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The health of Israel: Preventive medicine in a developing society
PREVENTIVE
MEDICINE
1,
121-140
(1972)
An historical review of social and medical problems and
The Health of Israel: Preventive Medicine in a Developing Society A.:MICHAEL Professor of Medicul -Hadassah Medical
Ecdlogy, School,
DAVIES Hebrew University Jerusalem, Israel
From its inception, Israel faced many medical and social problems consequent on the absorption of large numbers of immigrants with widely differing cultural backgrounds. Urgent problems of housing, the aged, and the chronic sick were alleviated and success achieved in the control of malaria, tuberculosis and those epidemics’ of childhood preventable by immunization. Expectation of life at birth is now 69.5 years for Jewish men and 73.3 for women; the figures for the Arab population. being 68.6 and 71.2. Infant mortality per 1,000 for Jews fell from 51.7 to 18.9 over 20 years and for Arabs, from 67.9 to 40.3. There is, however, a high morbidity, and an infant hospitalization rate of 25.9 admissions per 100 live births. An account is given of the uncohesive health setiices;the wide coverage of personal preventive care and the high utilization rates, &+ledwi& dissatisfaction of ambulatory curative services. The process of acculturation and improvement in living standaids have paralleled an increase in coronary heart disease, cancers, and stroke, the mortality of older immigrants from the West having increased disproportionately to that of Eastern immigrants. Examples are given of the differential morbidity patterns of the ethnic groups and the unusual opportunities for research in population genetics. With’the years there has been a “regression to a biological mean” but the welding of this old-new nation is bringing the same type of social and medical problems as in the West.
The State of Israel was recreated in 1948 after a lapse of nearly 1900 years. Within two decades, in an area the size of New Jersey, the population had more than tripled to 3 million, 60% of the increase being due to successive waves of immigration from over 100 countries. Each group contributed its own social and cultural mores; its patterns of morbidity and genetic constitution to the population “melting pot.” Welding of the exiles into a nation is an exciting Lnd complicated process, fraught with dangers and stumbling blocks. Some of the health consequences of this process, the challenges and the opportunities fbr intervention and research, from the point of view of one observer, form the substance of this report. THE
The narrow coastal plain summers and cool winters.
LAND
enjoys a Mediterranean climate with warm The mean monthly maximum temperature
121 @ 1972
by Academic
Press,
Inc.
humid in July
122
DAVIES
is around 3O”C, and the minimum, in February, 7-9°C. Sixty-three percent of the population live in this .area which contains the cities of Acre, Haifa, Tel Aviv, and Ashkelon as well as a variety of towns, villages, and settlements (3). Inland, commence the hills, with a lower relative humidity, peak temperatures a degree or two higher and colder winters, sometimes with snow. In the North, the hilly areas include.the cities of Nazareth and Safed. The rift to the East, between these hills and those of Syria, contains the Sea of Galilee and the Jordan River which flows down the rift valley to the Dead Sea. In the central part of the country, the Judean Hills surround Jerusalem (850 m high) and the level falls southward to Beersheba and the beginning of the Negev Desert. From here, the geographical center of the country, south to Eilat on the Red Sea, the days are hot and dry (40” or more), and the nights cold. Only 6% of the population live in this region, scattered in small and medium-sized settlements,(3), the controlling factor being the availability of water. The coastal plain is fertile, the north (Galilee) less so, and the Negev Desert least. But scientific irrigation and modem agriculture have restored some semblance of the Biblical “land flowing with milk and honey,” at least in part, and the country now exports small food surpluses. Settlement of this part of the world has been continuous for a million years; Homo carmetensis lived in caves near the coast and hunted bison and mammoths. In prebiblical times powerful nations had already developed to the North and South of the country and battled for supremacy over the Canaanites, Jebusites, Philistines, and other now extinct peoples. For the 400 years preceding World War One however, Palestine was a neglected unhealthy outpost of the Ottoman Empire known for endemic malaria, trachoma, and rabies, and swept, from time to time, by waves of plague, cholera, and smallpox. The efforts of the British Mandatory Government (19181948), and the Jewish settlement since 1921, began to control malaria, reduced trachoma, and succeeded in confining the great quarantinable diseases to small outbreaks. The enteric diseases and the dysenteries were still endemic, however, in 1948, and there were still pockets of malaria, bilharzia, hookworm, and several other parasitic diseases and zoonoses (16). THE
PEOPLE
At the founding of the State, there were 872,700 inhabitants, 716,700 of them Jews. The Jewish population comprised about a third (34.5%) who were native born, often of considerable ancestry in the land of their fathers, the others having immigrated over the years from many countries, 90% of them from Germany, Poland, and Russia. Of the non-Jewish population, roughly 70%.were Moslems, 21% Christians, and the remainder mainly Druze (Census, 1948 (3),). During the next three years the country received nearly 700,000 immigrants. They included the survivors of Hitler’s Europe, most of Iraq’s, and all of Yemen’s Jewry, many from North Africa, and a few from Englishspeaking countries. These were followed over the years by further waves of settlers from India, Tunisia, Algeria, Morocco, Poland, Iran, and Rumania
PREVENTIVE
1946
MEDICINE
50
55
IN
ISRAEL
60
123
65
70
YEAR FIG.
1. Jewish
immigration
to Israel
(thousands)
(1946-1968).
with a constant trickle from the free societies of the Americas and Northern Europe (Fig. 1). The “melting pot” became a “pressure cooker” and by 1970, the population had reached 3 million, Due to its favorable fertility and decreasing mortality, the Arab population kept pace and increased proportionately (Fig. 2). The new immigrants brought with them a variety of worms, parasites, and other pathogens to swell the menagerie of Israel. They also showed considerable variation in educational level, in fertility, and experience of, and attitudes to, health services (13,31). The population age structure was.also different for different groups as is shown in Fig. 3. Thousands of the settlers TOTAL JEWS
anc1 z
500
$
300
2 I I-
200
_----
__/--
/--
_-e-c
-’
/’
CM
NON-JEWS
___---: 1001 1 ’ 1 ’ ’ ’ ’ 1 ’ ’ ’ ’ 1 ’ ’ ’ ’ 1 ’ ’ ’ ’ I 1948 50 55 60 65 70 YEAR FIG.
2. The
population
of Israel
(1946-1968).
124
DAVIES
800
z&l 3044 15-29 o-14
48 29
FIG.
3. Population
of Israel
by continent
of birth
and broad
age groups
(1962).
had to be accommodated in temporary camps for years while houses were built and many of these, in turn, became crowded and inadequate. There was thus considerable social upheaval associated with the process of acculturation (13) and this, together with the financial situation of the country and war or the constant threat of war, forms the backcloth against which the health problems of this emerging nation must be viewed. THE
On of the dards rarily, Health
DISEASES
the whole, the health of the Jewish population had been better than that Arabs and this was attributable to higher educational and hygienic stanwith a greater accenton prevention, particularly in rural areas. Tempoat least, immigration upset this differential. Problems
of Immigrants
Immigration up to 1951 was unselective on health or social grounds and Israel received an undue proportion of old and chronically sick people. All early immigrants were examined on arrival with special attention to tuberculosis, venereal disease, trachoma, leprosy, and ringworm (15). After 1952, attempts were made to examine prospective immigrants in their countries of origin and treat them where necessary. Immigrants from Turkey in 1948-51 showed active tuberculosis in 9.3 per 1,000, from Eastern Europe, 4.2-5.1, from North Africa, 2.3, and 0.8 to 1.9 from other countries (16). Similarly, trachoma of various degrees was seen in 31% of immigrants from Morocco in 1955-6, while in 1957 mental diseases were diagnosed in 2.7 per 1,000 immigrants from Egypt, and in 2.3 per 1,000 of those coming from Poland. To take the example of the Moroccan immigrants, 9.5% showed some serious degree of chronic disease. One of the most immediate problems was that of tuberculosis. In 1934, the
PREVENTIVE
MEDICINE
IN
125
ISRAEL
death rate from tuberculosis in 17 urban centers was estimated to be 50.0 per 100,000 with a high prevalence of extrapulmonary disease among Moslems. It was estimated that of the arrivals in 1948-1951, 4,349 were in need of hospitalization for tuberculosis, and about 30,000 required medical supervision (17). The principles of control, in addition to provision of beds, were the establishment of a central register, the setting up of 18 regional chest clinics, and immunization of newborns and school children with BCG. Availability of antituberculosis drugs, coupled with good facilities for case finding, and surveillance with a policy of active surgery and rehabilitation wherever possible, permitted maximal use of the hospital beds. The average stay fell from 420 days in 1954, to 107 in 1963. The rehabilitation service included improvement of housing conditions and home treatment, so that over the years, the incidence and mortality of tuberculosis have fallen dramatically (Fig. 4). The problem still exists, however. In Jerusalem in 1961 11.6% of unvaccinated 12 year olds were Mantoux positive (29), while in 1968, 1,339 new cases were discovered in the whole of the country (25). The pattern of disease today is as in the West, 90% of the cases being pulmonary tuberculosis and the highest rates occuring in persons over 60. Clinics and treatment are free. Any physician can refer any patient with suspected lung disease of any type to one of the chest clinics for free x-ray and consultation. The same facilities are available directly for any citizen who cares to walk in. Another acute problem, malaria, was controlled more easily. In 1948 the incidence was 160 per 10,000 with a case fatality of 5%. Within a decade, the incidence had dropped to 0.1 (17). Other urgent problems were the infirm and aged immigrants, particularly those who were the sole survivors of their families. Special camps were set up for those in need of institutional care and from these they were moved to oldage homes or institutions for custodial care. Mentally disturbed immigrants were taken directly to a government hospital. Cases of active trachoma,
New
cases
(per
!O,OOO)
16
(per
19L7
L9
51
53
55
57
100,000)
59
61
63
65
67
69
YEAR FIG.
4. Morbidity
and mortality
of tuberculosis
among
Jews
in Israel
(1947-1969).
