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Between official negligence and popular unawareness
Health and the Arabs in Israel
"The Palestinian minority in Israel has a shorter life span than the Jewish majority, is sicker, and has less access, physical and financial, to health services and health-supporting conditions (sanitation, water, electricity, roads)." The words belong to Shulamit Avni of Physicians for Human Rights, speaking to Challenge on July 18, 2007.
One major indicator is the infant mortality rate among Arabs. It has declined over the years because of the high level of Israeli medicine in general, but the gap between Jews and Arabs remains. According to the Mossawa Center (Press release, June 18, 2006): of every thousand births, 3.23 Jewish babies die, compared to 7.96 Arab (15.8 among Bedouin). The gaps also remain in two other indicators: general mortality rates and life expectancy.
To the factor of ethnic discrimination we may add that of social class. The Arabs in Israel are the poorest sector. Accordingly, they suffer most from the privatization of medical services.
The poverty-illness connection
Despite the gaps, 91% of the Arabs in Israel say they are satisfied with the countryâ€™s health services, a slightly higher rate of satisfaction than among Jews. (1) The reason, probably, is that the National Health Law of 1994 cut the previous link between the payment of dues and the right to health care. The new law obliged the entire population to enroll in a health fund or face prosecution. Earlier, some 190,000 citizens-mostly Arabs- had no medical coverage at all. (2)
The new health law allotted money to the four health funds according to the number of members in each. As a result, the funds competed for members, recruiting from the periphery, including Arab villages. This led to the establishment of new clinics there, making primary health care more accessible.
The new law had a negative side, however. It permitted the Health Funds to offer a higher level of services to those who could pay. Two classes of health-service recipients were created. According to Physicians for Human Rights ("The Health System in Israel: Circles of Inclusion and Exclusion," April 7, 2007), the new law at first seemed to provide "a very progressive apparatus of inclusion, making it obligatory to enroll very weak populations in the public health services, people who were not previously insured in the Health Funds. But it soon became apparent that the law was nothing but another tool aimed at privatizing the health system."
The report explains that a supplementary law to the budget for 1998 "allowed the Health Funds to charge more for medicines and medical services and to add new dues for additional services. Today an ever widening population must forgo medicines and vital treatments because of their cost." In 2005, 15% of Israelis reported that they had to do without prescribed medicines.
In the year 2003, in the Arab sector, 39% reported that they had to forgo prescribed medicines because of economic hardship (Israelâ€™s Central Bureau of Statistics, 2004). Many factors are involved in the low level of health among Arabs in Israel. We may list the lack of infrastructure, the crowded living conditions, and the language barrier that they encounter on seeking medical services. (There is no trace of Arabic, for example, on the health-fund websites.)
But the decisive factor is poverty. Such is the conclusion of a research paper from July 2003 entitled " Equity and the Israeli Health Care System: Relative Poverty as a Health Risk Factor," by the Taub Center for Social Policy Studies in Israel.
The study begins with the statement that "the level of health in Israel is among the highest in the world." It continues, however: "There are gaps on either side of the average, connected to differences of economic situation, population traits and availability of medical services. There are signs that the discrepancy is likely to increase with the continuation of present trends in the divergence incomes, the funding of the health system, and the allocation of its resources."
The study finds that the increasing inequity causes "a decline in the ability of the weak groups to cope with difficult health conditions... These things hold... especially for the periphery and the Arab sector. In addition to the negative influence of the funding apparatus, they also suffer from low physical access to services in comparison with the central regions-despite the fact that the health situation of these populations is inferior."
The Taub study found a correspondence between mortality rates and socioeconomic index both among Jews and Arabs. It states that "the problem is more acute in the Arab population because of the more widespread poverty there." It likewise found that "weak groups that are subject to (relative) deprivation are exposed to special risk factors such as tobacco and drink...There is indication that health is harmed by psychological pressures derived from social isolation, low social status, job pressures and employment uncertainty." All of these characterize the Arab population.
A closed circle is created when the decline in health causes loss of income from work, an increase of medical expenses, and a consequent deepening of poverty.
The study points out that family expenditure for health has risen from 3.8% to 4.9%. This rise comes at the expense of other treatments, such as dentistry (not included in the health funds), and inhibits people from taking on the additional expense of supplementary health plans. In 2005, according to the Brookdale report (Endnote 1), only 47% of the Arab population had supplementary health coverage, compared with 79% of the population overall.
Lack of access to medical services
Despite the rise of clinics in Arab villages, the gap between the Arab and Jewish populations remains. In an article for the Mossawa Center (July 2007), Amin Fares writes that the Health Ministryâ€™s development budget for 2007 amounted to about 225 million shekels (NIS)-$55 million- of which only NIS 1.3 million (about 0.4%) was slated for Arab localities, mainly to build family health stations. This kind of allotment is typical. Yet Arabs constitute almost 20% of the population.
In 2007 the Mossawa Center issued reports on health services during the Lebanon War. These state that many of the problems suffered by the Arabs in and after the war resulted from a lack of psychological treatment. The schools, for example, are woefully short of Arabic-speaking psychologists (the shortfall is estimated at 75%). Emergency services, such as ambulances, were also lacking. The three hospitals in Nazareth (the only Arab hospitals in Israel) are underdeveloped. The Health Ministry designated NIS 8 million for them as part of the postwar recovery, but this sum does not appear clearly in the national budget for 2007.
