“Her dream, from childhood, has been to be an astronaut… She admits, however, that she is aware that the combination of being a woman, an Arab and a Muslim blocks her dream of becoming an astronaut. ‘After September 11,’ she says with a smile, ‘even in the United States I wouldn’t be able to succeed. That actually challenges me more. I guess I’ll have to go in for medicine.’”
That quote is from a May 2004 article in Haaretz (“Haifa’s Christian Schools Lead the League,” by David Ratner) about the Orthodox School in Haifa, run by the Greek Orthodox Church, whose students are meticulously chosen from the elite of Arab society and chalk up extraordinary achievements. One of the interviewees was Salma Abu Ful, a Muslim from the village of Jatt in the Triangle (a concentration of Arab communities in the country’s center), a student in the physics and electronics track, described in the article as “brilliant and highly motivated.”
Seventeen years later, it’s clear that she was a very prescient teen. She went on to medical school at Tel Aviv University, followed by a residency at Rambam Medical Center in Haifa in general surgery – one of the most challenging medical fields, and considered a male bastion – which she completed with an outstanding record. Abu Ful (today Salma Abo Foul-Darawsheh) broke through two glass ceilings: gender and race. At 34, she is already an expert in one of medicine’s most prestigious spheres. Recently she moved from Rambam to the Hospital of the Holy Family (better known as the Italian Hospital) in Nazareth, which serves principally the Arab population in Israel’s north, where she is focusing on breast surgery.
“I always wanted to be like my doctor father, who was praised and complimented by the people who came to our home, but what I actually wanted most was related to my love for stars and planets,” Abo Foul-Darawsheh says. “I very much wanted to be an astronaut, but I knew that my dream could not be realized. I am an Arab woman in Israel, and also an Arab woman after September 11. So I abandoned the first dream and remained with the second.”
What’s more challenging for you in your profession – being a woman or being an Arab?
“Both alike. I seem to choose the most difficult and most challenging things, and I don’t have transparent privileges like others do. I want to progress and show Arab women and Arab girls that we are capable of engaging in this profession.”
What happened to the other outstanding students in your graduating class whom Haaretz wrote about 17 years ago?
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“Of 40 students in the physics-electronics track, about 30 are doctors. Very few went into other fields. It’s not that capabilities are lacking – they exist in abundance. In my class there were brilliant students who could have gone far in plenty of professions, but they [and others like them] are left by the wayside: The feeling is that the glass ceiling is to be a doctor or a lawyer, and few people turn to engineering and high-tech.”
Why is that?
“They think they won’t find work, won’t have a secure source of income. Even though we are supposed to be in an equal labor market, where promotion is according to ability, there is discrimination, albeit unofficial – but it exists. It’s hard to find a job in certain fields, and people know that and go into other professions.”
No chance of success
The abundance of people from the Arab community in the health-care professions has become a fixture of local culture: the nurse who administers the coronavirus vaccine, the pharmacist in the drugstore who is ubiquitous enough to have been made a character on the satirical program “Eretz Nehederet,” and of course the physicians – all of them symbolizing the entrenchment of Israel’s Arab citizens in the medical fields.
This social phenomenon, which some see as setting the Arab elite on a track into this field, is expanding. New data issued by the Health Ministry in a 2020 report on health care personnel show that the Arabs and Druze in Israel, who make up about 20 percent of the country’s population, constitute almost half (46 percent) of recipients of medical licenses; half of the new nurses, male and female (50 percent, as compared with just 9 percent in 2000); and more than half the dentists (53 percent) and pharmacists (57 percent).
Of 40 students in the physics-electronics track, about 30 are doctors. Very few went into other fields. The feeling is that the glass ceiling is to be a doctor or a lawyer, and few people turn to engineering and high-tech.Abo Foul
In addition to the fact that Arabs comprise a vastly larger proportion of the medical field than their share in the population, this meteoric surge within just two decades has transformed the face of medicine in Israel. Besides the leap of more than fivefold in the number of Arab nurses since the start of the century, there has been a fourfold increase in the number of Arab physicians, the number of Arab dentists has more than doubled and the overall proportion of Arab pharmacists has almost tripled, from 21 percent in 2000 to 57 percent in 2020.
There are clear reasons that induce young Arabs to flock to the health care industry. “The medical professions are generally in the public arena, to which the terms of admission are a degree and a certificate. In high-tech, however, it’s not enough to have an engineering degree, you need connections such as [having served in the army’s intelligence unit] 8200, and also ‘soft’ skills that are less present in the Arab population,” explains Dr. Marian Tehawkho, director of the Center for Economic Policy of the Israeli Arab Society, part of the Aaron Institute at Reichman University (formerly the Interdisciplinary Center Herzliya).
She adds that “in many instances, Arab candidates have no chance of succeeding in an interview because of their low self-confidence, inferior articulation skills or imperfect Hebrew. These are matters that go beyond a formal degree. But in medicine, the degree and the certificate are sufficient. And because there is a chronic shortage of personnel in these professions, the health care system doesn’t have the privilege of not accepting people simply because they are Arabs. The medical professions are in need of staff.”