126
DAVIES
ringworm of the scalp and venereal disease were migrant camps and treated as necessary (16). Ethnic
Differences
detected
on arrival to the im-
in Disease
Once a small, compact nation in the “Land of Israel,” the Jews began their dispersion about 2,500 years ago. Following the destruction of the first Temple in 586 BCE came the Babylonian exile (Jeremiah, 52,28-30), and the Iraqi Jews of today contain elements of the Jewish population which remained in Babylon after the return in 538 BCE (Ezra, 2,1-70). The community of Kurdistan may also have been founded at this period, and there is evidence of an ancient community in Persia. The descendants of these dispersions form the “Mizrachim,” or Oriental Jews. From about 300 BCE, during the period of the second Temple, emigration from Israel was constant, and Jewish colonies were established in Egypt, Syria, the Balkans, and the Crimea. The main exodus took place after the year 70, when the second Temple was destroyed, and Jews settled in the lands of their Roman conquerors, Spain, Germany, Italy, and France. Expelled from Spain in 1492, many Jews went to Turkey, and their descendents are found today in Turkey and Bulgaria. Some found their way to the established communities in North Africa. In the 16th century other former Spanish refugees emigrated to the newly independent Netherlands to found the Dutch Jewish community. These migrants, originating in Spain are the “Sephardim.” In the 14th century, large numbers of Jews migrated eastwards from Germany to settle in what are now East Germany, Poland, Latvia, and Lithuania. After the Russian pogroms of 1882 there was mass migration westward, to England and the Americas. The descendants of these migrants form the bulk of the Jewish communities of the world and are called “Ashkenazim,” i.e., from Eastern Europe. Due to other population movements and to intermarriage with local inhabitants, few communities can be assumed to be of “pure” stock. Among the groups with least intermarriage are the Yemenites, whose community probably dates from the time of the first Temple, the Kurdish Jews, and the Jews of certain Tripolitanian villages. With the ingathering of these ancient and more recent communities into Israel, opportunities have arisen for genetic research on populations originally of the same stock, but separated for many generations. Consanguinity rates are higher in all Jewish communities than in Western populations. One and a half percent of marriages among Ashkenazi Jews were between first cousins in 1958 but the rates were much higher in Mizrachim, reaching 19% among some groups of Iraqi immigrants (14). It is not surprising therefore, that there are marked differences in age structure, educational level, fertility, customs, and beliefs between the different groups. Birth-order patterns which still pertained in Jerusalem in 1964-1966 (11) are shown in Fig. 5. The results of these and other differences are manifest in differences in disease patterns and some of these are illustrated in
PREVENTIVE
MEDICINE
IN
127
ISRAEL
l-
t
All Origins Israel-Jews
-o
e - - Q Israel-Non Jews A-‘. d Europe - Americas
lc FIG.
5. Distribution
-. 4 m---a
North Asia
Africa
s
of deliveries
I I
I
2
by birth
I
3 BIRTH
order
I
4 ORDER
and maternal
I
5-6
origin,
I
I
7-9
>I0
Jerusalem
(1964-1968).
Table I. In general, immigrants from less “sophisticated” societies showed less coronary heart disease, less diabetes, and less breast cancer, for instance, than immigrants from the West. On the other hand, they showed a much greater frequency of malnutrition, infections, and parasitic diseases. Diseases with a genetic background were particularly prevalent in certain immigrant groups. The gene for thalassemia (Cooley’s anemia) showed a high frequency (q-0.066) among the Kurdish Jews. Certain groups from Iraq and Yemen (as non-Jews from Sicily and Sardinia) showed unusual sensitivity to fava beans, and to sulfonamides. In particular, the tendency to favism, familial and exhibited as a sex-linked, incompletely dominant trait, was found in 60% of Kurdish Jews, 30% of Iraqi Jews, and 18.7% of Jews from Persia (27). Immigrant groups with especially low frequencies of specific diseases, served as the subjects of extensive researches, the outstanding examples being, Yemenites and coronary heart disease (12), and Kurdish Jews and diabetes (6). With time however, some of the health consequences of adapting to a western-type society have become apparent and the differences between the disease patterns of the immigrant groups have diminished considerably. Some indices of change are discussed in the section Indicators of Change.
128
DAVIES
FREQUENCY
TABLE I DISEASES IN IMMIGRANT
OF SPECIFIC
Continent Disease
38
lo-58
males females
males females
Europe & Americas 2.5
18
Multiple sclerosis (rates per 100,000) Urolithiasis (ages 41-50 (a)
Fractured neck of femur (ages 30+, rates per 1,000 per year) Suicide (age adjusted rates per 100,000) Cancer of breast (females, aged 35-64, rates per 100,000) Cancer of stomach, (males, 35-64, rates per lQO,OOO)
Asia 1.0
Glucose-g-phosphate dehydrogenase deficiency (%)
0.4
Source population
and notes samples”
autopsy survey,b standard technique, population over
screening subjectsC
of over
33
all diagnosed
10
47
screening of population samples, over 30,000 in 12 settlement+
6.6 10.8
6.1 8.1
9.0 8.1
14.3 22.8
cases
in Israeld
all cases in Jerusalem, 1957-1960’
all cases
recorded
1962-19638
54.0
132.4
Cancer registry, all cases 1960-1966, adjusted to World Standard Populatior+
18.6
34.8
as above
R Cohen, A. M. Metabolism, 10,50, (1961). * Ungar, H. and Laufer, A. Path. Microbial. 24,711, (1961). c Goldschmidt, E. (Ed.) ‘Genetics of Migrant and Isolate Populations,” d Alter, M. and Bomstein, B. World Neural. 3, 561, (1962). e Frank, M. J. Ural. 81, 497, (1959). ’ Levine, S. J. BoneJoint Surg. 52A, 1193, (1970). y Modan, B. Amer. J. Epidemiol. 91, 393, (1970). h Sternritz, R. and Costin, C. “Cancer in Israel, 1960-1966” Ministry
HEALTH
50
5000
3-8
7.7 7.9
THE
OF ISRAEL
of birth
N. Africa
Diabetes (%) Myocardial infarction at autopsy (acute and healed) (%)
POPULATIONS
1963.
of Health,
1970.
SERVICES
This is not the place for a detailed analysis of the historical and political reasons which led to the present patchwork quilt of Israel’s health services, which have not been able, conceptually or organizationally, to keep pace with the rapidly increasing and changing demands. Some description of our fragmented system of medical care is necessary however for a proper understanding of preventive problems.
PREVENTIVE
MEDICINE
IN
ISRAEL
129
The main authority for the nation’s health is the Ministry of.Health which, in principle; guides and controls all the health agencies through its network of 15 ,district and subdistrict offices. At the district level, the activities include environmental sanitation, mother and child health, epidemiology of communicable and noncommunicable disease, followup of the chronically ill, those qsuffering from mental disease or in need of rehabilitation, health aspects of town planning, supervision of nongovernmental hospitals, and control of drugs and poisons. The district health officer is thus responsible for supervision of the health and environmental services of his area, provided usually by the municipality or local authority, especially in areas of population concentration, in cooperation with a variety of public and private agencies. One of the most important functions of the medical officer of health is coordination of the activities of other agencies such as the Ministries of Agriculture (meat inspection, zoonoses), Social Welfare, Commerce and Industry (food control), and Education (School health), the local authority (vital statistics), and the specific medical services in the area. As well as the principal responsibility for the development of public health services, the Ministry has operational duties, running (in 1969) 34 hospitals with 9,764 beds, i.e., 43% of the total (3). In addition, it maintains directly two-thirds of the mother and child welfare stations, 16 schools of nursing, public health laboratories, child guidance and mental health clinics, rehabilitation centers, and a physiotherapy school. The main agencies providing ambulatory care are the Kupot Holim or medical insurance funds which cover over 90% of the population. By far the largest of these is the Kupot Holim, the health insurance fund of the General Federation of Labor with a membership of over 2 million (3). The Kupot Holim maintains 1,662 clinics all over the country, 10 general and 6 special hospitals (15.8% of the total beds), convalescent and rest homes, laboratories, pharmacies, physiotherapy clinics, mother and child welfare stations (27% of th.e .total) and a medical research institute. The smaller sick funds, offering health insurance only, are comparable to Blue Cross and Blue Shield in the U. S. A. and their members who need hospital care, are admitted to the institutions of other agencies. Malben, an agency supported by the American Joint Distribution Com.mittee started its activities at the end of 1949 to meet the needs of the tuberculous, the aged and chronically sick immigrants. At present, Malben provides institutional care for ill and aged immigrants, maintains sheltered workshops for the blind and handicapped and is involved, with other agencies in schemes for rehabilitation, care of the mentally ill and training of paramedical workers. More and more, in recent years, Malben has acted as a catalyst, providing stimulus and funds for the development of new demonstration services for handicapped children, the blind, psychiatric patients and the like. The Hadassah Medical Organization, a pioneer in the establishment of health services, is now responsible for the 650 bed University hospital in Jerusalem and is the active clinical partner in the Medical Center which comprises the schools of medicine, dentistry, pharmacy, bacteriology, public health, nursing and physiotherapy.
130
DAVIES
Haifa and Tel Aviv municipalities both operate their own hospitals in conjunction with the Ministry of Health as well as providing most of the preventive services and some medical care for the indigent. Each of the main cities have private and charity hospitals in addition, whose services are coordinated by the district medical officer. A full account of these and other services and a description of the various voluntary agencies is given in Grushka’s monograph (17).
Personal
Health
Services
Curative services are provided by salaried physicians of the sick funds, the Government, municipalities, public and private agencies. In addition, private medicine, on a fee-for-service basis, flourishes. Preventive services started out as neighborhood mother and child health centers and school health services. Since 1962, expanding services for the chronic sick, the aged and mental patients, have been progressively integrated, together with the MCH Centers, into regional health services. The antenatal and well baby services cover a high percentage of the population (Table II), the remainder receiving care from other clinics or private physicians. Hospital delivery is free and carries a cash benefit for each child paid by the National Insurance Institute. This is in addition to 12 weeks paid maternity leave to which all employed women are entitled. By 1969, virtually all Jewish births and nearly 90% of Arab births took place in hospitals, an increase from 85% and 4%, respectively, in 1948. Maternal mortality decreased from 11.5 per 10,000 live births in 1949 to 2.2 in 1968. The number of visits of well babies to the clinic is very high and averages 16 during the first year of life. Attendance is free, medical and social advice and the usual immunizations are given mainly by the public health nurse and the infant is examined 2-3 times by a pediatrician. The nurse makes an average of 3 visits to the home during the same period (17). The question has been raised as to what extent these 16 visits, or the 7.2 TABLE
II
ATTENDANCE AT MOTHER AND CHILD CARE CENTERS
Year
Percentageregistered
Percentageof infants immunized”
Pregnant Women
Smallpox
Infants
1950 1955
61 55
77 77
1960 1965 1969
77 68 70
88 92 91
71 78 78
DPT 85 90 91
a Based on reports from 72-89% of centers, data available only from 1960. Smallpox-percentage successful takes. DPT-percentage completing three injections. Poliomyelitis-2 injections of killed vaccine in 1960, subsequently, 3 feedings (Data from Statistical Abstracts of Israel and Ministry of Health reports).
Poliomyelitis 95 87 90
of live virus.
PREVENTIVE
MEDICINE
IN
131
ISRAEL
visits made by the pregnant women, are mandatory, or whether, in view of changing needs, they could be reduced in favor of other types of preventive service. The separation of preventive and curative services for the majority of the population requires a wasteful duplication of effort and may contribute to the extremely high infant hospitalization rate, 18% in Jerusalem (19). Preventive services are equally available for toddlers but the proportion under supervision drops to 70% in the second year of life and less thereafter (3). Organized school health services are provided for about 87% of all primary school children and about half of vocational and high school children depending on whether the school is run by the Department of Education or belongs to another agency which makes its own arrangements. Space permits only mention of the well-developed special education facilities for backward and disturbed children, the physically handicapped, and the chronically ill. Personnel
and Facilities
Israel enjoys the highest doctor-patient ratio in the world with one physician for each 422 inhabitants in 1969 (3). This ratio has varied between 412 and 438 over the past 20 years. The ratio of dentists and dental practitioners in 1969 was 1: 1,405 and pharmacists (including assistants) 1: 1,309 (3). Midwives continue to play an important role in deliveries and preventive care with a ratio of one per 6,000 population. The availability of hospital beds gives less cause for complacency, as construction has lagged behind needs. The number of beds increased from 5.55 per 1,000 population in 1948 to 7.90 in 1969 (see also Fig. 6), but beds in gen-
GENERAL
BEDS
CHRONIC
BEDS
20.000
1948
1950
1955
1960
1965
Year FIG.
