Goals and Background
Goals
Background
National Health Insurance Law
The Absence of Palestinian Arabs from Decision-Making Positions
Infant Mortality
Household Accidents among Arab children
Educational and Psychological Counseling
Learning Disabilities
Mental Health
Educational Opportunities
Lack of Arab Paramedical Professionals
Hereditary Diseases
Elderly Care
The absence of emergency medical services in the Arab unrecognized villages
Goals
Using advocacy, education and research, the Health Rights Center works to achieve optimal health and equal services for the Palestinian minority in Israel.
To accomplish this, we strive to:
Research the health status of Palestinians living in Israel, and the services provided to them, and promoting knowledge of their rights to these services. Raise Palestinian Arabs´ awareness of behaviors that endanger good health, by conducting educational programs and publishing and disseminating prevention-focused educational materials in Arabic. Motivate government agencies to provide the Arab community with quality health services through the full implementation of the National Health Insurance Law, and improvements to Israel´s health care system. Work with health-related NGOs, local and national government, and Arab health professionals to advance the overall state of Arab citizens’ health. Empower individuals to engage in healthy physical, social and psychological practices.
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Background
Introduction
Official health policies in Israel have developed to suit the needs of a primarily westernized Ashkenazi Jewish population. This approach has systematically ignored the needs of the Palestinian community. Since 1948, when the indigenous Palestinian community was forced into minority status in Israel, the community has endured an official health policy resulting in marginalization. This fact gains poignancy when we consider the holistic definition of health: a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. According to the World Health Organization´s Constitution, the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, political belief, economic or social condition.
Health status is impacted by a number of factors, including heredity, environment, lifestyle and healthcare delivery system. One of the most important factors is socio-economic status, which has been shown to have a major influence on levels of health in every country in which it has been studied (Giraldes, 1991). Educational attainment, particularly of mothers, is also directly related to the health of the community, as is unemployment, which often leads to multiple psychosocial and psychosomatic ailments in the unemployed and his or her family (Westcott, 1985).
In general, the health of Israelis compares favorably with that of residents of other developed countries. Life expectancy at birth is 76.7 years for men, a figure slightly higher than average for high-income countries, and 80.9 years for women, somewhat lower than the average for high-income countries. Two thirds of all deaths in Israel are caused by heart disease, cancer, and cerebrovascular diseases – the leading causes of death in the developed world.
Arab citizens of Israel have a low socio-economic status, so it is not surprising that their health lags behind that of the Jewish population. This is unsatisfactory, as planned national support systems have achieved a comparatively high health status level for large groups of Jewish immigrants arriving in Israel with limited means. Therefore there can be no doubt about the government´s ability to improve the health of targeted communities. All that is lacking in the case of Palestinian citizens is a commitment to an appropriate policy and adequate budgets.
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National Health Insurance Law
In 1995, the National Health Insurance Law made health insurance within Israel both compulsory and universal. All formal residents were obliged to join an insurance fund. No sick fund (health maintenance organization) was permitted to refuse membership on the basis of age, state of health or any other consideration. A uniform benefits package was stipulated and the list of services promulgated. In lieu of membership fees, which had differed from fund to fund, a health tax with two income gradations was imposed, to be collected by employers and transferred to the National Insurance Institute along with a health tax paid by employers (the latter was abolished in 1997). The law obligated the Treasury to cover the difference between the cost of service provision and the income collected.
The National Health Insurance Law has had two major positive effects on the Arab population in Israel. First and foremost, all Arab citizens now have health insurance. The second positive development was a direct outcome of the competition for membership among the four sick funds. This competition resulted in more accessible and higher quality primary health care for Arab citizens.
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The Absence of Palestinian Arabs from Decision-Making Positions
While the improvement in Arabs´ health status following the implementation of the National Health Insurance Law was heartening, it does not change the fact that the last ten years have seen little or no improvement in Arabs´ status on a number of important health issues. A conference organized by the Galilee Society at the end of 2002 essentially repeated the same issues facing the Arab community as had been addressed at a conference in 1994, eight years earlier. The 1994 event raised the issue of increases in the death rate from breast cancer of Arab women as compared to Jewish women, in spite of the fact that the incidence of the disease is less frequent for Arab women. No improvement could be seen by 2002. This disparity is attributed to a delay in diagnosis, resulting from Arab women´s lack of health knowledge, and the unavailability of services necessary for early prognosis. The same situation prevails regarding obesity and its relation to heart disease, stroke and diabetes,
which for many years have been major causes of death for Arab women.
There are few Palestinian decision-makers in Israel´s health policy bureaucracy. As a result, insufficient attention has been paid to the health of the Arab community. This matter is extremely serious, and has been corroborated by the State Comptroller in her 2002 report on health status.
