In Sickness and in Health

Despite Israel's national health law, various mechanisms still prevent Arab citizens from achieving full health equality.

As I sit in Rabin Medical Center with my 90-year-old father (whose eyesight, memory and hearing put my own to shame), I slowly add up the time I have spent in hospitals in Israel over the last 18 months attending to the health issues of both my late mother and my father.

As Dr. Samir carefully examines my father, my thoughts shift from being thankful for the comprehensive medical care provided by our universal national health care system to a matter of personal and professional concern: equality between Israel's Jewish and Arab citizens.

For more than a decade, I've worked for Sikkuy, an NGO run by Jewish and Arab citizens that has advocated for equality since 1991. Now, it suddenly strikes me that a model for ending the discrimination against Israel's Arab citizens in housing, education, welfare, land apportionment, job access and, indeed, health care, is staring me right in the face: Israel's national health system.

In 1994 the government of Israel enacted one of the most progressive and comprehensive national health insurance schemes available in any country, guaranteeing universal coverage to every citizen and resident. The law establishing the system was based on the principles of "justice, equality, mutual assistance and human dignity ..." It mandated quality care within a reasonable time frame and distance for everyone. The law made no distinction between Jews and Arabs (or any other groups), and in this it ended the inherent discrimination of the previous system, by which many Arab citizens found themselves unable to afford the monthly payments to the various kupot holim (HMOs), and the HMOs avoided making investments in health facilities in the country's Arab towns and villages.

The national health law mandated equality and fairness for all citizens, which meant that Arab citizens were guaranteed equal health treatment - period. The guarantee was formal, and it should be noted that the system still has many shortcomings when it comes to being totally egalitarian in both the services it provides and in its hiring and management policies vis-a-vis Arab citizens, but it is by far the fairest governmentally initiated system in Israel.

In fact, despite Israel's national health law, various mechanisms still prevent Arab citizens from achieving full health equality. The Arab infant mortality rate is more than double that of Jews, Arab life expectancy is significantly lower, and some of the gaps are actually increasing. According to the "Sikkuy Report 2007: The Equality Index," the "multi-year trends indicate that life expectancy at birth is rising consistently among both population groups, but among Arabs the increase is more moderate and therefore the gaps between Jews and Arab are steadily increasing."

This troubling situation is a consequence of a long history of discrimination in the health system, continued lower Health Ministry funding for health education in the Arab sector, as well as other lifestyle factors that need to be factored in if progress in reducing the gaps is to be made.

If we examine all the other government systems in Israel that enforce various levels of discrimination against Arab citizens (for example, separate Jewish and Arab school systems, in which the Arab schools are chronically and systematically underfunded; public hiring restrictions that discriminate against Arab citizens who have not served in the army - despite the fact that the state has never asked them to serve in the military; land administration rules that make it difficult, if not impossible, for Arabs to receive government lands for municipal expansion, housing, etc.), we discover that there is no aspect of day-to-day life in Israel in which Arab citizens receive a fair proportion of the resources distributed by the state. So the framework established by the national health law might just be the model that could solve the problem of unequal citizenship in Israel in all other spheres of life in which the government has the major say (mostly everything).

During my time in the hospitals, I have seen Arab and Jewish patients lying side by side (in sometimes overcrowded wards that they both complained about). Their families (Jewish and Arab) inquired as to the health of the other's loved one, shared stories and experiences and wished each other well day after day. Muslims kneeled in prayer near the elevators while Jews always had a proper synagogue in the hospital (an inequality that should be corrected).

My parents were treated by Jewish and Arab doctors (like Dr. Samir), nurses and technicians (men and women, religious and secular), cared for by Jewish and Arab orderlies and monitored by Jewish and Arab HMO supervisors.

No one ever conditioned treatment on whether a patient was Jewish or Arab, there was no separation by ethnic affiliation, and I saw absolute respect and trust accorded by both Jewish and Arab patients to the medical staff of the other nationality and vice versa, be they Arab or Jewish. If only life could be like that.

Furthermore, we have recently seen the appointment of the first Arab director of a government hospital (Western Galilee Hospital, in Nahariya) and an Arab colleague of mine at Sikkuy recently became the regional administrative head of a major HMO.

All this was accomplished without the need for loyalty oaths or threats to revoke the citizenship of Arab citizens. All it took was a fair and egalitarian national health law and the recognition by doctors and other health care professionals in Israel that separate medicine for Jews and Arabs would never be equal medicine.

Looking at the national health system, I am hopeful that the health gaps between Arabs and Jews can be steadily reduced and that with some foresight, our leaders will apply the lessons learned from the medical system to advance equality between Israel's Jewish and Arab citizens in all other spheres, too. This is of vital interest to Jews and Arabs alike.

Carl Perkal is the director of resource development for the Israeli NGO Sikkuy: The Association for the Advancement of Civic Equality in Israel.