career, then I retired from the army and started my career in the hospital system. I was the deputy director of Sheba Medical Center, then went to the Ministry of Health, I was the Director of the Medical Affairs, which is equivalent to the Surgeon General in the states-

Seth Adler: So, I wanna unpack those two things, if you don't mind, because we're here and Sheba and thank you for having me.

Arnon Afek: My pleasure.

Seth Adler: It's gargantuan, we were just talking about, this is the largest facility in Israel. But it seems like it must also rank pretty highly world wide. Can you give us a sense of the scope and the scale of the facility?

Arnon Afek: Yes. Well, Sheba Medical Center is Israel's largest hospital, it's Israel's main hospital, what we call the Hospital of the State, because it's a 1,800 bed hospital. It was founded by David Ben-Gurion, who was the first Prime Minister of Israel, and Chaim Sheba was at that time the Director General off the Ministry of Health and the Surgeon General of the IDF, Israel Defense Forces. And they established the main hospital, which has in scope first to treat people, but treat them in a very special way. We think about the '50s, not nowadays. So at that time they created the general hospital, which I direct right now, together with the rehabilitation hospital together, so if someone who's injured or sick can come out of the hospital in the most best functional way possible. So we not only treat them, we rehabilitate them.

Arnon Afek: So this is our first scope. Second we help many other hospitals, especially in the peripheral part of Israel. We have, for example, the Department of Cardiac Surgery in the small hospital in the north of Israel under our help. We help them also radiation oncology and support and so on, so we help all these people and places. And we have also an international assistant program, and we have many residents coming to us, we have a medical school. So we are quite a big hospital.

Seth Adler: Yeah, so and it would make sense then if you had a ... Well, important position at Sheba, that you would be tapped to be the Surgeon General as you say. You know. Equally.

Arnon Afek: You're right.

Seth Adler: Right.

Arnon Afek: I mean it goes both ways.

Seth Adler: Right.

Arnon Afek: Some of the people who were the directors at this hospital were before or afterwards Directors General of the Ministry of Health, and that's exactly what is my, I would say, position in the Ministry after I was chosen in Israel by the Minister of Health at that time. She asked me to become the Director General of the Ministry of Health. For us, it's a political appointment, though for me, I'm not a political person. For me, she took a professional, she wanted someone professional, she didn't want a politician. And when I told her "Minister German, look, I can help you with everything to do with the Israeli healthcare system, with the professional part, but I'm a very poor politicians. Don't ask me to go to the parliament and try to lobby the laws." She said to me "That's exactly what I'm looking for. Forget about the lobbying. I'll do the Knesset, you do the work."

Seth Adler: Perfect. There we go.

Arnon Afek: I loved that part. So I was there, then German ... You know, the government in Israel change all the time, that's part of our democracy. And came Minister ... Vice Minister, I would say, Litzman, Rabbi Litzman. He knew me from before, he said I brought my own Director General. I of course respected, but he asked me to remain as Deputy Director General. It was the first time that he brought a Director General who was not a physician. Until that time, until me, everyone were physicians. So he was the first one not a physician, and he needed someone to assist him with a lot of experience like me, so I remained for two more years there and helped him until he got the, I would say ... And helped him with all the medical issues around, and then I decided that enough is enough.

Seth Adler: Right.

Arnon Afek: Even when you speak about Deputy Director General of the Ministry, and went back to Sheba Medical Center as Director of the Acute Care Hospital. I'm in charge of all the physician, of the academy part in Sheba. I work very hard, but I like working.

Seth Adler: Yeah. When did you call Yuval, or did Yuval call you?

Arnon Afek: Well, it started when I ... One of the first mission I was given by the Director General when I become Deputy Director General, he said to me "Look, the Cannabis issue, someone has to take care of that. So be the ministerial part, the part at the ministry, that takes care of the Israeli Medical Cannabis Agency."

Seth Adler: I see.

Arnon Afek: Now-

Seth Adler: You were there recently then?

Arnon Afek: Yes. I started with Yuval together all these reform ...

Seth Adler: Three years ago. Three and a half years ago. Right.

Arnon Afek: About three years ago, first as Director General, but that was really on a very, I would say, a very high level.

Seth Adler: Sure.

