The Arab citizens of the state of Israel make up nearly a fifth of the total population of the country, and 90% of them were born, raised and educated in Israel. Despite the large size of the Arab minority and their long presence in the country, Arab localities still suffer from underdevelopment: their infrastructures are inferior to those in Jewish localities and they have been systematically discriminated against in national development plans and thus lack employment opportunities. Whatever the measure of socio-economic status, be it education achievements, income or level of occupation, Arab citizens are at the bottom of the ladder. As health status is inseparable from socioeconomic status, it is perhaps not surprising that the health of Arabs in Israel has lagged behind that of the Jewish population. On the other hand, the fact that planned national support systems have achieved a comparatively high health status level for large groups of Jewish immigrants arrriving in Israel with limited means illustrat es the potential effectiveness of a government policy designed to improve the health of specific communities, if it is implemented with commitment and backed up with adequate budgets.
The brief interval in the early 1990s, when the incumbent government recognized the unequal treatment of the Arab minority in Israel and adopted a social support ideology accompanied by policies aimed at narrowing the gaps, has since given way to the current (1998) government's firm commitment to free market policies and privatization practices that reproduce and exacerbate inequities.
Health Status Indicators
Despite extensive statistics on all aspects of life in Israel, specific data on the Arab minority are often lacking, and one is forced to draw conclusions based on footnotes, explanatory notes or extrapolations. In light of this neglect, The Israel Center for Disease Control deserves mention for incorporating and systematically analyzing most available morbidity and mortality data on Arabs as compared to Jews in its 1997 report (ICDC, 1997).
The table above offers a close look at Infant Mortality Rates over time. It reveals a persistent Relative Risk Ratio of Arabs to Jews amounting to twofold throughout the last four decades. As rates for both groups follow a downward trend, specific levels of infant mortality are reached by Arabs 10-20 years later than by Jews. If the Infant Mortality Rate is considered by the age of the infant's death, we find the Arab to Jewish Relative Risk Ratio to be higher in the post-neonatal period (3.4 in 1990-93), where the effects of the physical and economic home and community environment play a more decisive role. This ratio has been on the rise, whereas the Relative Risk Ratio in the neonatal period has remained stable at a lower level (1.5 in 1990-93) (CBS, 1997d, Table B). In the neonatal period, causes of infant mortality related to the birth process as well as those resulting from congenital malformations have a greater effect. Again, a closer look at Relative Risk Ratios by specific causes of death reveals t hat the discrepancy resulting from environmental and external factors is greater than that associated with genetic and obstetric ones. For example, in 1990-93, the Relative Risk Ratio of Infant Mortality Rates of Arabs to Jews from infections was 4 (the infant mortality rate from infectious diseases was low for both groups: 0.8 for Arabs and 0.2 for Jews), while that from congenital malformations was 2 (4.3 for Arabs and 1.8 for Jews) (CBS, 1997c, Tables 17 and 18). The comparisons are more striking when put in relative terms than in absolute ones. Moreover, throughout the past two decades, the Relative Risk Ratio of Arabs to Jews was higher for females than for males, possibly reflecting the traditional preferential treatment of males in Arab society.
Politically motivated statements by some government officials attribute the excess Infant Mortality Rate among Arab citizens of Israel to their high rate of consanguineous marriage. This seems to follow the discredited colonial tradition of "blaming the victim." While it is true that congenital malformation is higher among Arabs than Jews (accounting for 31% compared with 26% of infant deaths), as the above figures show, causes related to the environment and the health care system have resulted in greater disparities. Obviously, not all congenital malformations can be blamed on consanguineous marriages, as this is the second highest cause of infant mortality among Jews, for whom consanguineous marriages are not the rule. From clinical observations, as well as occasional reports in the Israeli medical literature, it is clear that various disabilities, including congenital deaf mutism and blindness and thalassemia, occur in various Arab clans due to consanguinity, but the case is not convincing when this is of fered as the sole or even main cause of excess mortality, as only 10-25% of congenital malformations are reported to be inherited in the standard obstetric literature. If we extend the consideration to higher age groups, we find that the Relative Risk Ratio of Arab to Jewish mortality is even greater for the 1-4 year age group, 2.5 for boys and 3 for girls in 1990-93. At this age, congenital malformations contribute less to mortality: 85% of such deaths occur in the first year of life (ICDC, 1997: 157).
