Circles of Exclusion: The Politics of Health Care in Israel

Introduction Four Stories of Exclusion

Introduction Four Stories of Exclusion My patient was as perplexed as she was outraged. “You can’t do it? What do you mean, you can’t do it?” she asked angrily. “I’ve been going there for years and years for my heart checkup! And now you’re telling me I have to start all over again at a new office, with a new doctor? No way!” she exclaimed as she stormed out of my office. Ms. Levana Malka,1 a sixty-year-old retired assistant kindergarten teacher who lived in Givat Hatmarim—one of the poorer sections of Tel Aviv—had cardiac valve disease since she was a child and developed hypertension in her fifties. To monitor and manage her condition she needed periodic checkups. From the time she developed her illness, she was insured at Kupat Holim Clalit—the sick fund run by the General Workers’ Union.2 When she was a teenager, she became a regular patient at a cardiology outpatient office at a public hospital and had continued to visit the same office, year after year, decade after decade, ever since, and she felt safe there. As the medical director of her neighborhood’s primary care clinic, I knew that she preferred to continue receiving care and follow-up in a place 2 Circles of Exclusion where she was well known. But even though I understood her anger and felt as frustrated as she was, I couldn’t do anything to help her. Due to both changes in public hospitals’ billing systems and financial pressures, Kupat Holim Clalit no longer allowed us to refer our patients to certain public hospitals for their follow-up. This meant that patients like Malka had to find a different cardiologist at a different institution. For Malka—whose life as a patient was centered at a particular institution, with its familiar staff, treatment, and follow-up—learning that she would be forced to change doctors, nurses, and her hospital was a shock that made it even harder for her to cope with her chronic illness. The situation was especially frustrating for her because her condition and age prevented her from switching to a financially more stable sick fund with better access to specialists’ care. Moreover, like most residents of the Givat Hatmarim neighborhood, Malka could not afford private care. Givat Hatmarim is located in what used to be the city of Jaffa and has become part of the Tel Aviv–Jaffa municipality. Predominantly Arab, Jaffa is one of the few areas in Israel where—albeit with some segregation— Arabs and Jews live together. But it is also one of the poorest parts of the unified city. Except for those living on the sea—in a section that is being gentrified—most of its residents struggle to make ends meet. Public services are not well developed and public investment is scarce, which leads to severe social problems. Givat Hatmarim (the Hill of Dates) is predominantly Jewish, but its residents are not much better off than Jaffa’s Arab population. Since the mid-1980s, cuts in public spending have intensified the preexisting problems of this largely low-income population and created a crisis in the public health care system. * * * I signed the petition without too much hope. Physicians for Human Rights–Israel, a human rights organization composed mostly of health care workers, was demanding that the state ministries connect the houses of two sick old men—Mr. Ahmad al Atrash and Mr. Shauki al Sana— to a source of electricity. Sixty-nine-year-old Ahmad and seventy-eightyear -old Shauki are Israeli Bedouins who reside in the unrecognized villages in the Negev desert, and both suffer from chronic obstructive pulmonary disease (COPD). Some 84,000 Bedouins live in forty-five villages Introduction 3 unrecognized by the Israeli state as a result of a conflict about ownership of their land. Bedouins have lived on their land for centuries, yet the Israeli state does not recognize the Bedouins’ ownership claims of significant areas of the Negev desert and has tried to pressure residents in these forty- five villages to move to seven Bedouin cities and renounce their claims to any ownership rights to the lands on which their villages were built. To pressure the Bedouin population to move, the state does not provide the villages with basic infrastructure, such as electricity, water, and sewage...