Arnon Afek: But when I was given charge of that, then I got in. And at the beginning, to me, it was quite ... I would say it wasn't very natural. Why? Because I've never even smoked a single cigarette in my life, neither to speak of Cannabis. I didn't even know what Cannabis looks like or how it smells like.

Seth Adler: No relationship whatsoever?

Arnon Afek: No relationship to Cannabis. So the first thing I asked from Yuval to do, bring me to a farm that grows Cannabis.

Seth Adler: Now we see it.

Arnon Afek: And when I did that, it was fascinating. Because a whole new world opened before me. It was really a fascinating world.

Seth Adler: What do you mean by that. You can't mean that you just saw plants, and that was interesting. Really, kind of ...

Arnon Afek: No, of course.

Seth Adler: Open the door for us so that we understand what you actually ... You as someone, a learned man, had to be re-educated completely and totally.

Arnon Afek: You know, we all have our prejudices. And I looked at Cannabis in a very prejudiced way as something that's with drugs, with abuse, with ... And not as a medical plant, and someone which can help people without the so-called secondary gain. This is, by the way, the main problem up to today, because the majority of the people did not undergo the same revolution or new setup in their minds like I went through.

Seth Adler: Right. Right.

Arnon Afek: So I decided to start studying. Whatever you do as a physician, the best thing I think, you know, is to study.

Seth Adler: Right.

Arnon Afek: So I start studying and a whole new world, a fascinating world, opened before me. And here we have a great opportunity in Israel, because, I think the father of modern use of Cannabis is Professor Raphael Mechoulam, and he's here from the Hebrew University where I studied medicine. So he's a great guy, I sat with him, I learned from all the people, and I started to understand that the main way to deal with Cannabis is to try to be as close as possible to medicine and to the world of medicine as we can.

Seth Adler: Yeah.

Arnon Afek: And I know them as physicians, so that was the idea of medicalization. We are not speaking about legalization or decriminalization, it's nothing within my scope. For that there's a parliament, it's their decision.

Seth Adler: That's another thing.

Arnon Afek: It's another thing. It's not my job.

Seth Adler: Right.

Arnon Afek: My job is to try to make the Cannabis as close to a medical grade Cannabis as possible. And with that, to try to help people. And that's exactly, in one word, the essence of the medicalization in Israel.

Seth Adler: Yeah. And before we dive in on medicalization, you're essentially speaking about learning about the endocannabinoid system. It's something that you were not taught in medical school.

Arnon Afek: Od course. Nobody speaks about that.

Seth Adler: For other physicians, other folks that are, you know ... Other doctors that are listening for the first time, to try to get some information about this, what would you say to colleagues?

Arnon Afek: I would say to colleagues it's ... Think of Cannabis the same you think of the dopaminergic system, or any other sympathetic system, or any other type of system in our body. Cannabis works on endogenous receptors, and these endogenous receptors which Cannabis works on, and the different substances within Cannabis ... We know there's THC and CBD and so on. We have endocannabinoid, the substances which professor Mechoulam discovered. And we have within us all signal transduction pathways and brain pathways, the same way that other substances work on. That's the way we should look at them. So of course there is abuse, or maybe use for other purposes, but put it aside. This is our endogenous pathway, you use them the right way, you can help people the same way as you give dopaminergic agonists or antagonists in Parkinson and whatever other diseases. It's no different.

Seth Adler: Right. So if we can match the right compounds form the Cannabis plant with the right-

Arnon Afek: ... receptor in our body, the right pathway, we can help people.

Seth Adler: We can treat the condition.

Arnon Afek: Exactly. For example, there are receptors which are part of our immune system, that has nothing to do with the psychogenic effects of Cannabis. Why to classify it all under the word of misuse, maluse, whatever, in parentheses of course.

Seth Adler: Right, yeah.

Arnon Afek: Look at it in the medical pathway.

Seth Adler: Yeah. And another thing I think to point out would be, if there are hundreds of cannabinoids, only one of them is THC.

Arnon Afek: Right.

Seth Adler: The rest have nothing to do with psychoactivity.

Arnon Afek: We don't know enough. We need to learn much, much more.

Seth Adler: There we go.