Standardized Mortality Rates
To compare mortality rates, The Israel Disease Control Center (1997) uses the age distribution control of the total population of Israel in the 1983 census. The results: agestandardized rates for deaths from all causes combined are higher for Arabs than for Jews, among men as well as women (See table below). This is true for two out of the three leading causes of death (heart disease and cerebrovascular events) as well as for deaths from external causes (mainly accidents), birth defects, hypertension, diabetes mellitus and infectious diseases. Two causes of death are of particular importance since they contribute more than others to the potential years of life lost up to age of 65. Cancer has a higher Age-Standardized Mortality Rate among Jews than Arabs in all sites except for lung cancer. However, time trends show a faster increase in such rates among Arabs than Jews in most sites (breast, lung, prostate, uterus, ovaries and central nervous system).
Age-Standardized Mortality Rates for all external causes of death are 30% higher among Arabs than Jews; the ratio for mortality resulting from auto crashes and collisions is 2:1. No detailed information is available for work-related fatalities by population group. However, indirect evidence attests to a much higher ratio among Arab workers: 80% of such deaths occur among building and industrial workers, two sectors in which Arabs are over-represented. The Labor Ministry found the incidence of work-related deaths and injuries among Arabs sufficiently alarming to call a special news conference in Nazareth in February 1998, to issue a press release in Arabic and to initiate a special Arabic language program for awareness raising.
Compared to mortality, morbidity statistics are more difficult to obtain in Israel, except for some specific diagnoses such as cancer and injuries sustained from auto crashes and collisions and other accidents. Differences in hospitalization rates are not necessarily a reflection of differences in morbidity rates but could be the outcome of data collection methods, accessibility of care, site of treatment, budget considerations and other factors. Reporting on mortality is more complete and more reliable than reporting on morbidity, though it is not always accurate in terms of cause. Discrepancy between hospitalization and mortality rates can be found with regard to infectious disease statistics. Hospitalization rates for infectious diseases are still significantly higher for Arabs than for Jews, except for pneumonia, but the gap in mortality rates closed by 1992-4. Cancer data reveal a similar pattern for most sites. While cancer mortality is lower for Arabs than for Jews, age adjusted rates for cancer incid ence show that the Relative Risk Ratio of Jews as compared to Arabs is much higher than the Relative Risk Ratio for cancer mortality. This means that on the whole relatively fewer cancer cases are diagnosed among Arabs than their deaths from cancer would suggest (ICDC, 1997: 82).
Life expectancy at birth reflects the overall mortality experience of the current population. In 1995, life expectancy for Arabs in Israel was 2.3 years shorter than for Jews (CBS, 1997a, Table 3.19). This difference is due mainly to the contribution of excess deaths in infancy and early life. The above table further illustrates the significance of infant and child mortality. Though they constitute less than a fifth of the total population and account for 30% of the total births, Arabs suffer nearly half of the total stillbirths and infant and early child deaths in Israel. Excess infant mortality among Arabs above what would be expected based on the infant mortality rate of Jews, accounts for nearly 12,000 potential years of life lost to age 65. To appreciate the significance of this statistic, it should be compared to the figure of 13, 190, the potential years of life lost up to age 65 for the entire population of Israel caused by heart disease, the leading cause of death. Time trends show no closing of the gap in life expectancy since the mid-eighties and a slight widening during the previous decade. Put differently, the following table indicates a ten-year chronological lag in the level of life expectancy at birth for Arabs, compared with that for Jews, during the last twenty-year period. A further fact, relevant to the health of the elderly, is that over the last two decades, there has been a 2-year gain in the life expectancy at age 65 among Jews, while Arab 65-year-olds gained only 0.7 years (ICDC, 1997: 54).
