The Workers' Health Fund in Eretz Israel: Kupat Holim, 1911-1937 (review)

Shifra Shvarts has written a book that charts the fascinating history of medical services in Israel. The period she covers is the twenty-six years from 1911 to 1937, and her focus is on the central health provider of the time, Kupat Holim (or General Health Fund). The time period she has selected is appropriate, although she does devote a lot of her attention to the earlier century as well as the first decade of the twentieth century. The central years of her story, however, cover the time beginning with the forerunners of the fund when the Jewish community was small and composed to a large extent of workers. The analysis continues through to a later stage when the Jewish community was under the rule of the British Mandate for Palestine but was engaged in building strong institutions of its own. In that one-generation time span, Shvarts is able to observe both the emergence of Kupat Holim and its reaction to alternative services—primarily Hadassah.

And what about today, now that Israel has been an independent state for fifty-six years? As Shvarts writes in her introduction (p. 1), "Although the majority of the citizenry of the state of Israel is insured by the health fund, even today questions tied to Kupat Holim's place, function and effectiveness remain solidly on the public agenda." Although Shvarts stays clear of writing polemically in favor, or critical, of Kupat Holim, she does believe that by studying the "key junctures" in its history and the "difficulties it encountered as the core body in health services in the country," it may be possible to find answers to the problems with which it struggles currently.

Shvarts's book can be read both as a component of the institutional history of Israel and as an unusual case study in the social history of medicine. Its contribution to the latter category has earned it a place in the series Rochester Studies in Medical History. Originally published in Hebrew as Kupat Holim ha-kelalit, 1911-1937, it appeared in 1997 as a product of the Ben-Gurion Research Center and Ben-Gurion University Press. Daniella Ashkenazy carried out the very able translation.

One of the many unusual aspects of Kupat Holim is that it is so large even though it exists in a country that is so small. Illustrating its focus on growth from the start, Shvarts provides a reproduction of a Kupat Holim advertisement of 1936 that reads: "Opening a new clinic every two days, 162 clinics were opened this year." In fact, with its 1300 clinics, fourteen hospitals, hundreds of pharmacies, institutes and labs, it is one of the largest health organizations in the world. For this reason alone, Kupat Holim merits scrutiny. Moreover, Kupat Holim started from nothing. In 1837, "there was not one hospital, clinic or even certified physician in the Jewish community . . . under Ottoman Turk rule" (p. 7). This lack of health services had a very damaging impact on the small groups of Jews that began arriving from Russia in 1880, thus innovations had to be made to meet their needs. By 1913, despite a very small Jewish population composed of family farmers and single roving workers, there was a startling change—sixteen hospitals, three health funds, and tens of certified Jewish doctors.

These services were sorely needed because the health conditions of the time were deplorable. Palestine was thought of as a "backwater" of civilization, a place that science had yet to visit. Shvarts describes drought, cholera (leading to the death of 20,000 individuals, most of whom were Arabs), quarantines, poverty, cattle diseases, and malaria, to name a few. She offers telling detail about the (un)sanitary conditions, the impact of earthquakes, the Crimean War, and the philanthropic initiatives from abroad that tried to improve the health of Jewish inhabitants. Mortality rates remained high until the beginning of the Second Aliyah period, when...