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Infant Mortality
In 2002, there were 5.3 infant mortalities in Israel per 1,000 live births, a rate similar to the average for countries whose per capita GNP is high (World Bank data). The infant mortality rate for Jewish children was 4.0 for every 1,000 live births, while for Arab children it was 8.4 for every 1,000 live births. The Arab Bedouin community in the Naqab had an even higher infant mortality rate of 15.0 for every 1,000 live births. This gap has not narrowed in the past 30 years.
Seeking to “blame the victim,” some government officials attributed the high infant mortality rate in Arab citizens of Israel to their high rate of consanguineous marriage. Congenital malformation is higher in Arabs than in Jews (31% compared with 26% of infant deaths respectively). Clinical observations and occasional reports in Israeli medical literature make it clear that various disabilities, including congenital deaf mutism, blindness and thalassemia, occur in various Arab clans due to consanguinity. Not all congenital malformations can be blamed on consanguineous marriages, however. Congenital malformations are the second highest cause of infant mortality among Jews, for whom consanguineous marriages are not the rule. According to standard obstetric literature, only 10-25% of congenital malformations are inherited. This leads us to the conclusion that environmental factors and inadequate healthcare are at least
equally important factors in the health disparities between Arabs and Jews.
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Household Accidents among Arab children
Household accidents among Arab children happen with startling regularity. In part, this scourge is due to a lack of awareness and education, the large number of children in each household, and a paucity of clubs and playgrounds in Arab localities, due to discriminatory planning. In the absence of open spaces, children spend their free time in the streets and crammed indoors. Arab children are thus exposed to indirect smoke and other dangerous substances such as Asbestos dust, asphalt and silicon. They are also harmed by unemployment which prevents their parents from making a living and exposes them to poverty, psychological tension and violence, all of which may effect their academic achievement.
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Educational and Psychological Counseling
Psychologists, counselors, social workers and truant officers play an important role in schools, complementary to that of classroom teachers. These professionals identify and address problems that affect students´ academic performance and help identify students with special education needs. They also provide services that allow some disabled children to remain in regular classrooms, and prevent students from dropping out. Despite higher than average drop-out rates and lower levels of academic performance, Arab schools have less counselors of any sort than Jewish schools. Those schools that do offer some counseling provide fewer services. The dearth of counseling services is an issue for both regular and special education Arab schools. A comparison of Jewish and Arab schools showed that 78.7% of Jewish schools offered educational counseling while as few as 36.2% of Arab schools did,
and that 83.2% of Jewish schools compared with 40% of Arab schools offered psychological counseling.
Part of the problem is in implementing stated policy. The 1997 State Comptroller´s Report took the government to task for the gap between the number of counselors to which Arab schools are legally entitled and the number they actually receive. According to the report, Arab schools received only 35% of the counseling hours to which they were entitled.
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Learning Disabilities
According to a survey by the Brookdale Institute, the proportion of children with special needs is higher in the Arab community than in the Jewish community, 8.3% and 7.6% respectively. The Brookdale Institute acknowledged that this is likely an underestimate, a consequence of the lack of an appropriate system for identifying and diagnosing children with learning disabilities in the Arab sector. (Children with Special Needs Stage I and Stage II: An Assessment of Needs and Coverage by Services, JDC-Brookdale Institute). Arab children have higher rates of severe disabilities than Jewish children, 5.4% and 3.3% of all children respectively. About 7% of Naqab Bedouin are hearing impaired, compared with 3% of the general Israeli population. These numbers underestimate the actual rate of disability among Palestinian Arab children.
The "Special Education Act" of Israel states that children with special needs are entitled to receive free special education in their communities (Article II and III, Special Education Act, 1988). Although the law ensures specific rights to all children with special needs, there is a lack of appropriate facilities, equipment and special needs professionals within the Arab community.
The Ministry of Education allocates fewer resources per Palestinian Arab child for integration and fewer special education services to help Arab children to stay in regular schools. Special education classes are larger in Arab schools than in Jewish schools. There are only 44 Arab and 222 Jewish Special Education schools, and only 45 special education kindergartens for Arabs, compared with 484 in the Jewish sector. Thus, many Arab parents who have children with special needs face a dilemma: send their child to a regular school that does not meet their child´s needs, send their child on a long daily commute to attend an Arab special education school, or, if one is available, register their child in a Jewish special education school. Faced with these choices, some parents decide to keep their children at home. At least 250 Arab special needs children aged 0 to 5 are kept at home.
5,232 Arab students from first through ninth grade that should attend special schools are enrolled instead in regular schools, and 30 out of 36 Arab institutions for special education are not properly equipped to meet the needs of the children (Shatil Report submitted to the Ministry of Education, 1998).