6. Hospital
beds
in Israel
(1948-1969).
1969
132
DAVIES
era1 hospitals have remained at 3.11 to 3.26 per 1,000 since 1960. The overall occupancy rate was 99.1% in 1969,92% for beds in general departments and 115.2%(!) for those in mental hospitals: During the past year, the situation has deteriorated even further. This shortage of accommodation has delayed the closing of many of the 68 private hospitals which provide only poor quality nursing care: Since they have 22.6% of the total beds (with an occupancy rate of 105.6%), there is no immediate alternative. Expenditure The World Health Organization study of the cost of health services showed that Israel expended 7.9% of the National Income on health services in 1959/1960, compared to 6.4% for the U. S. A. and 4.9% for Ceylon (1). Unlike such other “welfare” countries as Ceylon, Czechoslovakia and Sweden, a high proportion of health expenditure in Israel, more than half, comes from voluntary insurance (18). The budget of the Ministry of Health has averaged 4.5-4.6% of the total Government’s expenditure since 1964. In 1967/1968 this amounted to 225.2 million Israel pounds, representing 31.8% of the total national expenditure on health. The remainder was made up by local authorities with 2.2% while nonprofit institutions together with household expenditures accounted for 66% of the total remaining costs of the health services, excluding construction and equipment. Public clinics and preventive services consumed 38.8%, and hospitals 38.2% of the total expenditure while private doctors and private purchase of drugs and appliances accounted for 8.1% and 6.1%, respectively. Private expenditure on personal care and health was 692.8 millions, 6.4% of the total expenditure of the private sector in 1969 (3). A rough calculation of total expenditure on health for 1968 gives a figure of Ig470 ($134) per capita. Utilization
of Health
Services
Not only do Israelis spend a great deal on health services, they use them extensively and criticize them incessantly (31). These criticisms are aimed mainly at the sick funds and particularly at the giant Kupot Holim of the General Federation of Labor. The average Kupot Holim member sees his doctor 9 times each year, 8.7 times in the clinic, and 0.3 times at home (3). Just under half of the visits are for a new condition, or at least, are recorded as such, the rest being repeat visits. The smaller sick funds, which cover 20.3% of the population, reported 8.4 to 12.3 visits per insured person in 1969. About two-thirds of these visits are to general practitioners, the rest, to specialists of different kinds. Comparable figures from other countries are 3.1-7.2 visits in Britain, 5.2 in the Netherlands and 5.0-6.0 for members of the Health Insurance Plan of Greater New York (31). The number of prescriptions issued per Kupot Holim member per year is 18, compared to 5.6-10.0 for comparable situations (full coverage, no charge for drugs) in other countries. Interview data, reported elsewhere, suggests that not only is the reported number of visits an underestimate but that the insured population makes ad-
PREVENTIVE
MEDICINE
IN ISRAEL
133
ditional extensive use of private practitioners, particularly when children are involved. Sixteen percent of those interviewed reported more than 20 visits to doctors per year and there is evidence that the number is even higher (31). The high rate of utilization can be explained partly by the “system” and partly by the latent functions of the doctor (32). Demands for service and degree of satisfaction vary with ethnic group, social class, and time since immigration. One factor seems general, the longer the residence in Israel, the greater the utilization but, in spite of this, the greater the dissatisfaction and the use of other sources of medical care. User dissatisfaction and rising costs are the main factors which have led to a recent proposal for the creation of a National Health Insurance Agency. INDICATORS
OF CHANGE
Despite social upheaval and the stresses of immigration, the cruder indices of health status show a steady improvement comparable to that of many Western countries. Thus the life expectancy at birth for Jews, which in 1949 was 65.2 and 67.9 years for males and females, respectively, reached 69.5 and 73.3 twenty years later. The earlier figures for the Arab population are not available but the 1967-1969 expectancies were 68.6 and 71.2 (3). This improvement is due mainly, as in other countries, to the reduction in infant mortality. Over the period 1949-1969, the life expectancy at 45 increased by only 0.8 years for men, and I.2 for women. Before ascribing improvement in health indices to medical services, it is salutary to look at indices of standards of living (2). Real incomes have doubled over the past decade. By 1970, 96% of all families owned electric refrigerators while the proportion of Afro-Asian families had reached 92% from 17% in 1960. Possession of gas cookers, television sets, and washing machines is now similar in all ethnic groups. The education of children of immigrants from Eastern countries still lags however. Only 77% of them attend high school (up from 61% in 1964) compared to nearly all children of Western immigrants. Although housing has improved, 17% of Eastern immigrant families still live at a density of 3 or more per room compared with 49%, 10 years ago. And now to some of the health indices. lnfunt
Mortality
and Morbidity
Infant mortality rates for Jews decreased from 51.7 per 1,000 live births in 1949 to 18.9 in 1969. Data for the non-Jewish population was incomplete in the early years due to the under-registration of home deliveries but the recorded rate of 67.9 in 1952 had fallen to 40.3 in 1969. As may be seen from Fig. 7 the main differences between the two populations as well as the changes over time are due to differences and improvements in the postneonatal death rate. The stillbirth and neonatal death rates have changed but little, while the apparent increase in stillbirths in the non-Jewish population is due to an increase in the proportion of hospital deliveries, there being virtually no reporting of stillbirths delivered at home.
134
DAVIES
60
Rate
per
1000 50
FIG.
7. Perinatal
Ao-o .-.---.. A-~
and infant
Infant mortality Ntonatal death Post-neonatal Stillbirth
mortality
death
in Israel
(3-year
moving
averages)
(1949-1969).
Detailed analyses of the causes of death have been reported elsewhere (20). In Jerusalem, for example, 4% of the first month deaths and 45% of the deaths at l-11 months were due to environmental causes, i.e., infections, accidents, and sudden deaths in otherwise healthy, nonpremature infants. By 1964-1966 there were no significant differences in total death rates between the Jewish ethnic groups as defined by mother’s birthplace although the causes of death still differed between the groups. Although infant deaths have decreased, this is not the result of a decrease in morbidity but rather the use of the most expensive method of preventing death- hospitalization ofthe sick. In 1967 there were 25.9 admissions for each 100 children under one year of age (5). For Jerusalem, where the prospective perinatal study (11) p rovides more accurate data, the crude rate was similar, the rate for children admitted, once or more, being 18.1%. Ethnic origin of the mother was the most important factor determining hospitalization. Children or grandchildren of Arabs or immigrants from Asia and North Africa were at significantly higher risk, for both single and multiple admissions for all causes. Oddly enough, in multivariate analyses, the length of time in the country was not a factor but low maternal education, low birth weight, high birth order, and certain areas of residence were important determinants of admission (19). Under the welfare conditions of Israel, with Government paying most of the costs, the decision to admit to hospital is made on social grounds no less than for medical reasons. The prospects of reducing admissions of infants, requiring as they do, the collaboration of many agencies and Government of services, both between departments, are poor, due to the fragmentation medical and social services, and between the parts of the medical services themselves.
PREVENTIVE
Control
of Communicable
MEDICINE
IN
135
ISRAEL
Diseases
Although one may gain the impression, from the preceding paragraphs, that the preventive services do not prevent, nor the ambulatory curative services heal, the fact is that great strides have been made in the control of certain communicable diseases. Specifically, those diseases which are preventable by immunization, such as smallpox, diphtheria, pertussis, and poliomyelitis have ceased to be public health problems. Measles immunization, instituted more recently, is having its predicted effect, and rubella vaccine is now available for selected populations. But consider Fig. 8. Murine typhus is controlled, as malaria was eradicated, by the activity of a few sanitarians without involving most of the population. For diseases controlled by immunization of infants, such as diphtheria and poliomyelitis, provided services are available, the degree of participation required is minimal. The mother has only to bring her baby to a neighborhood center. The control of intestinal infections on the other hand, demands minimal standards of environmental sanitation and particularly, personal hygiene: Little improvement has been made. Lastly, most viral hepatitis in Israel is probably spread by contact, the epidemic curve shows a winter peak (28), and apart from the use of gamma globulin in selected situations, there is no clear method of prevention.
Morbidity
and Mortality
in Adults
A detailed account of morbidity and mortality patterns is beyond the scope of this survey. It is instructive, however, to consider heart disease, cancers, and stroke, the leading causes of death in Israel as elsewhere. Table III shows the mortality from these modem epidemics for the two broad population groups aged 15 and over (data from (4)). For each of these groups of disease, immigrants from Europe and the Americas are at a disadvantage. The rates have increased markedly over the years, in part due to the aging of the population but those for Western immigrants have increased disproportionately.
1951
FIG.
8. Selected
53
infectious
55
57
diseases
59
61
among
63
65
Jews
67
69
in Israel
(1951-1969).
136
DAVIES TABLE
III
MORTALITYRATES,PER 100,000 SELECTEDCAUSESBYCONTINENTOFBIRTH FORPOPULATIONAGED 15, YEARS AND OVER, 1951,195$?,~~~ 1969 1951 Cause and ICD code
Europe & Americas
101.6
Coronary heart disease, angina& ASHD (420.0-420.2) Malignant neoplasms (140-205) Vascular lesions of the CNS (330-334) All infectious diseases (001-138) n International
1959 Asia & North Africa
1969
Europe & Americas
Asia & North Africa
Europe & Ameridas
Asia & North Africa
40.7
259.4
92.7
464.4
167.1
135.3
64.1
235.7
88.2
327.6
108.9
88.9
78..4
111.1
100.2
206.4
154.8
31.3
55.6
16.2
14.0
13.5
11.8
Classification
of Disease,
W.H.O.
7th Rev.
1955.
This disparity holds true for older: narrow age bands. Initially, deaths from infectious diseases were more common among immigrants from Africa and Asia but the trend since 1959, with falling rates, is reversed. The greater mortality of western immigrants from heart disease, cancers, and stroke is mirrored in the figures for hospitalization (FTg.’ 9). As hos’pitalization is free in Israel, the only part of the population not,covered by sickness insurance or social welfare being the rich, the hospitalization,data probably reflect the morbidity patterns and it may be seen that the divergence with time is less marked than would be expected from the reij6rrted mortality. Reference has been made to other differences in disease incidence and prevalence between the ethnic groups. A full treatment of the cancers of selected sites may be found in the proceedings of a recent conference (8). RESOURCES,
OPPORTUNITIES
AND
CHALLENGES
The small size of the country and the blending, though still divergent, population groups, present many unusual features which favor research in the prevention of disease. Registers and Surveillance The quantity and quality of demographic information Qn the Jewish population is high, while that for Arabs, still deficient in some items, is constantly improving. There is a population register (8) which is regularly updated and the fact that each citizen has a unique identity number favors the linkage of records from different sources. Analyses of the causes of death are published regularly (4) as are analyses of hospitalized patients (5) based on a 12.5% systematic sample of discharge summaries. National registers are maintained of cases of tuberculosis and mental disease, while the Central Cancer Registry (8,33) is remarkably complete.
