The Israeli Melting Pot
LEARNING THE LANGUAGE OF HEALTH CARE.The New Physician
It was another hot and humid afternoon in Tel Aviv, Israel. The air conditioning was blasting as Dr. Eyal Ben Basat and I tried to get a history from a woman complaining of abdominal pain. English didn’t work; neither did French or Spanish. The woman was from Mongolia and only spoke Mongolian and a little bit of Mandarin-Chinese. Using exaggerated gestures, we tried to ascertain where the pain was (that was an easy one), its intensity and character (Basat did a stabbing imitation with his pencil), and whether there was any nausea or vomiting associated with the pain (I tried my best imitation of vomiting). Finally, we asked the patients in the waiting room if anybody could translate. One of them cautiously volunteered, but his attempts at Hebrew and English didn’t work. Welcome to the free clinic for migrant workers in Tel Aviv.
This encounter was not unique. Basat and I frequently struggled to get important information from patients who spoke only Romanian, French, Chinese, Polish, Bulgarian, Thai, Spanish, Burmese or Russian. As I came to understand during my 2001 primary care rotation in Israel, one of the main challenges in the clinic is not reaching a medical diagnosis or providing appropriate treatment—it is communicating with patients.
The presence of non-Jewish foreign labor migrants is a relatively recent phenomenon in Israel, having become notable during the early 1990s, when the government began recruiting foreign workers following the 1987 Palestinian uprising, known as the Intifada. Before then, the majority of the non-Jewish workers were Palestinians. The increasing influx of non-Jewish migrant workers has had a notable impact on society. At present, non-Jewish and non-Palestinian labor migrants—both documented and undocumented—account for approximately 10 percent of the labor force, according to the Israeli Central Bureau of Statistics. They’re changing not only the composition of the labor market but the ethnic fabric of Israeli metropolitan areas as well.
As it is in many Western developed nations, migrant workers are perceived by Israelis as incoming temporary labor and not as prospective citizens. Foreign workers are considered outsiders culturally, socially and politically. Even the term by which they are known in Israel, ovdim zarim (foreign workers), exemplifies their marginal status. The word “zar” in Hebrew, and its plural “zarim,” connotes an individual who is a stranger or different.
Many of these workers have encountered hardships and exploitation, including the struggle for access to social services. Regardless of their legal status, migrant workers suffer many of the same problems. They often live in substandard conditions, isolated from their families and familiar surroundings, and many lack adequate access to health-care services. Hospitals in Israel are reluctant to admit patients without adequate insurance. Illegally employed migrant workers can only receive medical treatment in Israel if they purchase private insurance or face a life-threatening condition. As a result of their inadequate or nonexistent health insurance coverage, many migrants often seek medical care only after complications worsen and require emergency care.
Physicians for Human Rights (PHR) has championed medical and human rights in Israel for several years, advocating for and lobbying on behalf of Palestinians, prisoners, Arab-Israelis and, more recently, migrant workers. In 1998, PHR opened a free clinic in South Tel Aviv to provide health-care services for migrant workers and their children. This is where I worked. The clinic is open five days a week and is staffed by more than 150 volunteer physicians, nurses and support personnel. It provides primary care and acts as an acute-care facility. When needed, referrals are made to specialists, who donate their time and sometimes their facilities.
There are, however, many limitations to the care provided. As with many such clinics serving a large population and providing acute care, patient encounters are short. And in South Tel Aviv, so much time is spent trying to understand what a patient is saying that little time is left to address the complaint and explain treatment. As a result, information gathering can suffer, and patient histories can be incomplete. Also, due to the volunteer nature of the clinic, physicians work only once or twice a month, so there is minimal continuity of care. Diagnostic work-ups can also be difficult. Often, they cost extra money and need to be done at outside facilities that charge the workers directly. Because of the cost constraints, only basic lab tests can be ordered, which means more complicated work-ups are typically neglected.
Drug treatment is also insufficient. To battle bloated expenses, PHR contracted with a local pharmacy to sell medications at or below market costs. But even the lower prices can be too expensive for the workers, many of whom earn minimum wage or less. Clinic volunteers have tried to lobby pharmacies and physicians’ offices to give away surplus medications like antibiotics, lipid-lowering drugs and anti-hypertensives. They’re then given to patients for free. But what arises is a situation in which the patient is given a drug based on what’s available and not necessarily on his condition. Additionally, many of these medications have outlasted their shelf lives but are distributed regardless.
While certainly not a perfect operation, the clinic provides basic medical services that would otherwise be unavailable to this population. As most who work in the clinic are quick to say, it is not and should not be the solution. It should only be a temporary measure until laws and regulations are created to require employers to provide health insurance to all of their employees. Furthermore, both the employers and the employees need to be educated about existing laws that mandate health coverage for foreign workers and their children.
Beyond the medical and social aspects of the rotation, my time in Israel has been remarkable for its human element. I was very impressed by the dedication of the physicians and the staff at the clinic. The other extraordinary people I met were the patients—people who left their homes and families in search of income or a better future for their children; they’re people who, nevertheless, continue to suffer, often in silence, many injustices.
One might argue that Israel is not the safest and most welcoming place to migrate to right now, but to many of the people I met—a woman who fled massacres in Rwanda, where her family was butchered; Albanians who risked their lives by escaping in small boats; impoverished Chinese and Nigerians—it’s an improvement over the lives they left behind.
Ranit Mishori is a first-year resident in the Georgetown University/Providence Hospital family practice program in Washington, D.C. She worked at the free clinic in Israel in July 2001.