Arab Women's Health
As Arab society in Israelis more patriarchal in its structure and orientation than most sectors of Jewish society, gender differences to the disadvantage of women are still evident in health status and health opportunity statistics. The table below offers a few comparative figures. Infant Mortality Rates by gender show a greater disadvantage for Arab female infants. This is true for the overall Infant Mortality Rates as well as for Infant Mortality Rates in the neonatal and post neonatal periods and the under-five period. Data on life expectancy at birth also show a greater disadvantage for Arab women vis-a-vis Arab men, compared to that of Jewish counterparts. Although female life expectancy is greater for both Arabs and Jews at all ages, at age 65 and above, the advantage of Arab women in terms of longevity is much smaller (0.4 years) than that of Jewish women (2.1 years). In terms of death from specific causes, Arab women have higher age-standardized rates of mortality from such causes of death as CVA, hy pertension, diabetes mellitus and asthma, compared both to Arab men and Jewish women. In comparison to Jewish women, Arab women have higher standardized rates of heart disease, the leading cause of death in Israel. Although Arab women exhibit lower cancer morbidity and mortality than Jewish woman, the incidence of breast cancer (the leading cause of cancer mortality in Israeli women) is increasing at a faster rate among Arab than among Jewish women. The same is true for cervical and ovarian cancer. In light of this finding, the limited participation of Arab women in breast cancer detection programs, especially mammography, deserves mention. This is reflected in the much higher Relative Risk Ratio of Arab to Jewish women in cases of mortality from breast cancer, compared to its incidence, implying later detection among Arab women and possibly earlier incidence among Jewish women. A similar discrepancy in the hospitalization versus mortality rates for hypertension implies under- utilization of health services b y Arab women (ICDC, 1997:61,79-80).
A major statistic in favor of Arab women's health is their reported low rate of smoking (ICDC, 1997: 238).
The Unrecognized Villages
The most highly disadvantaged segment of the Arab minority in Israel are residents of the unrecognized villages, so called as a result of the 1965 Planning and Zoning Law, which excludes over a hundred small Arab localities, in which over 80,000 persons reside, from residential zoning. On-site educational, health and other government seervices have been withheld from the residents of these communities.
Housing conditions in the unrecognized villages are severely inadequate due to the tight controls exercised by building and planning inspectors and the threat of demolition of new houses. Crowding is excessive and most houses lack water and electricity. Sewage is a major problem. The absence of any modem system of waste water disposal in such locations is the lesser problem; a greater threat to health are the streams of raw sewage from Jewish towns like Dimona which inundate stream beds through which residents of several Bedouin localities have to cross to reach their work places, markets, schools and even health services. Tractor-drawn tankers bringing in water for drinking and household purposes cross through raw sewage streams, a sure setup for fecal-oral disease transmission and outbreaks of gastroenteritis, hepatitis, and parasitic diseases (Kanaaneh, 1995:197; Kanaaneh, 1997: 7).
The practice of withholding basic services, including health services, constitutes a type of collective punishment and has been condemned by the international community (Kanaaneh, 1995:202). Currently it is being taken up at the Israel Supreme Court by Adala - the Legal Center for Arab Minority Rights in Israel and The Galilee Society - The National Arab Association for Health Research and Services. The harsh living conditions and socioeconomic deprivation of residents of unrecognized villages and the effects of substandard or nonexistent basic services result in a health status that is lower than that of any other group in Israel. In the Negev, for example, the Infant Mortality Rate of the Bedouin residents of unrecognized villages in 1995 was 13 per thousand live births, compared to 8 for other Negev Bedouins and 5 for Negev Jewish residents (Ministry of Health, 1997: 1). This Relative Risk Ratio of 3:2:1 has remained constant overtime. A greater disparity is seen in terms of congenital anomalies: the Rela tive Risk Ratio of giving birth to an infant with congenital malformation for Bedouin mothers is four-fold that for Jewish mothers. This is due in part to the high prevalence of consanguineous marriages among the Bedouins, but it is also related to other factors: infant mortality from congenital malformations has a Relative Risk Ratio of 7.5, reflecting the differences in living conditions and in accessibility and utilization of health services (Ministry of Health, 1994a: 2) between the Jewish and Bedouin sectors. A survey conducted jointly by the London School of Hygiene, the Southern District Health Office of the Israel Ministry of Health, and Ben Gurion University in 1996 found that a third of Bedouin mothers living outside the recognized localities did not visit the Mother and Child clinics (Hundt, 1996: 3). Similarly, a survey carried out for The Galilee Sociely - The National Arab Association for Health Research and Services in 1997 covering 19 remote Bedouin localities in the Negev found that only half of pregnant mothers had visited Mother and Child clinics, and that those who did made an average of less than half the recommended number of visits. Only about one-third of the infants and half of the toddlers were fully immunized in accordance with the recommendations for their ages (Kanaaneh, 1997: 4). The Israel Ministry of Health reports that 16 % of infants and 19 % of pregnant mothers from the unrecognized Bedouin villages in the Negev have no contact at all with the preventive health services (Ministry of Health, 1997, unpublished). Competition by the various health funds to enlist members of the Bedouin community has contributed to some improvement of the accessibility of curative primary health services, but the situation is still far from satisfactory.