PREVENTIVE Cancer all sites
MEDICINE
-
IN
137
ISRAEL Coronary heart disease
Ctrtbrovascular lesions
20 t-
d 20
15 -
-
15
10 -
-
10
5--
-5
L-L-L-1
O1955
60
65
70
1955
60
65
70
1955
0
60
65
70
YEAR
FIG. 9. (1955-1967).
Hospitalizations (-) Europe
per 1000 immigrant males aged + Americas; (- . - .) Asia + N. Africa.
45-64,
Surveillance of infectious diseases and investigation out by district health offices under the guidance of the Epidemiology which maintains a central national file. made of the utilization of the various health services reports of work absenteeism and its causes. Opportunities
for
selected
diagnoses
of outbreaks is carried Ministry’s Division of Regular analyses are and there are regular
for Research
These statistical resources are of immense value to epidemiological research. While clinical and biomedical research is conducted at a high level in several centers which enjoy international reputations (22,27), the unique potential of Israel lies in the opportunities inherent in her population laboratory. Systematic mining of this rich lode has not yet been achieved but some of the studies of individual diseases and conditions that have been made, illustrate the potential. Prominent are the series of population genetics commenced by Sheba (30) and Goldschmidt (14) and continued by their colleagues. These have led to detailed studies of tribal isolates, blood and hemoglobin types, haptoglobulins, enzyme deficiencies and familial Mediterranean fever, among others (14). Population studies of diabetes (6) and the effects of adaptation to Israel customs have added to our understanding of etiology. The possibility of tracing and examining all cases of multiple sclerosis in the population provided the basis for new epidemiological approaches (21). The degree of coverage by the preventive services have made the infant population an ideal testing ground for studies of poliomyelitis (10) and other vaccines while the efficacy of gamma globulin in the prevention of viral hepatitis has been measured in large population groups (26). Other examples in this far from complete list, are studies of toxemia of pregnancy in a total community (9), the national survey of retinal detachment, and
138
investigation under way. Experiments
DAVIES
of the value in Medical
of population
screening
for breast
cancer,
now
Care
A few years after the birth of the State, the now famous Kiryat Yovel health center was established by the Hadassah Medical Organization in a suburb of Jerusalem to give comprehensive care to families of a defined community of mixed immigrants (23). From this center have come many studies of social, health, and medical interaction, and a blueprint for the design and operation of an integrated service. The rural health centers of the Lachish area, Even Yehuda and Nehora formed another experiment where nurses, resident in small satellite villages, and backed up by the doctor and nurse of the central clinic became the first medical contacts of the population. Here, too, all preventive and curative care was provided by the same medical team (7) with a decrease in the work load of the physician and the need for hospitalization. The period 1948-1957 saw an increase in institutional care for the aged, and the chronic sick, pioneered by Malben. The trend in recent years has been towards care in the community and mention has been made of the conversion of the traditional mother and child care centers to foci of comprehensive neighborhood preventive activity. In this regard the pioneer mental health project in Jaffa may be mentioned. A center with only 40 beds, provides education, preventive and ambulatory care, through the neighborhood centers, for a population of 110,000. The integration of preventive services with the hospital may be seen in Ashkelon. The district health office is situated in the hospital building, the MOH is also director of the hospital, and the chief public health nurse has her office next to that of the chief nurse of the hospital. Hospital pediatricians and obstetricians work in the urban and rural preventive centers of the whole district, and continuity of care is assured for the population. Progress has also been made in breaking down the barriers and in integration of Kupot Holim physicians into the medical care system. It must be stated, regretfully, that these beginnings, successful in themselves, usually remain isolated experiments and have not been copied in other areas of the country. The main reason for this is the absence of a unified health planning authority. There are signs, however, that this may not be far off and if the proposed national insurance law, can be sufficiently improved, and removed from politics, the first step will have been taken. THE
EMERGING
NATION
It is difficult for one so close to the problems and emotionally involved, to appraise the degree to which the welding of a new nation has progressed. Fifty-five percent of marriages in 1968 were outside the ethnic group, compared to 5% in 1956 and, already, there are many indications of biological patterns of girls born in Israel to regression to an Israeli mean. Disease parents of different ethnic origins are more like each other and different from those of their parents (8). Fertility is becoming more an indicator of educa-
PREVENTIVE
ol
I
MEDICINE
/
I
1960
62
IN
ISRAEL
139
#(II 64
66
68
70
Year
FIG.
10. Notified
cases
of acute
gonorrhea
in Jewish
males
(1960-1969).
tional attainment than ethnic origin and the picture of malformations, morbidity and mortality in the offspring of the Israel-born mother bears little relationship to the origin of her parents (19). The deciding parameters are more social and cultural than medical and there is thus hope that the striving for social equality that characterizes Israel will unite the exiles into a single nation. Nation welding with a western orientation is not, however, an unmixed blessing and many of the traditional values, including patriarchal authority, have been victims of the process of acculturation (13). Among the health indicators that seem to presage the social upsets of the sixties and seventies is the increase in venereal disease (Fig. lo), and there are already signs that the world wide revolt of youth, although delayed and so far muted, has not left Israel unscathed. This is further evidence of the indivisibility of social and health problems, in Israel as elsewhere, but speculation as to where this may lead is beyond the scope of this review. REFERENCES 1. ABEL-SMITH, B. “Paying for Health Services.” Pub. H. Pap. 17, W. H. O., 1963. 2. Bank of Israel. “Report on Incomes and the Social Gap,” Jerusalem, 1971 (Hebrew). 3. Central Bureau of Statistics. “Statistical Abstract of Israel,“Vols. l-21,1949/1950-1971. Government Printer, Jerusalem. 4. Central Bureau of Statistics. “Causes of Death.” Annual publication (special series) Govemment Printer, Jerusalem. 5. Central Bureau of Statistics. “Diagnostic Statistics of Hospitalized Patients 1967,” Spec. Ser. 295, Jerusalem, 1969. 6. COHEN, A. M. Prevalence of diabetes among different ethnic Jewish groups in Israel. Metabolism 10, 50 (1961). 7. COHEN, J., MASSRY, S., DAVIES, A. M., MOOALLEM, F., ARNON, A., WEISKOPF, P., VARON, M., AND PARDESS, J. Morbidity in immigrant villages. Doctor, patient and nurse patient con-
140
8. 9.
10.
11.
12. 13. 14. 15. 16. 17. 18. 19.
20.
21. 22. 23. 24. 25. 26.
27. 28. 29. 30. 31. 32. 33.
DAVIES tacts in eight villages over three years. Mimeo pp. l-35. Ministry of Health, Department of Medical Ecology and Workers’ Sick Fund, Jerusalem, 1967. DAVIES, A. M. AND SACKS, M. (Eds). “Cancer and Other Chronic Diseases in Migrants to Israel.” Isr. J. Med. Sci. 7, 1331-1596, (1971). DAVIES, A. M., CZACZKES, W. J., SADOVSKY, E., PRYWES, R., WEISKOPF, P. AND STERK, V. V. Toxemia of pregnancy in Jerusalem. 1. Epidemiological studies of a total community. Isr. J. Med. Sci. 6, 253-266 (1970). DAVIES, A. M., MARBERG, K., GOLDBLUM, N., LEVINE, S. AND YEKUTIEL, P. Poliomyelitis in Israel 1952-59, Epidemiology and Evaluation of Salk Vaccination. Bull. W. H. 0.23, 53-72 (1960). DAVIES, A. M., PRYWES, R., TZUR, B., WEISKOPF, P. AND STERK, V. V. The Jerusalem perinatal study. 1. Design, organization and demographic base. Isr. J. Med. Sci. 5, 1095-1106 (1969). DREYFUS, F., TOOR, M., AGNON, J. AND ZLOTNICK, A. Observations on myocardial infarction in Israel. Cardiologia 30, 387 (1957). EISENSTADT, S. N. “Israeli Society,” Weidenfeld and Nicolson, London, 1967. GOLDSCHMIDT, ELISABETH (Ed.) “The Genetics of Migrant and Isolate Populations,” Williams and Wilkins Co., Philadelphia, 1963. GRUSHKA, TH. (Ed.) “The Health Services of Israel,” Ministry of Health, Jerusalem, 1952 (Mimeo). GRUSHKA, TH. (Ed.) “Health S ervices in Israel, 1948-1958,” Ministry of Health, Jerusalem, 1959. GRUSHKA, TH. (Ed.) “Health Services in Israel,” Ministry of Health, Jerusalem, 1968. HALEVI, H. S. National health expenditure, in “Health Services in Israel” (Th. Grushka, Ed.), pp. 402-408. Ministry of Health, Jerusalem, 1968. HARLAP, S., DAVIES, A. M., HABER, M., SAMUELOFF, N., ROSSMAN, H. AND PRYWES, R. Ethnic group, immigration and infant morbidity in West Jerusalem. Proc. 2nd Symp. Sot., Stress Dis., Stockholm, June 1971. LEGG, S., DAVIES, A. M., PRYWES, R., STERK, V. V. AND WEISKOPF, P. The Jerusalem perinatal study. 2. Infant deaths 1964-1966. A cohort study of socio-ethnic factors in deaths from congenital malformations and from environmental and other causes. 1sr.J. Med. Sci. 5, 1107-1116 (1969). LEIBOWITZ, U. Multiple sclerosis in immigrant and native populations of Israel. Lancet 2, 1323-1325 (1969). LOUVISH, M. (Ed.) “Facts about Israel, 1971,” Keter Publishing House, Jerusalem. MANN, K. J., MEDALIE, J. H., LIEBER, E., GROEN, J. J. AND GUTMAN, L. “Visits to Doctors,” Jerusalem Academic Press, 1970. MATRAS, J. “Social Change in Israel,” Aldine Pub. Co., Chicago, 1965. METZGER, J. N. “Tuberculosis in Israel, 1968,” Ministry of Health, Division of Chronic Diseases and Rehabilitation, Jerusalem, 1970. MOSLEY, J. W., REISLER, D. M., BRACHOT, D., ROTH, D. AND WEISER, J. Comparison of two lots of immune serum globulin for prophylaxis of infectious hepatitis. Amer. J. Epidemiol. 87,539-550 (1968). PRYWES, M. (Ed.) “Medical and Biological Research in Israel,” The Hebrew University, Jerusalem, 1960. REISLER, D. M., BRACHOT, D. AND MOSLEY, J. W. Viral hepatitis in Israel: morbidity and mortality data. Amer. J. Epidemiol. 92, 62-72 (1970). ROSENBERG, M. Tuberculosis in Jerusalem (Hebrew). Dapim Refuiim (Tel Aviv) 20, 375 (1961). SHEBA, CH. Epidemiologic surveys of deleterious genes in different population groups. Amer. J. Pub. Health. 52, 1101 (1962). SHUVAL, J. T. WITH ANTONOVSKY, A. AND DAVIES, A. M. “Social Functions of Medical Practice,” Jossey-Bass, San Francisco, 1970. SHUVAL, J. T., ANTONOVSKY, A. AND DAVIES, A. M. The doctor-patient relationship in an ethnically heterogeneous society. Sot. Sci. Med. 1, 141-154 (1954). STEINITZ, R. AND COSTIN, C. “Cancer in Israel, Facts and Figures, 1960-1966,” Ministry of Health and Israel Cancer Association, Jerusalem, 1970.