Arnon Afek: We still don't know about the Cannabis, we don't know about the other compounds, we don't know about the interactions between ... The degradation product. It's not just the hundreds we have, and the terpenes and the other substances which are within this wonderful plant. There's also interaction we don't even think or dream to know. So we know in a very, very superficial way, but there's one thing we do know, that it helps. It helps. It's not the drug for all the sicknesses in the world, and it's not without side effects. There are. But still, it has many, many beneficial effects, and it helps many, many patients. Give the best example, which I always quote, there are many kids here at Sheba with intractable epileptic attacks. Hundreds a day, which no other drugs help. When they were given Cannabis as a part of a trial, approved by the IRB Committee of Sheba. We started a trial. Blind way. It stopped to be blind after week or two.

Seth Adler: Yeah.

Arnon Afek: We stopped the trial, because we knew exactly who got the drug and who got the placebo, and the experiment was stopped, and the people got-

Seth Adler: To the naked man's eye, right?

Arnon Afek: Right.

Seth Adler: Yeah.

Arnon Afek: And the people ... Yeah. You could see ... The parents came complaining.

Seth Adler: Yeah, right. Yeah.

Arnon Afek: We know why, because they met the other parents with the control.

Seth Adler: Yeah.

Arnon Afek: Which said nothing helped, it's the same thing. And then the other [inaudible 00:15:08] "It's a miracle!"

Seth Adler: Yeah.

Arnon Afek: So the people, the parents whose kids go the placebo came complaining why. You couldn't really do a trial, so it was started with few people, then we went on and we knew that it helps.

Seth Adler: And the reason I say naked eye is because when we say double blind, it turned not blind-

Arnon Afek: No, but the way-

Seth Adler: ... you could see it clearly.

Arnon Afek: ... in good experiments, in good experiments, in something which really helps, which is quite rare in medicine. You don't see that many often. But sometimes you see, and then ethically you cannot continue the trial in these cases. But this is one example. Very, very, I would say, type of example which everyone likes to quote, but in other places it's not as good, or I would say there are other drugs which are as effective, and you should consider this certain drug versus the others.

Seth Adler: Yeah. So you said side effects. And I understand that the side effects are not what opioids provide to us. What do you mean by side effects as far as Cannabis, and if you can strike the balance between Cannabis and otherwise. Yeah.

Arnon Afek: Opioids, it's a very good example. When you consider giving Cannabis to patients, you must remember that because we're not speaking about the recreational Cannabis. I'm sorry that I'm repeating this point again and again-

Seth Adler: Not, that's fine.

Arnon Afek: ... it's very important-

Seth Adler: Here in Israel.

Arnon Afek: ... it's not either taking or nothing, because for your personal feeling. It's either taking Cannabis because, for example for severe pain, or taking opioids. So you must consider the patient where takes Cannabis or takes opioids. So what's worse? So there's some sort of dependence, I agree, but for opioid it's worse.

Seth Adler: Right.

Arnon Afek: And people with mental sickness, diseases, sometimes Cannabis can be harmful to them, but I won't say that opioid is for them is a extremely good option as well.

Seth Adler: Right.

Arnon Afek: So at the end, you cannot give a prescription through the radio, thru the web. You have to meet the patient, see what he takes, how severe is his conditions, what are his diseases. Think of the interaction and consider Cannabis. Don't look at Cannabis as no. There are certain physician, I must say this, for them Cannabis is like black flag. No way I'm going to give Cannabis.

Seth Adler: Okay.

Arnon Afek: On the other hand, there are other physician who say that Cannabis can treat all the world, and let everyone who enters my clinic get Cannabis, be happy and leave me alone.

Seth Adler: Right, yeah.

Arnon Afek: Okay, so it's not ... It's in between, probably.

Seth Adler: It's in between. And so that gets to you and kind of educating physicians. There is the Green Book, which is five books, which are your regulations here in Israel. First I'd like to discuss with you, sir, who might have had a hand in writing this, right?

Arnon Afek: Okay, so the Green Book is part of our regulation. What we did in order to medicalize Cannabis, we started with standardization and good practices. To grow, together with the Minister of Agriculture, to manufacture through a GMP approved plant, to distribute to pharmacies and to dispensing pharmacies, and teach physicians and write down all the medical knowledge, this scarce medical knowledge there is, and I come to it in a second. So we have a GAP, GMP, GDP ... And good security practices. Because we had also to secure the farms because of what we said before. And the most important, because I'm a physician and not a farmer, is the medical grade Cannabis clinical guidelines, the clinical practice what we call the GCP, which I had opportunity to write together with Magister Yuval Landschaft and Boaz Elbo from the Israeli Medical Cannabis Agency, and with Professor Raphael Mechoulam who's ... As I said before, our godfather of medical Cannabis in Israel.