In the 1999-2000 school year, 35,998 children attended special education classes in separate Special Education schools and in regular schools. (Proposed Budget for the Ministry of Education 2001) In addition, about 80,000 children in regular classes received special education services. (The Ministry of Justice´s Initial Periodic Report) The Israeli government, in its 2001 submission to the Committee on the Rights of the Child, stated that 18% of these children were Palestinian Arab. However, the Committee for Closing the Gap, in the Education Ministry´s Pedagogical Secretariat, reported to the ministry´s leadership in December 2000 that 30% of children needing special education were Arab. Therefore the reported 18% of Arab children receiving special education services in the regular school is far below the stated need.
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Mental Health
The mental health of a population is impacted by various factors. The causes of mental illness are widely accepted to be due to genetic make-up, external environmental factors or a combination of both. The proper diagnosis and treatment of people with a mental illness is influenced by public policy, education, access to treatment, political and cultural attitudes and income.
The incidence and severity of mental, neurological and psychosocial disorders among the Arab minority in Israel is per capita far greater than that of the Jewish population. The specific problems of the Arab community are not addressed in public policy formation due to unintentional discrimination rooted in a lack of information regarding the specific needs (genetic and environmental) of the Arab community. Behind this lack of information, a consistent policy of overt discrimination exists in matters of educational support and opportunity for workplace advancement. The lack of Arab mental health professionals has a negative impact on the Arab community on both the causal (environmental/perceived opportunities) and treatment (diagnosis/access to Arab mental health professionals) levels. Additionally, misguided and negative perceptions of mental illness among the Arab minority means that serious conditions may be unrecognized or neglected until it is too late to intervene.
Mental health services in Israel are concentrated in hospitals. The number of psychiatric beds available per capita is far lower in northern and southern Israel, where the Arab population in concentrated, than in the center of the country. Access to treatment for a mental illness is more dependent upon income than is treatment for other types of illnesses.
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Educational Opportunities
Discrimination and lack of achievement in education within the Arab community begins at an early age. In the unrecognized villages of the Naqab, few schools exist. To reach schools, Bedouin children must often travel long distances. Some of the schools lack electricity, making it difficult or impossible for them to operate.
To enter into colleges and universities, students must attain a minimum score on matriculation examinations. Other factors taken into consideration for university admission are secondary school curriculum and the results of psychometric exams. According to Central Bureau of Statistics (CBS) Statistical Abstract of Israel for 2000, 44.7% of non-Jewish applicants to university were rejected, while just 16.7% of Jewish applicants were rejected. Approximately 19% of the total population of Israel is Arab, but only 5.7% of degree recipients in the 1998-1999 school year were non-Jewish. The huge opportunity gap for economic and social advancement between Jewish and minority populations can be partially explained by the relative poverty of the Arab population. However,
socio-economic status isn´t the only factor that affects academic performance. When Jewish and Palestinian Arab children of the same economic status are compared, Jewish students regularly out-perform their Palestinian Arab counterparts. This is likely due to embedded cultural material in the testing apparatus.
Students´ motivation to become educated is affected by the returns that they believe their academic credentials will garner. The most obvious return on education is gainful employment. Job opportunities for educated Palestinian Arabs in Israel are limited due to employment discrimination. Also, certain labor markets, such as the military-industrial complex and many government jobs, are closed to them. In January and February 2001, 30% of the Palestinian Arabs registered at employment offices held advanced or professional degrees. Unemployment has detrimental effects beyond the obvious financial ones, sometimes leading to psychosocial and psychosomatic ailments. Additionally, people with low levels of education are more likely to report a need for psychiatric care. (Gross et al, 1997)
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Lack of Arab Paramedical Professionals
Demand for Arab paramedical professionals far exceeds supply. This situation is especially prevalent in the fields of diagnostic testing, professional treatment, psychology and communications. It is difficult for many Arabs to consult with Jewish paramedical professionals because of the language barrier. Monolingual Hebrew-speaking speech therapists cannot help disabled Arabic-speaking children improve their speech, nor is it effective for a Hebrew-speaking didactic tester to diagnose Arabic-speaking children and develop a curriculum for education in Arabic. Of 1,185 speech therapists in Israel, only 21 are Palestinian Arab (Discrimination Diary, Arab Association for Human Rights, August 2000). Therefore, it is essential for the health and development of Arab children with special needs to be tested and treated by Arabic-speaking paramedical professionals.