MEDICINE
1,
121-140
(1972)
An historical review of social and medical problems and
The Health of Israel: Preventive Medicine in a Developing Society A.:MICHAEL Professor of Medicul -Hadassah Medical
Ecdlogy, School,
DAVIES Hebrew University Jerusalem, Israel
From its inception, Israel faced many medical and social problems consequent on the absorption of large numbers of immigrants with widely differing cultural backgrounds. Urgent problems of housing, the aged, and the chronic sick were alleviated and success achieved in the control of malaria, tuberculosis and those epidemics’ of childhood preventable by immunization. Expectation of life at birth is now 69.5 years for Jewish men and 73.3 for women; the figures for the Arab population. being 68.6 and 71.2. Infant mortality per 1,000 for Jews fell from 51.7 to 18.9 over 20 years and for Arabs, from 67.9 to 40.3. There is, however, a high morbidity, and an infant hospitalization rate of 25.9 admissions per 100 live births. An account is given of the uncohesive health setiices;the wide coverage of personal preventive care and the high utilization rates, &+ledwi& dissatisfaction of ambulatory curative services. The process of acculturation and improvement in living standaids have paralleled an increase in coronary heart disease, cancers, and stroke, the mortality of older immigrants from the West having increased disproportionately to that of Eastern immigrants. Examples are given of the differential morbidity patterns of the ethnic groups and the unusual opportunities for research in population genetics. With’the years there has been a “regression to a biological mean” but the welding of this old-new nation is bringing the same type of social and medical problems as in the West.
The State of Israel was recreated in 1948 after a lapse of nearly 1900 years. Within two decades, in an area the size of New Jersey, the population had more than tripled to 3 million, 60% of the increase being due to successive waves of immigration from over 100 countries. Each group contributed its own social and cultural mores; its patterns of morbidity and genetic constitution to the population “melting pot.” Welding of the exiles into a nation is an exciting Lnd complicated process, fraught with dangers and stumbling blocks. Some of the health consequences of this process, the challenges and the opportunities fbr intervention and research, from the point of view of one observer, form the substance of this report. THE
The narrow coastal plain summers and cool winters.
LAND
enjoys a Mediterranean climate with warm The mean monthly maximum temperature
121 @ 1972
by Academic
Press,
Inc.
humid in July
122
DAVIES
is around 3O”C, and the minimum, in February, 7-9°C. Sixty-three percent of the population live in this .area which contains the cities of Acre, Haifa, Tel Aviv, and Ashkelon as well as a variety of towns, villages, and settlements (3). Inland, commence the hills, with a lower relative humidity, peak temperatures a degree or two higher and colder winters, sometimes with snow. In the North, the hilly areas include.the cities of Nazareth and Safed. The rift to the East, between these hills and those of Syria, contains the Sea of Galilee and the Jordan River which flows down the rift valley to the Dead Sea. In the central part of the country, the Judean Hills surround Jerusalem (850 m high) and the level falls southward to Beersheba and the beginning of the Negev Desert. From here, the geographical center of the country, south to Eilat on the Red Sea, the days are hot and dry (40” or more), and the nights cold. Only 6% of the population live in this region, scattered in small and medium-sized settlements,(3), the controlling factor being the availability of water. The coastal plain is fertile, the north (Galilee) less so, and the Negev Desert least. But scientific irrigation and modem agriculture have restored some semblance of the Biblical “land flowing with milk and honey,” at least in part, and the country now exports small food surpluses. Settlement of this part of the world has been continuous for a million years; Homo carmetensis lived in caves near the coast and hunted bison and mammoths. In prebiblical times powerful nations had already developed to the North and South of the country and battled for supremacy over the Canaanites, Jebusites, Philistines, and other now extinct peoples. For the 400 years preceding World War One however, Palestine was a neglected unhealthy outpost of the Ottoman Empire known for endemic malaria, trachoma, and rabies, and swept, from time to time, by waves of plague, cholera, and smallpox. The efforts of the British Mandatory Government (19181948), and the Jewish settlement since 1921, began to control malaria, reduced trachoma, and succeeded in confining the great quarantinable diseases to small outbreaks. The enteric diseases and the dysenteries were still endemic, however, in 1948, and there were still pockets of malaria, bilharzia, hookworm, and several other parasitic diseases and zoonoses (16). THE
PEOPLE
At the founding of the State, there were 872,700 inhabitants, 716,700 of them Jews. The Jewish population comprised about a third (34.5%) who were native born, often of considerable ancestry in the land of their fathers, the others having immigrated over the years from many countries, 90% of them from Germany, Poland, and Russia. Of the non-Jewish population, roughly 70%.were Moslems, 21% Christians, and the remainder mainly Druze (Census, 1948 (3),). During the next three years the country received nearly 700,000 immigrants. They included the survivors of Hitler’s Europe, most of Iraq’s, and all of Yemen’s Jewry, many from North Africa, and a few from Englishspeaking countries. These were followed over the years by further waves of settlers from India, Tunisia, Algeria, Morocco, Poland, Iran, and Rumania
PREVENTIVE
1946
MEDICINE
50
55
IN
ISRAEL
60
123
65
70
YEAR FIG.
1. Jewish
immigration
to Israel
(thousands)
(1946-1968).
with a constant trickle from the free societies of the Americas and Northern Europe (Fig. 1). The “melting pot” became a “pressure cooker” and by 1970, the population had reached 3 million, Due to its favorable fertility and decreasing mortality, the Arab population kept pace and increased proportionately (Fig. 2). The new immigrants brought with them a variety of worms, parasites, and other pathogens to swell the menagerie of Israel. They also showed considerable variation in educational level, in fertility, and experience of, and attitudes to, health services (13,31). The population age structure was.also different for different groups as is shown in Fig. 3. Thousands of the settlers TOTAL JEWS
anc1 z
500
$
300
2 I I-
200
_----
__/--
/--
_-e-c
-’
/’
CM
NON-JEWS
___---: 1001 1 ’ 1 ’ ’ ’ ’ 1 ’ ’ ’ ’ 1 ’ ’ ’ ’ 1 ’ ’ ’ ’ I 1948 50 55 60 65 70 YEAR FIG.
2. The
population
of Israel
(1946-1968).
124
DAVIES
800
z&l 3044 15-29 o-14
48 29
FIG.
3. Population
of Israel
by continent
of birth
and broad
age groups
(1962).
had to be accommodated in temporary camps for years while houses were built and many of these, in turn, became crowded and inadequate. There was thus considerable social upheaval associated with the process of acculturation (13) and this, together with the financial situation of the country and war or the constant threat of war, forms the backcloth against which the health problems of this emerging nation must be viewed. THE
On of the dards rarily, Health
DISEASES
the whole, the health of the Jewish population had been better than that Arabs and this was attributable to higher educational and hygienic stanwith a greater accenton prevention, particularly in rural areas. Tempoat least, immigration upset this differential. Problems
of Immigrants
Immigration up to 1951 was unselective on health or social grounds and Israel received an undue proportion of old and chronically sick people. All early immigrants were examined on arrival with special attention to tuberculosis, venereal disease, trachoma, leprosy, and ringworm (15). After 1952, attempts were made to examine prospective immigrants in their countries of origin and treat them where necessary. Immigrants from Turkey in 1948-51 showed active tuberculosis in 9.3 per 1,000, from Eastern Europe, 4.2-5.1, from North Africa, 2.3, and 0.8 to 1.9 from other countries (16). Similarly, trachoma of various degrees was seen in 31% of immigrants from Morocco in 1955-6, while in 1957 mental diseases were diagnosed in 2.7 per 1,000 immigrants from Egypt, and in 2.3 per 1,000 of those coming from Poland. To take the example of the Moroccan immigrants, 9.5% showed some serious degree of chronic disease. One of the most immediate problems was that of tuberculosis. In 1934, the
PREVENTIVE
MEDICINE
IN
125
ISRAEL
death rate from tuberculosis in 17 urban centers was estimated to be 50.0 per 100,000 with a high prevalence of extrapulmonary disease among Moslems. It was estimated that of the arrivals in 1948-1951, 4,349 were in need of hospitalization for tuberculosis, and about 30,000 required medical supervision (17). The principles of control, in addition to provision of beds, were the establishment of a central register, the setting up of 18 regional chest clinics, and immunization of newborns and school children with BCG. Availability of antituberculosis drugs, coupled with good facilities for case finding, and surveillance with a policy of active surgery and rehabilitation wherever possible, permitted maximal use of the hospital beds. The average stay fell from 420 days in 1954, to 107 in 1963. The rehabilitation service included improvement of housing conditions and home treatment, so that over the years, the incidence and mortality of tuberculosis have fallen dramatically (Fig. 4). The problem still exists, however. In Jerusalem in 1961 11.6% of unvaccinated 12 year olds were Mantoux positive (29), while in 1968, 1,339 new cases were discovered in the whole of the country (25). The pattern of disease today is as in the West, 90% of the cases being pulmonary tuberculosis and the highest rates occuring in persons over 60. Clinics and treatment are free. Any physician can refer any patient with suspected lung disease of any type to one of the chest clinics for free x-ray and consultation. The same facilities are available directly for any citizen who cares to walk in. Another acute problem, malaria, was controlled more easily. In 1948 the incidence was 160 per 10,000 with a case fatality of 5%. Within a decade, the incidence had dropped to 0.1 (17). Other urgent problems were the infirm and aged immigrants, particularly those who were the sole survivors of their families. Special camps were set up for those in need of institutional care and from these they were moved to oldage homes or institutions for custodial care. Mentally disturbed immigrants were taken directly to a government hospital. Cases of active trachoma,
New
cases
(per
!O,OOO)
16
(per
19L7
L9
51
53
55
57
100,000)
59
61
63
65
67
69
YEAR FIG.
4. Morbidity
and mortality
of tuberculosis
among
Jews
in Israel
(1947-1969).