Seth Adler: I like to call him the Copernicus of Cannabis.

Arnon Afek: Exactly. And you know, I think that he should have gotten Nobel Prize for his discoveries.

Seth Adler: Of course.

Arnon Afek: But if someone would give Nobel prize for Cannabis, so ... We spoke about prejudices. No, it's a prejudice ... No, I'm afraid that nobody will give, but anyway, he got the prize of Israel. He's an extremely renowned and known scientist throughout the world, and we had opportunity to write this book, and we edit all what is known. In regarding the clinical indication, which is the heart of the book, very little is known. Why? Because what happened, it ... Cannabis has been used for many, many years. Through the ancient time, the Greek, the Egyptian, the Indian, in India and in China. But, during the recent years, through the 1950s and '60s, the middle of the 20th century, when all medicine underwent a revolution based on what we called evidence-based medicine, it remained out of the Cannabis.

Arnon Afek: Why? Because it was declared a dangerous drug, so you couldn't study it in your lab. Professor Mechoulam was fortunate enough to have very good relationship with the Israeli police, that gave him the Cannabis which they confiscated as a drug-

Seth Adler: But as we know, that's because he knows how to drink a cup of coffee. Right? If you know the story.

Arnon Afek: Okay. And exactly. He was fortunate. Other countries you didn't get that, because you couldn't investigate. If you had it in your lab, you were considered a criminal, so they didn't investigate. And because you couldn't use it for your medical treatment, then you couldn't conduct trials. So there's no evidence-based medicine, so each time I come with an indication, they ask me for evidence based medicine. I tell them there is no evidence-based medicine, because we couldn't get the opportunity to have evidence-based medicine. And then, so some of the people tell me "Start the trials."

Seth Adler: Okay.

Arnon Afek: I said "What about the patients who are sick right now?" We can't always wait for these trials.

Seth Adler: Right.

Arnon Afek: So what we did, apart from collecting all the little information, the scarce information there is on the internet, we also started working with group of leaders in each one of the medical fields. Physician, Israel Medical Association, scientific boards, and we sit together, we add up the information, we start with an indication, and I tell you, we know that some of them, with time, with more and more information that we get in, we probably will declare uneffective, or even worse. But I do believe that in meantime, we will add more indications. And I hope more and more with time, based on evidence-based medicine trials. For example, there's a huge trial conducted right now at Shaare Zedek, which we all wait for the results regarding what Cannabis in autism.

Seth Adler: Yes.

Arnon Afek: We're looking forward. It can be a revolution, because we know, we have anecdotal saying that it helps.

Seth Adler: Yeah.

Arnon Afek: And we don't really have as a medical profession to help ... Much help these people, unfortunately.

Seth Adler: And maybe that is the answer to my question, which is, if we've got the nervous system and the immune system, which can be affected by Cannabis, which is remarkable in and of itself. The fact that you jump to autism as well, or that it can treat autism, I'm surprised that the research community, at a very high level, are surprised at the results, or at least the prospective results of Cannabis with autism. Why is that?

Arnon Afek: Because we don't really understand autism. I think there is a lot of evidence lacing about autism, and we feel very frustrated ... I'm not an expert in pediatric medicine, I'm a pathologist by profession, and I'm a cardiovascular pathologist. So I'm not really well within the research, but I know about autism, and we don't understand enough autism. We don't understand how people get it. We understand that it's becoming a bigger and bigger problem through time. And maybe we diagnose more than we used in the past, or I would say less severe cases, more milder cases are being diagnosed right now, and we try to help the people.

Seth Adler: Right.

Arnon Afek: But you know, it's a spectrum of a disease. And in severe cases, which the family stand and have nothing to do, then I do hope that we'll be able to help with Cannabis. You're right, it's not unlogical that it will help. But to me to say it helps means also to open up the ... If I know that Cannabis helps, and I know or partly know the pathways, the brain pathways of Cannabis, it might open opportunity for researchers that study autism to learn about the brain pathway and the pathogenesis or the etiopathogenesis of Cannabis.

Seth Adler: Right.