National Health Insurance Law
The National Health Insurance Law has had two major positive effects on the Arab population in Israel. First and foremost, the delinking of payment of fees (taxes) from the right to health care has meant the bridging of the gap in health insurance coverage: all Arab citizens now have health insurance - by law.
The second positive development was a direct outcome of the competition for membership among the four health funds. Residents of peripheral communities in Israel, including Arab communities, were actively recruited, and new clinics and specialist services were established in such areas. In the Negev, for example, special transportation began to be provided by competing health funds at pick-up points far into desert dirt roads to and from the primary health care facilities. The competition resulted in greater accessibility and in improvement in the quality of primary health care for Arab citizens.
Availability of Services
There is very little recent data comparing the availability of health services in Jewish and Arab localities.
One survey of 148 Arab towns and villages carried out in 1996 (Hassan) found that 28 lacked primary curative health care facilities, so that residents had to travel elsewhere to seek care for their sick. The only health care service available in most of the other localities was Mother and Child clinics. Pediatricians were available in 50 of these communities and gynecologists in 35 of them, mostly on a part-time basis, and other specialists were to be found mainly in the few cities included in the survey.
School health services are far from adequate in Arab schools, and Mother and Child clinics in Arab villages are below the national average in terms of staffing and availability in peripheral localities. The planned construction of some 80 such centers, fewer than half of which were completed by 1998, has improved primary health care delivery, but accessibility still lags behind that for Jewish localities.
Prevention and Life Styles
A family with a member suffering pain, discomfort, or a direct threat to his her life will actively seek help within the health care system regardless of obstacles. However, compliance with health promoting advice from experts will be very limited if even minimal social, economic or cultural hindrances intervene. Action by individuals may appear to be reckless from a professional point of view but may well reflect the inner logic of the particular circumstances of the individuals involved.
Starting with birth defects in Israel, there is a marked difference in the compliance of pregnant Arab and Jewish women with recommendations for amniocentesis (ICDC, 1997: 160). In 1992, 16% of pregnant Arab women and 68% of pregnant Jewish women aged 37 years or more carried out the recommended procedure. For those under age 37 the difference is even greater: 0.6 and 19 percent, respectively. As a result, though only 57 out of a total of 220 Downs fetuses were to Arab mothers (26%), they had 48 out of 88 Downs births and only 9 out of 123 aborted fetuses. Issues of religious belief, social pressure, level of awareness, and program outreach are involved here.
Accidents are preventable to a large degree, particularly among children. The mortality rates for children from auto crashes and collisions and other accidents are shown in the tables on p.21. The significance of these statistics is not only in their amenity to prevention, which depends mainly on behavior change, but also in the general economic effects and the potential years of life lost. There is a marked discrepancy between mortality and morbidity rates: whereas the overall childhood mortality rate from accidents among Arabs is more than twice that among Jews, the rate of children's emergency room visits due to accidents is actually lower among Arabs than Jews by about one third (National Council for the Child, 1997: 183), indicating differences in accessibility and utilization of health services.
Immunization coverage is over 90% among both Arabs and Jews. However, this statistic is based on reports from Mother and Child clinics. Under-reporting is found mainly in two groups: the well-to-do Jewish residents of Central district suburbs who chose to immunize their children at private pediatric clinics, and the Bedouin children in remote Negev localities. The latters' reported coverage was 72% in 1994; out of those reported, only 84% were immunized fully at the end of their first year of life, i.e., 60% of all infants (Ministry of Health, 1997).