126
DAVIES
ringworm of the scalp and venereal disease were migrant camps and treated as necessary (16). Ethnic
Differences
detected
on arrival to the im-
in Disease
Once a small, compact nation in the “Land of Israel,” the Jews began their dispersion about 2,500 years ago. Following the destruction of the first Temple in 586 BCE came the Babylonian exile (Jeremiah, 52,28-30), and the Iraqi Jews of today contain elements of the Jewish population which remained in Babylon after the return in 538 BCE (Ezra, 2,1-70). The community of Kurdistan may also have been founded at this period, and there is evidence of an ancient community in Persia. The descendants of these dispersions form the “Mizrachim,” or Oriental Jews. From about 300 BCE, during the period of the second Temple, emigration from Israel was constant, and Jewish colonies were established in Egypt, Syria, the Balkans, and the Crimea. The main exodus took place after the year 70, when the second Temple was destroyed, and Jews settled in the lands of their Roman conquerors, Spain, Germany, Italy, and France. Expelled from Spain in 1492, many Jews went to Turkey, and their descendents are found today in Turkey and Bulgaria. Some found their way to the established communities in North Africa. In the 16th century other former Spanish refugees emigrated to the newly independent Netherlands to found the Dutch Jewish community. These migrants, originating in Spain are the “Sephardim.” In the 14th century, large numbers of Jews migrated eastwards from Germany to settle in what are now East Germany, Poland, Latvia, and Lithuania. After the Russian pogroms of 1882 there was mass migration westward, to England and the Americas. The descendants of these migrants form the bulk of the Jewish communities of the world and are called “Ashkenazim,” i.e., from Eastern Europe. Due to other population movements and to intermarriage with local inhabitants, few communities can be assumed to be of “pure” stock. Among the groups with least intermarriage are the Yemenites, whose community probably dates from the time of the first Temple, the Kurdish Jews, and the Jews of certain Tripolitanian villages. With the ingathering of these ancient and more recent communities into Israel, opportunities have arisen for genetic research on populations originally of the same stock, but separated for many generations. Consanguinity rates are higher in all Jewish communities than in Western populations. One and a half percent of marriages among Ashkenazi Jews were between first cousins in 1958 but the rates were much higher in Mizrachim, reaching 19% among some groups of Iraqi immigrants (14). It is not surprising therefore, that there are marked differences in age structure, educational level, fertility, customs, and beliefs between the different groups. Birth-order patterns which still pertained in Jerusalem in 1964-1966 (11) are shown in Fig. 5. The results of these and other differences are manifest in differences in disease patterns and some of these are illustrated in
PREVENTIVE
MEDICINE
IN
127
ISRAEL
l-
t
All Origins Israel-Jews
-o
e - - Q Israel-Non Jews A-‘. d Europe - Americas
lc FIG.
5. Distribution
-. 4 m---a
North Asia
Africa
s
of deliveries
I I
I
2
by birth
I
3 BIRTH
order
I
4 ORDER
and maternal
I
5-6
origin,
I
I
7-9
>I0
Jerusalem
(1964-1968).
Table I. In general, immigrants from less “sophisticated” societies showed less coronary heart disease, less diabetes, and less breast cancer, for instance, than immigrants from the West. On the other hand, they showed a much greater frequency of malnutrition, infections, and parasitic diseases. Diseases with a genetic background were particularly prevalent in certain immigrant groups. The gene for thalassemia (Cooley’s anemia) showed a high frequency (q-0.066) among the Kurdish Jews. Certain groups from Iraq and Yemen (as non-Jews from Sicily and Sardinia) showed unusual sensitivity to fava beans, and to sulfonamides. In particular, the tendency to favism, familial and exhibited as a sex-linked, incompletely dominant trait, was found in 60% of Kurdish Jews, 30% of Iraqi Jews, and 18.7% of Jews from Persia (27). Immigrant groups with especially low frequencies of specific diseases, served as the subjects of extensive researches, the outstanding examples being, Yemenites and coronary heart disease (12), and Kurdish Jews and diabetes (6). With time however, some of the health consequences of adapting to a western-type society have become apparent and the differences between the disease patterns of the immigrant groups have diminished considerably. Some indices of change are discussed in the section Indicators of Change.
128
DAVIES
FREQUENCY
TABLE I DISEASES IN IMMIGRANT
OF SPECIFIC
Continent Disease
38
lo-58
males females
males females
Europe & Americas 2.5
18
Multiple sclerosis (rates per 100,000) Urolithiasis (ages 41-50 (a)
Fractured neck of femur (ages 30+, rates per 1,000 per year) Suicide (age adjusted rates per 100,000) Cancer of breast (females, aged 35-64, rates per 100,000) Cancer of stomach, (males, 35-64, rates per lQO,OOO)
Asia 1.0
Glucose-g-phosphate dehydrogenase deficiency (%)
0.4
Source population
and notes samples”
autopsy survey,b standard technique, population over
screening subjectsC
of over
33
all diagnosed
10
47
screening of population samples, over 30,000 in 12 settlement+
6.6 10.8
6.1 8.1
9.0 8.1
14.3 22.8
cases
in Israeld
all cases in Jerusalem, 1957-1960’
all cases
recorded
1962-19638
54.0
132.4
Cancer registry, all cases 1960-1966, adjusted to World Standard Populatior+
18.6
34.8
as above
R Cohen, A. M. Metabolism, 10,50, (1961). * Ungar, H. and Laufer, A. Path. Microbial. 24,711, (1961). c Goldschmidt, E. (Ed.) ‘Genetics of Migrant and Isolate Populations,” d Alter, M. and Bomstein, B. World Neural. 3, 561, (1962). e Frank, M. J. Ural. 81, 497, (1959). ’ Levine, S. J. BoneJoint Surg. 52A, 1193, (1970). y Modan, B. Amer. J. Epidemiol. 91, 393, (1970). h Sternritz, R. and Costin, C. “Cancer in Israel, 1960-1966” Ministry
HEALTH
50
5000
3-8
7.7 7.9
THE
OF ISRAEL
of birth
N. Africa
Diabetes (%) Myocardial infarction at autopsy (acute and healed) (%)
POPULATIONS
1963.
of Health,
1970.
SERVICES
This is not the place for a detailed analysis of the historical and political reasons which led to the present patchwork quilt of Israel’s health services, which have not been able, conceptually or organizationally, to keep pace with the rapidly increasing and changing demands. Some description of our fragmented system of medical care is necessary however for a proper understanding of preventive problems.
PREVENTIVE
MEDICINE
IN
ISRAEL
129
The main authority for the nation’s health is the Ministry of.Health which, in principle; guides and controls all the health agencies through its network of 15 ,district and subdistrict offices. At the district level, the activities include environmental sanitation, mother and child health, epidemiology of communicable and noncommunicable disease, followup of the chronically ill, those qsuffering from mental disease or in need of rehabilitation, health aspects of town planning, supervision of nongovernmental hospitals, and control of drugs and poisons. The district health officer is thus responsible for supervision of the health and environmental services of his area, provided usually by the municipality or local authority, especially in areas of population concentration, in cooperation with a variety of public and private agencies. One of the most important functions of the medical officer of health is coordination of the activities of other agencies such as the Ministries of Agriculture (meat inspection, zoonoses), Social Welfare, Commerce and Industry (food control), and Education (School health), the local authority (vital statistics), and the specific medical services in the area. As well as the principal responsibility for the development of public health services, the Ministry has operational duties, running (in 1969) 34 hospitals with 9,764 beds, i.e., 43% of the total (3). In addition, it maintains directly two-thirds of the mother and child welfare stations, 16 schools of nursing, public health laboratories, child guidance and mental health clinics, rehabilitation centers, and a physiotherapy school. The main agencies providing ambulatory care are the Kupot Holim or medical insurance funds which cover over 90% of the population. By far the largest of these is the Kupot Holim, the health insurance fund of the General Federation of Labor with a membership of over 2 million (3). The Kupot Holim maintains 1,662 clinics all over the country, 10 general and 6 special hospitals (15.8% of the total beds), convalescent and rest homes, laboratories, pharmacies, physiotherapy clinics, mother and child welfare stations (27% of th.e .total) and a medical research institute. The smaller sick funds, offering health insurance only, are comparable to Blue Cross and Blue Shield in the U. S. A. and their members who need hospital care, are admitted to the institutions of other agencies. Malben, an agency supported by the American Joint Distribution Com.mittee started its activities at the end of 1949 to meet the needs of the tuberculous, the aged and chronically sick immigrants. At present, Malben provides institutional care for ill and aged immigrants, maintains sheltered workshops for the blind and handicapped and is involved, with other agencies in schemes for rehabilitation, care of the mentally ill and training of paramedical workers. More and more, in recent years, Malben has acted as a catalyst, providing stimulus and funds for the development of new demonstration services for handicapped children, the blind, psychiatric patients and the like. The Hadassah Medical Organization, a pioneer in the establishment of health services, is now responsible for the 650 bed University hospital in Jerusalem and is the active clinical partner in the Medical Center which comprises the schools of medicine, dentistry, pharmacy, bacteriology, public health, nursing and physiotherapy.
130
DAVIES
Haifa and Tel Aviv municipalities both operate their own hospitals in conjunction with the Ministry of Health as well as providing most of the preventive services and some medical care for the indigent. Each of the main cities have private and charity hospitals in addition, whose services are coordinated by the district medical officer. A full account of these and other services and a description of the various voluntary agencies is given in Grushka’s monograph (17).
Personal
Health
Services
Curative services are provided by salaried physicians of the sick funds, the Government, municipalities, public and private agencies. In addition, private medicine, on a fee-for-service basis, flourishes. Preventive services started out as neighborhood mother and child health centers and school health services. Since 1962, expanding services for the chronic sick, the aged and mental patients, have been progressively integrated, together with the MCH Centers, into regional health services. The antenatal and well baby services cover a high percentage of the population (Table II), the remainder receiving care from other clinics or private physicians. Hospital delivery is free and carries a cash benefit for each child paid by the National Insurance Institute. This is in addition to 12 weeks paid maternity leave to which all employed women are entitled. By 1969, virtually all Jewish births and nearly 90% of Arab births took place in hospitals, an increase from 85% and 4%, respectively, in 1948. Maternal mortality decreased from 11.5 per 10,000 live births in 1949 to 2.2 in 1968. The number of visits of well babies to the clinic is very high and averages 16 during the first year of life. Attendance is free, medical and social advice and the usual immunizations are given mainly by the public health nurse and the infant is examined 2-3 times by a pediatrician. The nurse makes an average of 3 visits to the home during the same period (17). The question has been raised as to what extent these 16 visits, or the 7.2 TABLE
II
ATTENDANCE AT MOTHER AND CHILD CARE CENTERS
Year
Percentageregistered
Percentageof infants immunized”
Pregnant Women
Smallpox
Infants
1950 1955
61 55
77 77
1960 1965 1969
77 68 70
88 92 91
71 78 78
DPT 85 90 91
a Based on reports from 72-89% of centers, data available only from 1960. Smallpox-percentage successful takes. DPT-percentage completing three injections. Poliomyelitis-2 injections of killed vaccine in 1960, subsequently, 3 feedings (Data from Statistical Abstracts of Israel and Ministry of Health reports).
Poliomyelitis 95 87 90
of live virus.
PREVENTIVE
MEDICINE
IN
131
ISRAEL
visits made by the pregnant women, are mandatory, or whether, in view of changing needs, they could be reduced in favor of other types of preventive service. The separation of preventive and curative services for the majority of the population requires a wasteful duplication of effort and may contribute to the extremely high infant hospitalization rate, 18% in Jerusalem (19). Preventive services are equally available for toddlers but the proportion under supervision drops to 70% in the second year of life and less thereafter (3). Organized school health services are provided for about 87% of all primary school children and about half of vocational and high school children depending on whether the school is run by the Department of Education or belongs to another agency which makes its own arrangements. Space permits only mention of the well-developed special education facilities for backward and disturbed children, the physically handicapped, and the chronically ill. Personnel
and Facilities
Israel enjoys the highest doctor-patient ratio in the world with one physician for each 422 inhabitants in 1969 (3). This ratio has varied between 412 and 438 over the past 20 years. The ratio of dentists and dental practitioners in 1969 was 1: 1,405 and pharmacists (including assistants) 1: 1,309 (3). Midwives continue to play an important role in deliveries and preventive care with a ratio of one per 6,000 population. The availability of hospital beds gives less cause for complacency, as construction has lagged behind needs. The number of beds increased from 5.55 per 1,000 population in 1948 to 7.90 in 1969 (see also Fig. 6), but beds in gen-
GENERAL
BEDS
CHRONIC
BEDS
20.000
1948
1950
1955
1960
1965
Year FIG.
