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One of the people most prominently mentioned last week in the Finance Ministry's annual report on wages in the public sector was heart surgeon Prof. Azai Appelbaum. As head of the cardiac surgery ward at Soroka Medical Center in Be'er Sheva - the only such unit in the south of the country - Appelbaum receives a gross wage of NIS 107,000 a month from the Clalit health maintenance organization. In the framework of the highly irregular wage agreement, Appelbaum undertook not to practice private medicine.

The huge salary that Appelbaum has been getting from the HMO for the past decade did not prevent the Clalit and Soroka managements - including Dr. Yitzhak Peterburg, current CEO of the Cellcom cellular telephone company and director of Soroka and Clalit at the time in question, and Prof. Shlomo Mor-Yosef, current director of the Hadassah university hospitals and former director of Soroka - from adopting a forgiving attitude toward complaints about the payments made by patients to Appelbaum for operations he performed in Soroka. According to the complaints, the additional payments were made directly to Appelbaum or to his department's research fund.

In 1998, for example, as reported in Haaretz (June 11, 1999), a family from the northern Negev city of Kiryat Gat complained that it had paid Appelbaum several thousands of shekels following an operation that was performed on the mother of the family. Then director of Soroka Prof. Mor-Yosef replied that "the money the family gave Prof. Appelbaum was deposited in the hospital fund."

In such a manner, Mor-Yosef implicitly admitted that Appelbaum had received money from the family of a patient he had operated on, and that instead of asking the police to investigate the matter, the money had been returned to the family in the form of a Clalit HMO check. Soroka and Clalit followed the same pattern with regard to additional complaints as well: Appelbaum denied them all and the Soroka and Clalit made do with his denials.

In other instances, following proof of payment to a doctor at a public hospital (whether such payment was made directly to the doctor, or to the department's fund) for surgery or treatment at the hospital, doctors have been convicted of soliciting or receiving a bribe - an offense that carries a prison term of up to seven years. This phenomenon is prevalent at a significant number of the public hospitals in Israel and is known in Hebrew as "black medicine." Sometimes, there appears to be a direct link between doctors' wages and their willingness to receive additional payments.

The oft-lenient handling of complaints about "black medicine" is not exclusive to Clalit. The health and legal authorities, together with the police and the Civil Service Commission, always make a point of noting that they take a grave view of physicians who demand and receive bribes. In practice, however, they often display a forgiving attitude toward the phenomenon, despite its harsh moral, economic and medical ramifications.

In some cases, even when complaints about the practice of "black medicine" are filed against physicians, they are not always investigated - as was the case in 2001 with information that was submitted by the controller of the Health Ministry himself, Aryeh Paz, to the Israel Police's National Fraud Squad concerning the director of cardiac surgery at Sheba Medical Center, Tel Hashomer, Prof. Aram Smolinsky (Smolinsky denies all the allegations against him).

The Fraud Squad informed the controller that it had decided not to look into the information, claiming that the matter was under the jurisdiction of the Health Ministry. And when complaints are investigated, the courts or the Health Ministry tend to go easy on the physicians.

A recent case in point involved gynecologist Dr. Ilon Lachman, who was convicted in 1998 by the Supreme Court of soliciting bribes from two maternity patients when he was the director of the obstetrics ward at Yoseftal Hospital in Eilat, an institution that is also owned by the Clalit HMO. Following the conviction and punishment - three months of public service - a disciplinary complaint was filed against Lachman. About a month ago, the commission that heard the complaint recommended that former health minister Nissim Dahan make do with a token punishment. Dahan took the commission's advice.

The members of the commission - senior Health Ministry official Dr. Michael Dor; Dr. Mariana Bernstein, representative of the Israel Medical Association; and attorney Dan Eldad, from the Jerusalem District Attorney's Office - had plenty to say about the gravity of what Lachman had done, and even noted that his license to practice medicine should be revoked permanently; but in the end, they found that because of the length of time that had passed since the incidents in question, and for other reasons, a symbolic punishment would be sufficient.

At the same time, the commission made it clear to the health minister that he would have to make a "value-oriented" decision as "the minister elected to represent the public interest" - a formulation that would seem to indicate an expectation for a tougher decision than the one the committee itself had recommended. Similarly, the manner in which the commissions described the incidents is not consistent with its recommendation: The three members of the panel found this was "one of the most serious and most repugnant of phenomena in Israeli society. The bribery causes a pushing aside of medical considerations intended to save lives in favor of foreign considerations... sheer greed."

They also noted that the fact that Lachman's actions were part of a widespread phenomenon in the country made it necessary to fight it by means of deterrent punitive measures. Nevertheless, the commission and the health minister made do with a token punishment, thereby helping to consolidate one of the ugliest phenomena in Israeli medical practice.