Arnon Afek: So I'm very, very excited to hear what are the result when they will open up and will tell what the results of the trial are. I think it will cause an international "Wow!", or international ... At least I hope if it will be positive, we hope.

Seth Adler: Right, yeah. All right, so we will wait on that. In the meantime, you are taking physicians through the GCP, the Good Clinical Practices. So take us through exactly what's happening with the doctors that you already have seen, that have gone through these classes, and the ones that are coming.

Arnon Afek: As I told you before, we decided to make it as close to medicine as possible. So what these physicians can do, they can take the patients, they can check them. And then at the end, if they decided Cannabis is the right answer for them, based on what they learned through our courses on the medical clinical guide, or their medical decision, then they can describe Cannabis and give permit to Cannabis. And you go to the pharmacy, you buy medical grade Cannabis. It's not the same Cannabis you grow in your background with the birds around and all the pollution. It's Cannabis which was grown under the GAP and produced without contaminations and can be given to kids with cancer and nausea and vomiting, which we know Cannabis help.

Seth Adler: Right.

Arnon Afek: So it's different, and this was, in fact, part of the new method what started it less ... Five days ago.

Seth Adler: Exactly.

Arnon Afek: The first time a patient went to the physician, got a prescription, went to the pharmacy, bought Cannabis oil, and was given ... I'm very proud. That means we're still on trial or pilot, but we are on the right track, I believe.

Seth Adler: Absolutely. And you mentioned that physician that was able to prescribe, and it's because of those classes. Just give us a sense of what happens in the room, and by that, in part, I mean what are the physicians ... Their minds are changing in front of you. And that must be interesting to see, from a fellow ... Right? Doctor.

Arnon Afek: Those who come are ones who of course believe in Cannabis. If they don't believe in Cannabis at all, then they aren't objective to it, like a large part-

Seth Adler: You're starting-

Arnon Afek: ... of the medical world.

Seth Adler: Yeah.

Arnon Afek: But they don't really know all what we are going to tell them. So once they get in, and I see their inquisitive minds ... I know how physicians are thinking and working.

Seth Adler: Exactly.

Arnon Afek: And throughout our very long training, we learn to think in a very scientific method. And what we give to them is the idea and the notion and the information, that says Cannabis is like an ... Not any other medical plant. I would say any other medicine, because it's not a single dose.

Seth Adler: Right.

Arnon Afek: But still. And that's something that changed their mind. We give them the proof, and I even give a lecture. I lecture on the ethical issues of giving Cannabis, exactly a case ... I give them a case of a woman who was pregnant. We don't give Cannabis in pregnancy, but in her case, because she ... We re-discussed the issues, and when we considered the alternative, the opioid alternative, we decided even looking at the side of the fetus and its rights and chances of survival, intrauterine growth, it's even better Cannabis than other. We took the decision, with the leading teratologist of Israel, with the ethical advisor, her personal gynecologist. So we did it ... And I discussed this case with them, because we had so many ethical issues that we had to face. I did it at the highest ministerial level, because it's such a tough decision to make. Giving Cannabis in pregnancy it's one of the hardest decision, but as a physician you can take, but still ... You know, every patient is different every situation different. It's not that I'm going to prescribe Cannabis to all pregnant women. The answer is no.

Seth Adler: Right.

Arnon Afek: No, no and no.

Seth Adler: Well, I spoke to Mauro [Maricone 00:28:46], because there is risk there, so to speak. I'll put it in my words, it's probably not very medical. But what you're saying is based on the other risks, this was the risk to take. Understood. So you are seeing doctors' minds change in front of you.

Arnon Afek: Exactly.

Seth Adler: As we go here, as far as the GCP, what do you expect over the next 6 months, 12 months, 18 months?

Arnon Afek: A huge decision should be taken by the Israeli government whether to export or not Cannabis. Why is it important? Israel is a very small country, and a very, very limited market. And to sustain, Israel as a country highly depends on export. Mainly not of export, of ideas of startups, of innovations like ... I always quote ... You were today, you told me, at the Volcani Institute.

Seth Adler: Sure.

Arnon Afek: They invented there the cherry tomato. Would you believe that the cherry tomato was invented in Israel?

Seth Adler: In the building I was in?