That perception has been internalized by Arab society, Tehawkho relates. “My cleaning woman sent her son to study medicine abroad. She worked for seven or eight years just to finance his studies, but as she told me, ‘I know that the moment he completes the degree, he will have a good life.’ So it was worth her while to invest a fortune. She wouldn’t have invested like that [for him to study] engineering. In her village she sees people who studied medicine and are earning significantly larger salaries than anyone else in the village. She also knows that once he passes the licensing exam, his future in the profession is guaranteed.”
Prof. Riad Agbaria, a clinical pharmacologist and formerly head of the pharmacy school at Ben-Gurion University of the Negev, is devoting large efforts to promoting a path for minorities into the health care profession. One of his initiatives was a project called “Buds of Medicine in the Desert,” which prepares Bedouin and residents of remote Negev towns for a profession in medicine. “In Arab society [in Israel], a conception has arisen that the health care sector consists of free professions that enable independence. With a license, one can open a drugstore, a private clinic, anything. The same phenomenon is found among all the minorities in the world: They are always looking for something that is not below the radar of the state, of the government.”
The high demand for staff in the health care system also ensures the Arabs’ future in the profession, he adds. “If young Arabs study teaching or engineering, what will they do with that? They will have difficulty finding a job. If two people, Mohammed and Moshe, are up for the same job and have the same qualifications, it’s a sure thing that Moshe will be hired. But in medicine, we haven’t yet arrived at a sufficient number of doctors that makes it possible for the system to prefer Jews.”
Pride – and concern
The extraordinarily high participation of the Arab population in the field of health care is a great source of pride in the Arab community, but is also starting to arouse considerable concern within it and elsewhere. As Abo Foul-Darawsheh notes about her high school classmates, a very large – perhaps too large – percentage of outstanding Arabs enter the medical profession, whether willingly or not – thus leaving many other occupations with a disproportionately low percentage of individuals from the Arab population.
“The decision about what subject the children will study is in the hands of the parents,” Agbaria says. “When Arabs graduate from high school at the age of 18 they are not drafted and don’t embark on a prolonged trip to the East, so their parents send them to study medicine. It’s very important for Arab society to have the young generation enter more professions – for them to follow their hearts, because that is the only way to excel. If someone is born to be a computer engineer, they will not excel in medicine, because they lack passion for the profession.
“The parents need to switch gears in this regard. I established a theater group to provide a response on this topic, and we’re putting on plays in schools and for parents to show them that excellence needn’t necessarily lead to medicine. In my case, for example, I studied pharmacology and not medicine, even though my father wanted me to become a physician, because pharmacology was what interested me. And the truth is that for me the lectures in chemistry and biochemistry were like a whole world, riveting.”
He adds, “We want start-up people. A doctor, a pharmacist, a nurse – they work alone. In contrast, if you have a start-up, you influence your whole surroundings. There is an Arab entrepreneur named Hassan Mahajami, whose father I persuaded that he wasn’t suited to study medicine. At age 29, he completed a Ph.D. in computers at the Technion [Israel Institute of Technology, in Haifa], established a start-up, and today employs 500 people. If he’d studied medicine, what contribution would he have made to Arab society? Far less. So it’s important for us to have Arabs major in other subjects.”
In an article published in Haaretz last month (“The VC Fund Betting on Israel’s Arabs,” by Amitai Ziv, September 2), officials from the venture capital fund Takwin spoke about the effort being made to attract young Arabs into high-tech, with an emphasis on entrepreneurship. “If you want to effect social change, it’s not enough for three percent of high-tech people to be Arabs working at Intel and Microsoft,” said Fadi Swidan, the fund’s vice president for business and market development. “You need entrepreneurs who will found companies in the places they came from and create employment there. Every engineer at such a company produces three to five support jobs, from marketing personnel to the company’s suppliers. We need local success stories to create more daring and more entrepreneurship. Jobs at corporations are important, but we also need entrepreneurs who will found companies in the periphery.”
“The fact that the best students are [only] becoming physicians has consequences,” says Dr. Guy Shalev, a medical anthropologist and co-chair of the board of Physicians for Human Rights-Israel. “Voices in Arab society say, and justly so, that society also needs sociologists, philosophers, poets, that society needs an intellectual elite.”
The fact that the best students are becoming physicians has consequences. Voices in Arab society say, and justly so, that society also needs sociologists, philosophers, poets – an intellectual elite.Dr. Guy Shalev
In his view, the outstanding students are set on a track into the health care industry because “they say that there, they will be appreciated as they are, and they will be able to advance if they do good work. Add to that the high status of medicine in Arab society, where every parent’s dream is for the child to become a physician, in part so they won’t encounter discrimination. That is characteristic among minorities. Jews, too, flocked to medical schools in the United States and Europe. The tendency of a minority that fears for its fate to enter medicine is understandable, but the price to society is significant.”