There are several positions, budgeted by the government and private institutions, waiting to be filled by Arab paramedical professionals. The main barrier lies in the very high entrance requirements (high grade point average, matriculation scores, recommendations etc.) to Israeli universities combined with the poor quality of elementary and high school education in the Arab community. For some students, the cost of university tuition and living expenses is prohibitive. Additionally, some of the programs are only offered at select universities (i.e. speech therapy is offered only at the Department of Communication Disorders in Tel Aviv University, which accepts only 40 students a year, of which three were Arabs in 1999).This is especially true for the Bedouins of the Naqab, probably the most marginalized group in the country.
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Hereditary Diseases
While the government takes full responsibility for the treatment of hereditary diseases common among Jews of European descent, most hereditary diseases prevalent in the Palestinian community are not part of the official health package. Furthermore, the localities where these diseases are prevalent, such as the Bedouin community in the Naqab, are often used as research fields producing high certifications for Israeli scientists, without the Arab citizen benefiting. Another cause for concern is the budget for preventative health measures. While nonexistent for the Arab community, new immigrants from the former Soviet Union and Ethiopia are well-served by the government´s largesse in this area.
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Elderly Care
Access to nursing homes is not guaranteed under Israel´s public health system. Senior citizens who require inpatient care because of an acute but transitory problem, such as a fracture or pneumonia, obtain it from their health fund. In contrast, senior citizens who need long term care due to decreased mobility or loss of cognitive functions may find themselves footing the bill. Health problems increase with age, and the average per capita outlay for persons over the age of 65 is about 4 times the average expenditure.
The link between socio-economic status and good health has been well-documented and is well illustrated with regard to elderly care in Israel. In 1997, 75% of persons aged 65 years and over had a monthly income less than the national average wage, and "44% of this age group (82% of Arabs, 75% of immigrants, 32% of veteran Jews) reported an income under half of the national average wage." (CBS, "Elderly in Israel", January 2001). In 2000, 17.6% of all Israeli families were living below the poverty line, while the proportion of Arab families living below the poverty line was 42.9% (National Insurance Institute). The proportion of elderly who obtain assistance solely from family members is higher among Arabs than among Jews.
Elderly Arabs have higher rates of morbidity than their Jewish counterparts. When Jewish and Arab populations aged 65 years and over were asked to assess their health, 49% of Jewish men rated their health as "good to very good", while only 31% of Arab men considered themselves to be in good health. 35% of Jewish women rated their health as “good to very good.” 29% of Arab women placed themselves in this category. The Central Bureau of Statistics remarks that, "Self-assessment of health is considered a good predictor of actual health." These figures again attest to the lack of knowledge and access to care found in most Arab communities.
While the proportion of those aged 65 years or older is much smaller among the Arab population (3.8%) than among Israel´s Jewish majority (11.5%), the absolute number of Arab elderly is expected to increase dramatically in coming decades (Clarfield et al., 2000). Attention to this population will become increasingly important as access to treatment and the need for Arab professionals specializing in elder care become critical.
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The absence of emergency medical services in the Arab unrecognized villages
A special note must be made regarding the urgency for intervention in the Naqab. One of the most serious problems found in the unrecognized villages is the absence of emergency medical services. Discriminatory policies have led to a disheartening lack of infrastructure, road signs and maps, seriously impairing the ability or willingness of emergency service vehicles to enter the villages. The situation has life or death consequences for the entire Bedouin population. As is often the case, though, its most vulnerable members- the elderly, infants, toddlers and women- bear the brunt of respiratory ailments and other endemic problems often requiring urgent care.
In the July, 2003 report "No Man´s Land" (Physicians for Human Rights – Israel and the Regional Council for the Unrecognized Villages) provided the following example:
Case Study: The death of Ida Abu-Wadi
At midday on April 9, 2003, Ida Abu-Wadi, a 78-year old woman, left her home in the unrecognized village of Albat in order to visit her son, who lived nearby. Ida suffered from various health problems. When she reached her son´s home, she collapsed in his arms and lost consciousness. While her grandson attempted to resuscitate her, the family called the Magen David Adom (the Israeli equivalent to the Red Cross/ Red Crescent) station. The station told them that since no ambulance was available at the Arad station, a mobile intensive care unit would be sent from Beer Sheva, and would reach the meeting point at Houra intersection within 20 minutes. Relatives took Ida to the meeting point in their private car. When they reached Houra intersection, after some 15 minutes, they once again contacted the station, only to learn that the mobile unit had been delayed. Accordingly, they continued to drive toward Shoket intersection,
while the grandson continued his efforts to resuscitate Ida. When they reached the intersection, they saw that the unit had not yet arrived. They continued toward Beer Sheva, and eventually found the mobile unit waiting at Omer intersection some 40 minutes after they called for help. The medical crew pronounced Ida dead.
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