Ever since the passage of the National Health Law, independent clinics have arisen, although they are linked to the health funds. Any two doctors working for a health fund can team up, provided that each has at least a thousand patients on file, and establish their own clinic, including a nurse and a secretary. The health funds encourage this trend, because it enables them to increase membership in distant places without investing in infrastructure, specialists or equipment. The doctors work in the regular health clinics for part of the day, after which they increase their salaries by working in their own. They receive patients from the health-funds and are paid by the latter, according to the number of visits they receive.
The new clinics have the advantage of accessibility, for many are located in parts of the villages where no public transport is available, and they also offer the possibility of a personal relationship between doctor and patient. On the other hand, they relieve the health funds of responsibility to establish full-scale clinics staffed by expert doctors with advanced equipment. Today, independent clinics treat 40% of Arab patients.
The main problem of the independent clinics concerns chronic illnesses (such as diabetes, high blood pressure, heart ailments) and cancer (where early detection is important). Patients suffering from these are referred to the central clinics or the hospitals, but the small staff of the independent clinic is unable to perform the necessary follow-ups. The patients themselves are not usually conscious of the need for follow-up. These drawbacks, as well as the distance from specialists and advanced equipment, render the large proportion of independent clinics problematic.
Shulamit Avni points to the core of the problem: "In order to stop the continuing discrimination practiced against the Palestinian minority in Israel, the State-and its various authorities-must diligently build a long-term strategy and initiate a policy of affirmative action in infrastructures. Such a policy must relate not only to closing the gaps in the level of health, but also to a major improvement in the socioeconomic conditions that have a detrimental impact on the right to health. These include gaps in income, education and access to the labor market."
The First Victims are Women
The Arab diet and way of life used to be more wholesome than today. Women worked in agriculture and ate homemade food. Their cancer rate was much lower than that of Jewish women. It is still lower (among Arab men as well), but the tendency is reversing in alarming proportions. Heart disease was and is higher among Arabs, and fewer recover from it. In these illnesses, diet plays an important role along with genetic factors. (Barbara Swirski, Hatim Kanaaneh and Amy Avgar, "Health Policy Goals for the 21st Century" (Hebrew), Adva Center, December 2000.) As in other fields, Arab women are on the bottom rung when it comes to health. 42% are overweight. Dr. Ablah Abu Alawan, head of a Klalit health-fund clinic in Nazareth, explains: "Our society is in transition between the traditional country way of life and the consumer mode of the affluent society. But the fact that women do not go out to work, and their lack of awareness about the risks of excess weight and the importance of exercise, make the problem more severe."
As a result of changes in the Arab way of life, the rate of diabetes among Arab women is double that among Jewish. Noha Zeidan, a clinical dietician, told Challenge on July 20: "By the time they are 36 years old, 42% of the women are overweight, and within ten years they have diabetes. The main reason is that they have adopted fast food such as hamburgers, shwarma, and pizza. This coincides with the entry of the big chains into the villages. These compete with the neighborhood stores, selling stacks of goodies and candies."
"Arab women," claims Zeidan, "seek to copy the western kitchen in all its forms without having first learned the importance of weight watching, exercise and regular checkups. Ramadan, for instance, which used to be mainly a month of prayer and spirituality, has become a month where the stress is on eating, and plenty."
According to Zeidan, "Womenâ€™s lack of independence and their inferior social status cause psychological pressures that hasten the eruption of illness. The society pushes women to serve the extended family and neglect themselves. Another factor is their distance from mammography and ultrasound equipment. Many find in food a kind of compensation for all that is lacking in their lives."
The basket of subsidized medicines does not include birth control devices. The Association for Civil Rights in Israel, along with others, petitioned the High Court for their inclusion, saying: "Unwanted pregnancies keep women from gaining autonomy over their lives and bodies. They are less able to exercise their right to plan the timing of pregnancies." The Court rejected the petition.
Abu Alawan and Zeidan stress how important it is to change certain customs. There is the absurdity, for example, of serving cigarettes in the house of mourning, despite the high rate of lung cancer among Arabs. Or there are the rituals of hospitality, in which food is piled sky high and sweet drinks multiply.
As an example of a positive measure for changing habits, Abu Alawan points to the walking paths, three kilometers long, that the Klalit Health Service has established in a number of Arab villages. "The woman," she says, "isnâ€™t just the weak factor in the society. She is also the factor for change and renewal. Doctors should take on the task of raising the consciousness for change, especially among women, and women must meet the challenge."
(1) Revital Gross, Shuli Brammli-Greenberg and Ronit Matzliach, "Public Opinion on the Level of Service and Performance of the Health Care System Ten Years after the Introduction of National Health Insurance," Myers-JDC-Brookdale Institute, 2005.
(2) The new law exacts a health tax based on monthly income (3.1% of gross wages for the first 2000 NIS, 4.8% thereafter), with a parallel tax on employers. For poorer families this amount is lower than the dues they previously paid. The unemployed are charged about 138 NIS ($35) per month. Patients must also pay about 15 NIS for each doctorâ€™s visit or other service, and although most medicines are subsidized, patients have to pay for them as well.