“The policy is that we don’t separate, we don’t discriminate. But beneath the surface, I’m not sure I can tell you that we don’t turn a blind eye and say okay, if there’s a way to deflect conflict, to prevent friction, so be it.”
That remark, uttered by a nurse at a large Israeli hospital, was just a snippet from dozens of interviews with medical staff at 11 major Israel hospitals in a study on separating Jewish and Arab patients.
The study shows that the practice of assigning Jewish and Arab patients to separate rooms is deeply ingrained despite the denials by hospital administrators and other officials in the health system. And hospitals generally accede to patients’ requests for separate rooms.
The study was conducted by Prof. Yael Keshet, chairwoman of the Sociology of Health and Wellness Division of Western Galilee College, and Ariela Popper-Giveon, a researcher in medical anthropology and cultural anthropology at Jerusalem’s David Yellin College of Education. It was published in the December issue of the Israel Journal of Health Policy Research.
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Officials often boast about the warm coexistence between Jews and Arabs in the state health system, where there is a higher proportion of Arab employees than elsewhere in the public sector – 12 percent compared with 6.8 percent. But that harmony dissolves when patients enter the picture.
In their study, Keshet and Popper-Giveon combined quantitative and qualitative approaches. The quantitative part was based on a survey of 760 Israelis – 505 Jews and 255 Arabs. The respondents were asked to rank from 1 (“absolutely disagree”) to 5 (“fully agree”) the degree to which they agreed with various statements.
The qualitative part consisted of interviews with 50 nurses, physicians and administrators at 11 public hospitals.
The core question that Jewish respondents were asked was: Should Jewish patients be allowed to choose to be in a [hospital inpatient] room only with Jews? Thirty percent said they fully or mostly agreed with this statement.
The Arab respondents were asked the same question, in Arabic rather than in Hebrew, and with the words “Arab” and “Arabs” replacing “Jewish” and “Jews.” Twenty-one percent said they fully or mostly agreed.
Over the years, a number of media outlets have published evidence showing the segregation of Arab and Jewish patients in hospital inpatient wards, particularly maternity wards. Keshet and Popper-Giveon’s study shows that this appears to be a common occurrence based on unofficial policy. And of course those numbers of 30 percent and 21 percent show that this phenomenon has grassroots backing from patients themselves.
‘In many cases cultural, not racist’
“Going deeper into the analysis of the data, we find that the more religious people are, including Jews and Arabs, the more they wish to be placed in a room with people like themselves,” Keshet said.
She said this phenomenon tended to increase the less the education, but parameters such as sex, age and medical condition were not correlated with a desire to be separated.
According to a nurse in a maternity ward who was interviewed for this study, “it comes from Jewish patients. Arab patients have never asked me to do so. Jewish patients may ask me to do them a favor and not place them beside an Arab. I don’t know .... It’s a dilemma.”
On the one hand, she said, staff want to satisfy patients’ wishes because, after all, hospitals are also about marketing, with a lot of competition between hospitals.
“You want to attract a larger segment of the population, so everything’s connected to money, right?” she said. “You need private patients, some of them bring in a lot of money to the hospital, so you don’t want to cross these people, but you also don’t want to discriminate. You end up quite confused.”
The prohibition on ethnic segregation in hospital wards is included in the law on patients’ rights. It says a caregiver or medical institution will not discriminate between patients based on religion, race, sex, nationality, origin and the like.
In their study, the researchers say the motive for segregation isn’t always clear. It could be discrimination and racism, or it could be an attempt to match people culturally and minimize potential sources of friction.
“There is some ambiguity regarding the attitude of medical personnel toward separating patients. The ones dealing with the problem are the nurses, who are responsible for assigning rooms in the department,” Popper-Giveon said.
“They try to optimize and improve a patient’s experience in the hospital and in many cases they preemptively segregate, before receiving a request. In many cases their motive is cultural, not racist, but behind this there are often racist, discriminatory and segregationist aspects.”
‘You want people like yourself’
The line between racism and a legitimate patient request is not always clear. “In pediatric wards we also segregate nowadays,” said a (Jewish) doctor who was part of the study.
His hospital tries to have rooms for Arabs and rooms for Jews; it also has separate rooms for secular Jews and Orthodox Jews.
“The rationale is that there is a different mentality, different smells, different manners of behavior. There are differences. Peace and quiet on the ward is something that patients want,” the doctor said.
“If there are three patients to a room, you want people like yourself .... You don’t want them turning on the radio on the Sabbath if you’re observant, and you don’t want roommates bringing in chametz during Passover.” So his hospital tries to separate Arabs from Jews, and so on.
“Sometimes things are said that are unpleasant to my ears, such as ‘I don’t want to be with these Arabs, they stink, they bring the whole family here to visit.’... We try to address these problems but I can’t educate people.”
One Arab doctor who was interviewed told of an incident in which a Jewish woman refused to have an Arab boy placed in her son’s room.
“I told her we didn’t force anyone to remain in the department, and that anyone who wanted could sign themselves out,” the doctor said. “And that’s what happened, she left. We try to comply with people’s wishes, but not in cases such as these.”
Other questions in the survey, which were analyzed for another study, showed that 30 percent of Jewish patients and the same percentage of Arab patients preferred family physicians from their own ethnic community.
Also, 4 percent in each community reported that they at least once had refused to be treated by a doctor, nurse or pharmacist from the other ethnic group. (It was assumed the incidence was much higher but participants were loath to admit it.)
“Here too there was a correlation between the degree of religiosity of the respondent and his or her preference for a caregiver from the same ethnic group,” Keshet said.
As one hospital director put it, “I believe that only a small portion of this is blatant racism, such as a statement that ‘the female terrorist from East Jerusalem has arrived with the next terrorist,’ put her in that room.”
He added: “The fact that there is legitimization – for instance when Jewish women ask not to share a room with an Arab woman – is problematic for me. Ultimately there need to be written policies in these matters. But that’s not what will change reality. Sometimes the teams don’t really understand what’s wrong with this.”
Another (Jewish) nurse said: “Sometimes, I feel hurt on their behalf, such as when people say they don’t want to share a room with them. I tell them they’re missing out and that it’s too bad. If only they got to know one another.”
At the end of the study, the researchers recommend that policies be crafted to prevent segregation. “A situation in which there are rooms for Arabs and rooms for Jews is unethical, it’s insulting, it hurts and in many cases the segregation is unsatisfactory to both sides,” Keshet said.
She and Popper-Giveon believe the Health Ministry should intervene and give guidelines to prevent the turning of this phenomenon into an institutional norm. Health care is a humane and universal area that should steer clear of politics, ethnic discrimination and racism, Keshet said.