Cancer statistics provide an insight into another aspect of prevention, namely early detection. Over the years, cancer mortality has been lower among Arabs than Jews. This is true for the total mortality from cancer and for all cancers individually, with the exception of deaths from lung cancer among males. The age-adjusted rates for cancer incidence, on the other hand, show that the Relative Risk Ratio of Jews to Arabs is higher than the Relative Risk Ratio for cancer mortality, indicating less early detection among Arabs than Jews (ICDC, 1997: 82). Two additional figures illustrate the lack of early detection and health-promoting behavior among Arabs. Mammography is recommended and available at no cost once every two years for women over the age of 50. An annual breast exam by a physician is recommended as well. Here the disparities are striking: 81% of Arab women and 58% of Jewish women over 50 reported never having had a mammogram, with 84% (Arab) and 36% (Jewish) never having had a manual breast exam (I CDC, 1997: 122). More Arab women had a mammogram than a manual breast exam by a physician. This may be the result of the automated mammography scheduling, whereby women between the ages of 50 and 70 receive invitations in the mail to schedule a mammogram. It also could mean that some physicians refer women patients for mammography without first performing a physical exam, a negligent practice.
Infant Mortality Rates Infant Mortality Rates by Population Group (per 1,000 live births) Year Arabs Jews 1955-59 (*) 60.6 32.1 1965-69 (*) 43.8 20.8 1975-79 (*) 32.6 15.0 1979-80 23.5 12.5 1983-84 20.0 10.6 1987-88 16.9 8.3 1991-92 14.5 7.2 1996 9.3 5.0 (*)Moslems vs. Jews Source: Central Bureau of Statistics, 1997, Socio- demographic Characteristics of Infant Mortality Based on Data for 1990-1993, Table 25; Statistical Abstract of 1997, Table 3.1. Selected Health Status Indicators of Arab and Jewish Citizens of Israel - 1995 Arabs Jews RRR (*) Stillbirths per 1000 live births 6.8 3.2 2.3 Infant Mortality Rates per 1000 live 9.3 5.0 1.9 births (1996) Under 5 Mortality Rates per 1000 live Births 13.0 6.6 2.0 Age Standardized Mortality Rates per 100,000 population Men 740 640 1.2 Women 560 460 1.2 (*)Relative Risk Ratio of Arabs to Jews Source: Calculated from Central Bureau of Statistics, Statistical Abstract of Israel 1997, Tables 3.1 and 3.21). Potential Years of Life up to Age 65 Among Arab Citizens of Israel from Selected Causes Excess Potential Arabs' Share Years of Life Lost of Total Stillbirths 1995 7,900 49% Infant Mortality 1996 11,600 46% Under 5 Mortality 1995 14,300 46% Source: Calculated from Central Bureau of Statistics, Abstract of Israel 1997a, Tables 3.1 and 3.21. Life Expectancy by Population Group Arab Jewish Male Arab Jewish Female General Year Male Male Gap Female Female Gap Gap at birth 1970-74 68.5 70.6 2.1 71.9 73.8 1.9 2.0 1980-84 70.8 73.1 2.3 74.0 76.5 2.5 2.4 1990-94 73.5 75.5 2.0 76.3 79.2 2.9 2.5 at age 65 1970-74 15.3 13.7 -1.6 15.7 14.8 -0.9 -1.3 1980-84 14.7 14.6 -0.1 15.4 16.0 0.6 0.3 1990-94 16.0 15.8 -0.2 16.4 17.9 1.5 0.7 Source: CBS, Statstical Abstract of Israel 1997, Table 3.19; ICDC, 1997:56). Comparison of Health Status Indicators by Gender Male Female Relative Risk Ratio (*) of Infant 1.8 2.3 Mortality Rates 1990-93 Relatave Risk Ratio (*) of Under 5 2.5 3.0 Mortality Rate 1990-93 Difference in Years Between Jews 2.0 2.9 and Arabs in Life Expectancy at Birth 1990-94 (*)Relative Risk Ratio of Arab to Jewish Source: Calculated from CBS, 1997, Socio-demographic Characteristics of Infant Mortality Based on Data for 1990-1993; XIX; and from CBS, Statistical Abstract of Israel 1997, Table 3.21. Mortality Rates from Accidents, 1994 Arabs Jews Relative Risk Ratio of Arab to Jewish 0-4 years Auto crashes and collisions 9.6 1.0 10 Other accidents 10.1 3.0 3 5-14 years Auto crashes and collisions 6.9 2.0 3 Other accidents 3.2 0.6 5 15-19 years Auto crashes and collisions 11.4 12.0 1 Other accidents 7.0 3.6 2 Source: National Council for the Child, 1997, Children in Israel. Annual Yearbook, Table 9C.