6. Hospital
beds
in Israel
(1948-1969).
1969
132
DAVIES
era1 hospitals have remained at 3.11 to 3.26 per 1,000 since 1960. The overall occupancy rate was 99.1% in 1969,92% for beds in general departments and 115.2%(!) for those in mental hospitals: During the past year, the situation has deteriorated even further. This shortage of accommodation has delayed the closing of many of the 68 private hospitals which provide only poor quality nursing care: Since they have 22.6% of the total beds (with an occupancy rate of 105.6%), there is no immediate alternative. Expenditure The World Health Organization study of the cost of health services showed that Israel expended 7.9% of the National Income on health services in 1959/1960, compared to 6.4% for the U. S. A. and 4.9% for Ceylon (1). Unlike such other “welfare” countries as Ceylon, Czechoslovakia and Sweden, a high proportion of health expenditure in Israel, more than half, comes from voluntary insurance (18). The budget of the Ministry of Health has averaged 4.5-4.6% of the total Government’s expenditure since 1964. In 1967/1968 this amounted to 225.2 million Israel pounds, representing 31.8% of the total national expenditure on health. The remainder was made up by local authorities with 2.2% while nonprofit institutions together with household expenditures accounted for 66% of the total remaining costs of the health services, excluding construction and equipment. Public clinics and preventive services consumed 38.8%, and hospitals 38.2% of the total expenditure while private doctors and private purchase of drugs and appliances accounted for 8.1% and 6.1%, respectively. Private expenditure on personal care and health was 692.8 millions, 6.4% of the total expenditure of the private sector in 1969 (3). A rough calculation of total expenditure on health for 1968 gives a figure of Ig470 ($134) per capita. Utilization
of Health
Services
Not only do Israelis spend a great deal on health services, they use them extensively and criticize them incessantly (31). These criticisms are aimed mainly at the sick funds and particularly at the giant Kupot Holim of the General Federation of Labor. The average Kupot Holim member sees his doctor 9 times each year, 8.7 times in the clinic, and 0.3 times at home (3). Just under half of the visits are for a new condition, or at least, are recorded as such, the rest being repeat visits. The smaller sick funds, which cover 20.3% of the population, reported 8.4 to 12.3 visits per insured person in 1969. About two-thirds of these visits are to general practitioners, the rest, to specialists of different kinds. Comparable figures from other countries are 3.1-7.2 visits in Britain, 5.2 in the Netherlands and 5.0-6.0 for members of the Health Insurance Plan of Greater New York (31). The number of prescriptions issued per Kupot Holim member per year is 18, compared to 5.6-10.0 for comparable situations (full coverage, no charge for drugs) in other countries. Interview data, reported elsewhere, suggests that not only is the reported number of visits an underestimate but that the insured population makes ad-
PREVENTIVE
MEDICINE
IN ISRAEL
133
ditional extensive use of private practitioners, particularly when children are involved. Sixteen percent of those interviewed reported more than 20 visits to doctors per year and there is evidence that the number is even higher (31). The high rate of utilization can be explained partly by the “system” and partly by the latent functions of the doctor (32). Demands for service and degree of satisfaction vary with ethnic group, social class, and time since immigration. One factor seems general, the longer the residence in Israel, the greater the utilization but, in spite of this, the greater the dissatisfaction and the use of other sources of medical care. User dissatisfaction and rising costs are the main factors which have led to a recent proposal for the creation of a National Health Insurance Agency. INDICATORS
OF CHANGE
Despite social upheaval and the stresses of immigration, the cruder indices of health status show a steady improvement comparable to that of many Western countries. Thus the life expectancy at birth for Jews, which in 1949 was 65.2 and 67.9 years for males and females, respectively, reached 69.5 and 73.3 twenty years later. The earlier figures for the Arab population are not available but the 1967-1969 expectancies were 68.6 and 71.2 (3). This improvement is due mainly, as in other countries, to the reduction in infant mortality. Over the period 1949-1969, the life expectancy at 45 increased by only 0.8 years for men, and I.2 for women. Before ascribing improvement in health indices to medical services, it is salutary to look at indices of standards of living (2). Real incomes have doubled over the past decade. By 1970, 96% of all families owned electric refrigerators while the proportion of Afro-Asian families had reached 92% from 17% in 1960. Possession of gas cookers, television sets, and washing machines is now similar in all ethnic groups. The education of children of immigrants from Eastern countries still lags however. Only 77% of them attend high school (up from 61% in 1964) compared to nearly all children of Western immigrants. Although housing has improved, 17% of Eastern immigrant families still live at a density of 3 or more per room compared with 49%, 10 years ago. And now to some of the health indices. lnfunt
Mortality
and Morbidity
Infant mortality rates for Jews decreased from 51.7 per 1,000 live births in 1949 to 18.9 in 1969. Data for the non-Jewish population was incomplete in the early years due to the under-registration of home deliveries but the recorded rate of 67.9 in 1952 had fallen to 40.3 in 1969. As may be seen from Fig. 7 the main differences between the two populations as well as the changes over time are due to differences and improvements in the postneonatal death rate. The stillbirth and neonatal death rates have changed but little, while the apparent increase in stillbirths in the non-Jewish population is due to an increase in the proportion of hospital deliveries, there being virtually no reporting of stillbirths delivered at home.
134
DAVIES
60
Rate
per
1000 50
FIG.
7. Perinatal
Ao-o .-.---.. A-~
and infant
Infant mortality Ntonatal death Post-neonatal Stillbirth
mortality
death
in Israel
(3-year
moving
averages)
(1949-1969).
Detailed analyses of the causes of death have been reported elsewhere (20). In Jerusalem, for example, 4% of the first month deaths and 45% of the deaths at l-11 months were due to environmental causes, i.e., infections, accidents, and sudden deaths in otherwise healthy, nonpremature infants. By 1964-1966 there were no significant differences in total death rates between the Jewish ethnic groups as defined by mother’s birthplace although the causes of death still differed between the groups. Although infant deaths have decreased, this is not the result of a decrease in morbidity but rather the use of the most expensive method of preventing death- hospitalization ofthe sick. In 1967 there were 25.9 admissions for each 100 children under one year of age (5). For Jerusalem, where the prospective perinatal study (11) p rovides more accurate data, the crude rate was similar, the rate for children admitted, once or more, being 18.1%. Ethnic origin of the mother was the most important factor determining hospitalization. Children or grandchildren of Arabs or immigrants from Asia and North Africa were at significantly higher risk, for both single and multiple admissions for all causes. Oddly enough, in multivariate analyses, the length of time in the country was not a factor but low maternal education, low birth weight, high birth order, and certain areas of residence were important determinants of admission (19). Under the welfare conditions of Israel, with Government paying most of the costs, the decision to admit to hospital is made on social grounds no less than for medical reasons. The prospects of reducing admissions of infants, requiring as they do, the collaboration of many agencies and Government of services, both between departments, are poor, due to the fragmentation medical and social services, and between the parts of the medical services themselves.
PREVENTIVE
Control
of Communicable
MEDICINE
IN
135
ISRAEL
Diseases
Although one may gain the impression, from the preceding paragraphs, that the preventive services do not prevent, nor the ambulatory curative services heal, the fact is that great strides have been made in the control of certain communicable diseases. Specifically, those diseases which are preventable by immunization, such as smallpox, diphtheria, pertussis, and poliomyelitis have ceased to be public health problems. Measles immunization, instituted more recently, is having its predicted effect, and rubella vaccine is now available for selected populations. But consider Fig. 8. Murine typhus is controlled, as malaria was eradicated, by the activity of a few sanitarians without involving most of the population. For diseases controlled by immunization of infants, such as diphtheria and poliomyelitis, provided services are available, the degree of participation required is minimal. The mother has only to bring her baby to a neighborhood center. The control of intestinal infections on the other hand, demands minimal standards of environmental sanitation and particularly, personal hygiene: Little improvement has been made. Lastly, most viral hepatitis in Israel is probably spread by contact, the epidemic curve shows a winter peak (28), and apart from the use of gamma globulin in selected situations, there is no clear method of prevention.
Morbidity
and Mortality
in Adults
A detailed account of morbidity and mortality patterns is beyond the scope of this survey. It is instructive, however, to consider heart disease, cancers, and stroke, the leading causes of death in Israel as elsewhere. Table III shows the mortality from these modem epidemics for the two broad population groups aged 15 and over (data from (4)). For each of these groups of disease, immigrants from Europe and the Americas are at a disadvantage. The rates have increased markedly over the years, in part due to the aging of the population but those for Western immigrants have increased disproportionately.
1951
FIG.
8. Selected
53
infectious
55
57
diseases
59
61
among
63
65
Jews
67
69
in Israel
(1951-1969).
136
DAVIES TABLE
III
MORTALITYRATES,PER 100,000 SELECTEDCAUSESBYCONTINENTOFBIRTH FORPOPULATIONAGED 15, YEARS AND OVER, 1951,195$?,~~~ 1969 1951 Cause and ICD code
Europe & Americas
101.6
Coronary heart disease, angina& ASHD (420.0-420.2) Malignant neoplasms (140-205) Vascular lesions of the CNS (330-334) All infectious diseases (001-138) n International
1959 Asia & North Africa
1969
Europe & Americas
Asia & North Africa
Europe & Ameridas
Asia & North Africa
40.7
259.4
92.7
464.4
167.1
135.3
64.1
235.7
88.2
327.6
108.9
88.9
78..4
111.1
100.2
206.4
154.8
31.3
55.6
16.2
14.0
13.5
11.8
Classification
of Disease,
W.H.O.
7th Rev.
1955.
This disparity holds true for older: narrow age bands. Initially, deaths from infectious diseases were more common among immigrants from Africa and Asia but the trend since 1959, with falling rates, is reversed. The greater mortality of western immigrants from heart disease, cancers, and stroke is mirrored in the figures for hospitalization (FTg.’ 9). As hos’pitalization is free in Israel, the only part of the population not,covered by sickness insurance or social welfare being the rich, the hospitalization,data probably reflect the morbidity patterns and it may be seen that the divergence with time is less marked than would be expected from the reij6rrted mortality. Reference has been made to other differences in disease incidence and prevalence between the ethnic groups. A full treatment of the cancers of selected sites may be found in the proceedings of a recent conference (8). RESOURCES,
OPPORTUNITIES
AND
CHALLENGES
The small size of the country and the blending, though still divergent, population groups, present many unusual features which favor research in the prevention of disease. Registers and Surveillance The quantity and quality of demographic information Qn the Jewish population is high, while that for Arabs, still deficient in some items, is constantly improving. There is a population register (8) which is regularly updated and the fact that each citizen has a unique identity number favors the linkage of records from different sources. Analyses of the causes of death are published regularly (4) as are analyses of hospitalized patients (5) based on a 12.5% systematic sample of discharge summaries. National registers are maintained of cases of tuberculosis and mental disease, while the Central Cancer Registry (8,33) is remarkably complete.
