Major issues in women's health.

• Position: Israel

The issue of equity in health care for women is complex and needs to be examined on many different and interrelated levels. At the most basic level is the question of gender disparities in scientific knowledge. Recent evidence suggests that modern medicine has amassed less information about the epidemiology of disease and its treatment in women than in men (National Institute of Health, 1991: 7). Gaps in scientific knowledge and data on women, in turn, limit our understanding of their unique health needs, leading to gender bias in public policy, in medical education and training and ultimately in clinical practice and service delivery (Laurance and Weinhouse, 1994: 60-82). The question, therefore, is not whether women in Israel receive equivalent care, compared to men, but rather whether they get the kind of care they require given their gender-specific needs.

Health and Illness

The Gender Gap

Life Expectancy

The gender gap in life expectancy in Israel is 4 years: 79.5 for women and 75.5 for men (CBS, 1997a, Table 3.19). This difference is significantly smaller than the average of seven years difference in the life expectancies of men and women in most of the developed world. In fact, while Israel ranks among the top five countries in the world in terms of life expectancy for men, women are not even in the top ten (ICDC, 1997: 5557). These trends alone suggest an untapped potential of the health care system with respect to women. The challenge for epidemiologists, health policy analysts and planners is to attempt to explain these differences and respond appropriately.

The longer life expectancies of women relative to men means not only that women are dependent on the medical care system for longer periods in their lives, but also that they are more likely to be alone as they get older, with no one to care for them when they are ill. Women constitute 57% of the population over 65 (CBS, 1997: Table 2.10). By age 75-79, only 27% of them live with a partner, compared to 82% of the men in the same age group (Modan et al, 1996). These differences, too, need to be taken into account in health policy and planning.

Gender Differences in Mortality

The leading causes of death for both men and women in Israel, across the life span, are heart disease, cancer and stroke, in that order. In 1994, 5,560 women died of heart disease compared to 5,837 men. There were 3,773 deaths from cancer among women and some 4,200 among men (CBS, 1997b). For every Israeli woman who died of breast cancer, more than 6 died of heart disease.

Age standardized mortality rates for most of the leading causes of death are higher among men than among women throughout the developed world. In Israel, however, women are at greater risk of dying of cancer than are men for much of the life cycle. In 1994, cancer accounted for 44% of all deaths in women ages 55-64 and heart disease for 25%. By ages 7579, the situation is reversed: heart disease accounts for over 40 % of female mortality and cancer for about one-fourth. Among men, the risk of dying of heart disease or cancer is roughly equivalent throughout most of the life cycle, with the largest relative increase after age 65.

While Israeli men have one of the lowest mortality rates for cancer among men in some 20 countries where registries are kept, Israeli women have among the highest in the world higher than the mortality rates from cancer in European countries, but lower than that in America (Zadka, 1993). This is accounted for primarily by breast cancer, which in 1994 claimed over 800 lives, nearly twice as many as colon cancer--the next leading cause of death in Israeli women. In men, lung cancer heads the list of causes of mortality with some 706 deaths annually, followed by colon cancer (CBS, 1997: Table 3.22).

Gender Differences in Morbidity

Women are known to suffer more than men from many chronic conditions such as hypertension, diabetes, osteoporosis, depression, incontinence and other bladder problems, chronic fatigue and migraine headaches - the so called "cripplers" as opposed to the "killers" (Paltiel, 1988: 189-211).

Gender differences are consistently found in reported physical and emotional well-being, as well as in actual disability, particularly among the elderly and the poor in Israel. Salzberger, for example, studied 360 married Israeli couples over a ten year period. In families classified as moderately or severely deprived, she found that functional impairment due to illness increased 350% for women, compared to 58% for men. Women were more likely than men to report multiple health problems, which they attributed to pregnancy and childbirth, persistent side effects of previous illness and family stress. Among the most frequently cited ailments were emotional disorders and depression (Salzberger, 1990, 1991: 41-50).

Studies of elderly persons also reveal more illness and disability in women. The rate of disability among those over the age of 75 is 50% higher in women than in men, and since women are more likely to be living without a spouse, they are also more likely to be placed in institutional care (Stessman et al, 1996). Relative to men, elderly women report higher rates of hypertension and abdominal problems, as well as muscle or joint pain, chronic fatigue, digestive problems, respiratory problems and a host of other chronic conditions (ibid; CBS, 1994).

A survey of 450 Jerusalemites over the age of 70 revealed gender differences in morbidity for every condition...