Agbaria agrees. “We have no philosophers, no historians, we don’t have enough outstanding people in art, though a trend in those directions is beginning,” he says. It’s critical, he adds, to expand into other fields. “It’s not by chance that discrimination is far less felt in the sphere of health care. It’s like that thanks to medical teams consisting of both Jews and Arabs who work shoulder to shoulder. If we compare it, for example, to the core sphere of housing and construction, there are no Arabs among the decision makers in that sphere. During the coronavirus pandemic period, the Arabs were on the front lines [in medicine], also as managers, and it should be the same in all areas of life.”
Tehawkho, however, doesn’t accept the use of the term “set on a track.” “It’s true that Arab engineers are lacking in high-tech, and I would like them to integrate into that realm for the good of Arab society and the country as a whole, but there are large barriers that are hard to overcome,” she says. “If it’s easier for Arabs to integrate into health care professions, there is no problem with that.”
Restrictions on studying abroad
The stream of young Arabs and Druze into the health care field does have less positive sides as well as a rapidly approaching glass ceiling of even more limited medical school options. One of the problems is that many of them study abroad, which places enormous economic pressure on their families along with personal difficulties for the student, and often thrusts them into subpar medical schools. According to Tehawkho, many of them are pushed into studying abroad. “There aren’t enough openings for students in Israel, and that raises the admission criteria to these fields. Many Jews who aren’t accepted into medical school in Israel will choose other local alternatives, such as engineering instead of medicine. However, there is less likelihood that Arabs will turn to high-tech. They will prefer to go abroad and study for many years in a foreign language, because they have fewer alternatives.”
The numbers continue to be astounding. According to the Health Ministry’s chief economist’s office, 67 percent of license recipients in all the health care professions in 2017-2018 were from the Arab population. In addition, 63 percent of all the medical students, 84 percent of the nursing students and 82 percent of the pharmacology students were Arabs.
“There are about 4,000 nursing students in the Arab American University in Jenin – 1,000 students in each year of the four-year course. That means that in one year, they admit the same number of students as all the nursing schools in Israel. And that’s just in one university, and doesn’t include [other institutions in] Nablus and Abu Dis,” Agbaria says. “It’s obvious that there will soon be a glut in the nursing profession,” he says. Data compiled by the Galilee Society – The Arab National Society for Health Research and Services shows that about 10,000 Israeli Arabs are currently studying medicine abroad.
There’s a similar issue in the field of occupational therapy. “There are more Arab students in the paramedical professions in the Jenin university than in Israeli academia, and prominent among them is occupational therapy,” Tehawkho says. According to a study she conducted together with Hanin Matar, “There are five times more Arab students in Jenin than in Israel, and the number is already approaching all the occupational therapy students in Israel, including the Jews.”
That situation will probably change soon. Tehawkho notes that in April 2019, the Israeli Health Ministry announced that it would no longer recognize occupational therapy studies undertaken at the Jenin university. “An inspection conducted by the Medical Professions Licensing Department in 2019 showed that the standard of teaching in these professions, with all its various elements, is low and does not comply with the acceptance criteria in Israel,” the ministry wrote on its English-language website.
But the major change expected in the near future involves the flagship profession: medicine. Three years ago, the Health Ministry announced a dramatic reform regarding the study of medicine abroad, namely that it would only recognize such studies in countries that are members of the Organization for Economic Cooperation and Development or that had received special recognition. That decision was made when the ministry realized that thousands of Israelis were enrolled in substandard medical schools in countries like Romania, Armenia, Moldova and Ukraine, and that they graduated with almost no practical experience, which is crucial in medical studies. The result will be that within two to three years, medical frameworks attended by thousands of Israelis – with most of them apparently Arab Israelis – will abruptly shut down. Only those who began their studies in such institutions by 2019 were given authorization to complete them and sit for the Israeli licensing exam.
While the decision seems to adversely affect the large number of Arabs from Israel who until now had enrolled in medical schools in these countries, in fact it protects society as a whole and the Arab community in particular from physicians whose studies were at a low standard. “I would not want bad doctors to enter the health care system, because in the end everyone suffers from that, and I would not want a problematic situation to continue just so that Arabs are able to find employment,” Tehawkho says.
“What I would like to see,” she continues, “is for the barriers that prompt them to pursue their studies in those places to be dealt with – because they are not accepted for studies in Israel, not accepted in the good places. The root of the problem is the Arab education system, which is very weak. That’s the big story, but the symptom of a far larger problem.”
Abo Foul-Darawsheh, whose husband is also a surgeon at Rambam, says that despite her early dreams of space travel, she is happy that she ended up as a physician. “There is tremendous satisfaction in it. I chose a beautiful profession, in which you both diagnose the problem and also operate and resolve it,” she says. “I moved from Haifa to Nazareth with the aim of contributing to my community in places where the health maintenance organizations don’t make the service accessible, so that the Arab women I meet will get the best medical care, and medical problems will not be overlooked. The villages don’t have sufficient access to mammography and breast surgery, and I am working to get to the villages physically periodically.”