PREVENTIVE Cancer all sites
MEDICINE
-
IN
137
ISRAEL Coronary heart disease
Ctrtbrovascular lesions
20 t-
d 20
15 -
-
15
10 -
-
10
5--
-5
L-L-L-1
O1955
60
65
70
1955
60
65
70
1955
0
60
65
70
YEAR
FIG. 9. (1955-1967).
Hospitalizations (-) Europe
per 1000 immigrant males aged + Americas; (- . - .) Asia + N. Africa.
45-64,
Surveillance of infectious diseases and investigation out by district health offices under the guidance of the Epidemiology which maintains a central national file. made of the utilization of the various health services reports of work absenteeism and its causes. Opportunities
for
selected
diagnoses
of outbreaks is carried Ministry’s Division of Regular analyses are and there are regular
for Research
These statistical resources are of immense value to epidemiological research. While clinical and biomedical research is conducted at a high level in several centers which enjoy international reputations (22,27), the unique potential of Israel lies in the opportunities inherent in her population laboratory. Systematic mining of this rich lode has not yet been achieved but some of the studies of individual diseases and conditions that have been made, illustrate the potential. Prominent are the series of population genetics commenced by Sheba (30) and Goldschmidt (14) and continued by their colleagues. These have led to detailed studies of tribal isolates, blood and hemoglobin types, haptoglobulins, enzyme deficiencies and familial Mediterranean fever, among others (14). Population studies of diabetes (6) and the effects of adaptation to Israel customs have added to our understanding of etiology. The possibility of tracing and examining all cases of multiple sclerosis in the population provided the basis for new epidemiological approaches (21). The degree of coverage by the preventive services have made the infant population an ideal testing ground for studies of poliomyelitis (10) and other vaccines while the efficacy of gamma globulin in the prevention of viral hepatitis has been measured in large population groups (26). Other examples in this far from complete list, are studies of toxemia of pregnancy in a total community (9), the national survey of retinal detachment, and
138
investigation under way. Experiments
DAVIES
of the value in Medical
of population
screening
for breast
cancer,
now
Care
A few years after the birth of the State, the now famous Kiryat Yovel health center was established by the Hadassah Medical Organization in a suburb of Jerusalem to give comprehensive care to families of a defined community of mixed immigrants (23). From this center have come many studies of social, health, and medical interaction, and a blueprint for the design and operation of an integrated service. The rural health centers of the Lachish area, Even Yehuda and Nehora formed another experiment where nurses, resident in small satellite villages, and backed up by the doctor and nurse of the central clinic became the first medical contacts of the population. Here, too, all preventive and curative care was provided by the same medical team (7) with a decrease in the work load of the physician and the need for hospitalization. The period 1948-1957 saw an increase in institutional care for the aged, and the chronic sick, pioneered by Malben. The trend in recent years has been towards care in the community and mention has been made of the conversion of the traditional mother and child care centers to foci of comprehensive neighborhood preventive activity. In this regard the pioneer mental health project in Jaffa may be mentioned. A center with only 40 beds, provides education, preventive and ambulatory care, through the neighborhood centers, for a population of 110,000. The integration of preventive services with the hospital may be seen in Ashkelon. The district health office is situated in the hospital building, the MOH is also director of the hospital, and the chief public health nurse has her office next to that of the chief nurse of the hospital. Hospital pediatricians and obstetricians work in the urban and rural preventive centers of the whole district, and continuity of care is assured for the population. Progress has also been made in breaking down the barriers and in integration of Kupot Holim physicians into the medical care system. It must be stated, regretfully, that these beginnings, successful in themselves, usually remain isolated experiments and have not been copied in other areas of the country. The main reason for this is the absence of a unified health planning authority. There are signs, however, that this may not be far off and if the proposed national insurance law, can be sufficiently improved, and removed from politics, the first step will have been taken. THE
EMERGING
NATION
It is difficult for one so close to the problems and emotionally involved, to appraise the degree to which the welding of a new nation has progressed. Fifty-five percent of marriages in 1968 were outside the ethnic group, compared to 5% in 1956 and, already, there are many indications of biological patterns of girls born in Israel to regression to an Israeli mean. Disease parents of different ethnic origins are more like each other and different from those of their parents (8). Fertility is becoming more an indicator of educa-
PREVENTIVE
ol
I
MEDICINE
/
I
1960
62
IN
ISRAEL
139
#(II 64
66
68
70
Year
FIG.
10. Notified
cases
of acute
gonorrhea
in Jewish
males
(1960-1969).
tional attainment than ethnic origin and the picture of malformations, morbidity and mortality in the offspring of the Israel-born mother bears little relationship to the origin of her parents (19). The deciding parameters are more social and cultural than medical and there is thus hope that the striving for social equality that characterizes Israel will unite the exiles into a single nation. Nation welding with a western orientation is not, however, an unmixed blessing and many of the traditional values, including patriarchal authority, have been victims of the process of acculturation (13). Among the health indicators that seem to presage the social upsets of the sixties and seventies is the increase in venereal disease (Fig. lo), and there are already signs that the world wide revolt of youth, although delayed and so far muted, has not left Israel unscathed. This is further evidence of the indivisibility of social and health problems, in Israel as elsewhere, but speculation as to where this may lead is beyond the scope of this review. REFERENCES 1. ABEL-SMITH, B. “Paying for Health Services.” Pub. H. Pap. 17, W. H. O., 1963. 2. Bank of Israel. “Report on Incomes and the Social Gap,” Jerusalem, 1971 (Hebrew). 3. Central Bureau of Statistics. “Statistical Abstract of Israel,“Vols. l-21,1949/1950-1971. Government Printer, Jerusalem. 4. Central Bureau of Statistics. “Causes of Death.” Annual publication (special series) Govemment Printer, Jerusalem. 5. Central Bureau of Statistics. “Diagnostic Statistics of Hospitalized Patients 1967,” Spec. Ser. 295, Jerusalem, 1969. 6. COHEN, A. M. Prevalence of diabetes among different ethnic Jewish groups in Israel. Metabolism 10, 50 (1961). 7. COHEN, J., MASSRY, S., DAVIES, A. M., MOOALLEM, F., ARNON, A., WEISKOPF, P., VARON, M., AND PARDESS, J. Morbidity in immigrant villages. Doctor, patient and nurse patient con-
140
8. 9.
10.
11.
12. 13. 14. 15. 16. 17. 18. 19.
20.
21. 22. 23. 24. 25. 26.
27. 28. 29. 30. 31. 32. 33.
DAVIES tacts in eight villages over three years. Mimeo pp. l-35. Ministry of Health, Department of Medical Ecology and Workers’ Sick Fund, Jerusalem, 1967. DAVIES, A. M. AND SACKS, M. (Eds). “Cancer and Other Chronic Diseases in Migrants to Israel.” Isr. J. Med. Sci. 7, 1331-1596, (1971). DAVIES, A. M., CZACZKES, W. J., SADOVSKY, E., PRYWES, R., WEISKOPF, P. AND STERK, V. V. Toxemia of pregnancy in Jerusalem. 1. Epidemiological studies of a total community. Isr. J. Med. Sci. 6, 253-266 (1970). DAVIES, A. M., MARBERG, K., GOLDBLUM, N., LEVINE, S. AND YEKUTIEL, P. Poliomyelitis in Israel 1952-59, Epidemiology and Evaluation of Salk Vaccination. Bull. W. H. 0.23, 53-72 (1960). DAVIES, A. M., PRYWES, R., TZUR, B., WEISKOPF, P. AND STERK, V. V. The Jerusalem perinatal study. 1. Design, organization and demographic base. Isr. J. Med. Sci. 5, 1095-1106 (1969). DREYFUS, F., TOOR, M., AGNON, J. AND ZLOTNICK, A. Observations on myocardial infarction in Israel. Cardiologia 30, 387 (1957). EISENSTADT, S. N. “Israeli Society,” Weidenfeld and Nicolson, London, 1967. GOLDSCHMIDT, ELISABETH (Ed.) “The Genetics of Migrant and Isolate Populations,” Williams and Wilkins Co., Philadelphia, 1963. GRUSHKA, TH. (Ed.) “The Health Services of Israel,” Ministry of Health, Jerusalem, 1952 (Mimeo). GRUSHKA, TH. (Ed.) “Health S ervices in Israel, 1948-1958,” Ministry of Health, Jerusalem, 1959. GRUSHKA, TH. (Ed.) “Health Services in Israel,” Ministry of Health, Jerusalem, 1968. HALEVI, H. S. National health expenditure, in “Health Services in Israel” (Th. Grushka, Ed.), pp. 402-408. Ministry of Health, Jerusalem, 1968. HARLAP, S., DAVIES, A. M., HABER, M., SAMUELOFF, N., ROSSMAN, H. AND PRYWES, R. Ethnic group, immigration and infant morbidity in West Jerusalem. Proc. 2nd Symp. Sot., Stress Dis., Stockholm, June 1971. LEGG, S., DAVIES, A. M., PRYWES, R., STERK, V. V. AND WEISKOPF, P. The Jerusalem perinatal study. 2. Infant deaths 1964-1966. A cohort study of socio-ethnic factors in deaths from congenital malformations and from environmental and other causes. 1sr.J. Med. Sci. 5, 1107-1116 (1969). LEIBOWITZ, U. Multiple sclerosis in immigrant and native populations of Israel. Lancet 2, 1323-1325 (1969). LOUVISH, M. (Ed.) “Facts about Israel, 1971,” Keter Publishing House, Jerusalem. MANN, K. J., MEDALIE, J. H., LIEBER, E., GROEN, J. J. AND GUTMAN, L. “Visits to Doctors,” Jerusalem Academic Press, 1970. MATRAS, J. “Social Change in Israel,” Aldine Pub. Co., Chicago, 1965. METZGER, J. N. “Tuberculosis in Israel, 1968,” Ministry of Health, Division of Chronic Diseases and Rehabilitation, Jerusalem, 1970. MOSLEY, J. W., REISLER, D. M., BRACHOT, D., ROTH, D. AND WEISER, J. Comparison of two lots of immune serum globulin for prophylaxis of infectious hepatitis. Amer. J. Epidemiol. 87,539-550 (1968). PRYWES, M. (Ed.) “Medical and Biological Research in Israel,” The Hebrew University, Jerusalem, 1960. REISLER, D. M., BRACHOT, D. AND MOSLEY, J. W. Viral hepatitis in Israel: morbidity and mortality data. Amer. J. Epidemiol. 92, 62-72 (1970). ROSENBERG, M. Tuberculosis in Jerusalem (Hebrew). Dapim Refuiim (Tel Aviv) 20, 375 (1961). SHEBA, CH. Epidemiologic surveys of deleterious genes in different population groups. Amer. J. Pub. Health. 52, 1101 (1962). SHUVAL, J. T. WITH ANTONOVSKY, A. AND DAVIES, A. M. “Social Functions of Medical Practice,” Jossey-Bass, San Francisco, 1970. SHUVAL, J. T., ANTONOVSKY, A. AND DAVIES, A. M. The doctor-patient relationship in an ethnically heterogeneous society. Sot. Sci. Med. 1, 141-154 (1954). STEINITZ, R. AND COSTIN, C. “Cancer in Israel, Facts and Figures, 1960-1966,” Ministry of Health and Israel Cancer Association, Jerusalem, 1970.