Arnon Afek: In the building you were in. Did you know that, for example, Israeli people invented the disk-on key? The disk-on-key changed our world. It's something you carry all the information in your pocket. So it also was invented by Israelis. Now, in order to sustain our startup nation, and all the ideas that has to do with Cannabis, you have to export. You can not keep it within your very small market. You don't need more than one plant GMP approved to produce all the Cannabis you need for Israel. But in order to increase this, you have to export. And the government and the Chief Economic Advisor of the Prime Minister of Israel today said that they ... With the precaution he took, he's for the export, and I hope it will be ... Why I think it's important, apart from the Israeli economy.

Arnon Afek: The second issue, because this method I think is good for many, many other countries with Western type medicine like Israel, and it will be an opportunity for them to learn and to know the ways, and to be back to us. Because I told you, I am not sure that all the indications we wrote are so effective. Even speaking with my ... Describing so, in such green lights ... The issue of epilepsy, that doesn't mean that all epileptic kids Cannabis is the answer.

Seth Adler: Right.

Arnon Afek: For a certain population, well chosen, it might be the answer. But many other ... There are other answers even better. I don't know.

Seth Adler: Right.

Arnon Afek: So sharing information means people from all over the countries with larger population can come back to us and tell us look or not.

Seth Adler: This is what we found. Right.

Arnon Afek: Cannabis help, but it's not just Cannabis. Cannabis with THC X percent, CBB the other, CBN the third. So we ... To standardize, and they come back. So it's vital for us to use our method.

Seth Adler: Yeah.

Arnon Afek: Everything is free on the internet. The GAP are in Hebrew, although I know may countries told me they already translated it. The GMP, we are writing it in English. The Green Book, it will be in English. We have the first edition, now we are working on the second edition, which I hope will bring a true message, medical message to the world.

Seth Adler: Unbelievable. We will keep checking in with you as that evolution occurs. I have three final questions for you, I'll tell you what they are, I'll ask you them in order.

Arnon Afek: Okay.

Seth Adler: What most surprised you in Cannabis, this is gonna be a difficult question to answer. What's most surprised you in life, which actually might be easier, and on the soundtrack of your life. One track, one song, that's gotta be on there. I do ask that of everyone. First things first. What's most surprised you in Cannabis?

Arnon Afek: I think what surprised me in Cannabis is the emotional issue that has to do with Cannabis. When I went to the parliament as Director General of the Ministry of Health and spoke about things which, to me, looked the most important in the world, like gender differences in acute MI between men and women. One, women are not diagnosed. Nobody came to the committee at the Knesset, at the parliament. You will speak of Cannabis in their rarest, nobody heard of disease, the whole room is full of people. People speak about Cannabis in a very emotional way. You add in our leading internet newspaper site Ynet, some news about Cannabis you will have millions of people entering. Speak about other medical issue, nobody cares. So it's a very emotional, and I still don't understand it.

Seth Adler: Interesting. What's most surprised you in life?

Arnon Afek: Life itself. It's a miracle.

Seth Adler: It really is.

Arnon Afek: It's a miracle, it's ... I think there is ... If you want to see there is divine force, but think of the wonderful world. Think of Cannabis. How God, or how nature made such a plant, a wonderful plant with so many effects appear. How did they know to create cannabinoid, the effect, the endocannabinoid system? It's so wonderful.

Seth Adler: It is. It's amazing. All right, this will probably be the most difficult question for you, on the soundtrack of your life. One track, one song that's gotta be on there.

Arnon Afek: So I would pick a song in English you know, I think. The song is called You Raise Me Up.

Seth Adler: Ah.

Arnon Afek: Do you know it?

Seth Adler: I don't know it. Who's the artist?

Arnon Afek: The artist is Josh Groban, and it says like that "You raise me up so I can stand on mountains. You raise me up to walk on stormy seas. I am strong when I am on your shoulders. You raise me up to more than I can be." You can look for the lyrics.

Seth Adler: We will.

Arnon Afek: It's on YouTube, as usual. Everything is.

Seth Adler: Everything is, exactly.

Arnon Afek: Including Cannabis.

Seth Adler: Professor Afek, thank you so much for your time, we'll check in with you down the line.

Arnon Afek: With pleasure. [Hebrew 00:34:40].

Seth Adler: And there you have Arnon Afek. Very much appreciate his time. Very much appreciate your time. Stay tuned.

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Cannabis Economy is a real-time history of legal cannabis. We chronicle how personal and industry histories have combined to provide our current reality.