The Joys of Clalit

I hate Clalit. Clalit is one of the four major Sick Funds (health insurance companies) in Israel, and has shaped my interaction with the health care system in Israel. While Israel has top-notch care available in major hospitals in Jerusalem, the experiences in the Clalit clinic in the Palestinian town where I've visited as a patient have only served to make me resolve never to go back. Those details aren't as funny as the new events from today, so I'll share with you the latter and not the former.

Health insurance became mandatory for every Israeli citizen in 1995 (The National Health Insurance Law), which forbade the sick funds from refusing membership to anyone. As a result, health insurance became more accessible to the Palestinian citizens. Despite this, there remain major health discrepancies for the Palestinian population in several areas, including breast cancer early detection and survival, and infant mortality rates: 4.0 in 1,000 live births for Jewish citizens of Israel, 8.4 for Palestinian citizens, and 15.0 for the Bedouin in the Naqab (World Bank).

I can never look at statistics like these without also considering the West Bank and Gaza as well. It doesn't make sense to me to consider the situation inside Israel by itself. Israel exercises sovereignty (no matter what the PA stands for) over the whole of the territory of Mandate Palestine and then some. So let's just keep in mind people like this woman, who risked major complications by posing as an Israeli to try to get major surgery, while the person she posed as had a different blood type. Israel controls the resources available to hospitals in the Occupied Territories, and controls peoples' fundamental access to those resources. It makes more sense to keep the whole in mind.

But since I'm talking about how I hate Clalit, let's focus on 48. (Not even the areas taken into Israel by the wall, since I don't think the people living in the annexed parts, if they have Palestinian or Jerusalem ID, have Sick Fund coverage. For more information on the Sick Funds and the role they play regarding the Palestinian population inside of Israel, Rhoda Ann Kanaaneh explores this issue in depth in one of her chapters in her book (which is awesome and you should read) Birthing the Nation. Highly simplified version: the Sick Funds act as contraception-pushers for Palestinian women, and the opposite for Jewish women, bringing the politics of Israel's 'demographic challenge' into people's reproductive decisions.

That isn't the main reason why I hate Clalit. My personal enmity for Clalit is due to stuff like this:

Me: [calls Clalit Clinic in Nazareth, navigates Arabic menu, does not press 2 for Hebrew]
Clalit Clinic: [answers in Hebrew]
Me: Hello, do you speak English?
Clalit: One minute. [puts me on hold]

[Repeat asking for English speaker three times, put on hold each time, give up. From here on, everything with Clalit is in Arabic.]

Me: Hello I am coming tomorrow for an appointment and I need to know what bus goes by the clinic.
Clalit: One minute. [puts me on hold, no one answers and phone goes to fax. I call back.]

[Repeat the above four times, get fifth person.]

Me: Listen, do not hang up on me, you are the fifth person I'm talking to, I have an appointment tomorrow and I need to know how to get to the clinic.
Clalit: I don't know.
Me: You can't ask someone?
Clalit: No, we are four here and we all drive.
Me: You can't look outside and see the bus sign?
Clalit: No, we aren't Egged.
Me: Ok, where are you located?
Clalit: Near the French Hospital.
Me: Ok thanks.

[Look up bus to Nazareth in general on website, find bus at 7 am, call Egged, get told there is no bus at 7 am. Decide to take taxi. Remember I should get prescribed a blood test for which I should fast, and that the other Clalit Clinic required you to make a separate appointment entirely for labwork in a lab only open three days per week.]

Me: [Calls Clalit again.]
Clalit: Hello?
Me: Hello, I have an appointment with the doctor tomorrow and I know I will need to take a blood test. Can I make an appointment for the blood test?
Clalit: We don't do those appointments. You should talk to the nurses for that.
Me: Ok, can I talk to them?
Clalit: To who?
Me: The nurses.
Clalit: Oh sure. One minute. [puts me on hold.]

[phone rings until goes to fax. I call back again, press 3 for nurses.]

Me: Hello, I need to make an appointment for a blood test tomorrow. I want to know if it's possible to do it in the morning and record my name now.
Clalit: One minute.

[rings 47 times, periodically interrupted by a woman who checks to see I'm still there and then lets it ring again. at least I don't have to call back.]

Clalit Nurse: Hello?
Me: Hello, I need to make an appointment for a blood test.
Clalit Nurse: One minute. [puts me on hold.]

[Repeat four times.]

Fifth Clalit Nurse: Hello?
Me: Hello, I have to do a blood test tomorrow, can I please record my name for that?
Fifth Clalit Nurse: The lab is open until 9:30 am. There is no need to record your name.



Tarboush Tip: Will

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On Breast Cancer, Palestinians in Israel, and Haifa Wahbe

A little while ago I attended a Breast Health Study Day put on by the Arab branch of the Israeli Cancer Association in Nazareth for Palestinian Arab women citizens of Israel. Cancer is a difficult issue here; people often don’t even want to say the word. Breast cancer gets into even more touchy territory (no pun intended). You’re talking about boobs in a generally conservative society and then putting boobs AND illness in the same sentence.

These attitudes are reflected in the survival rates of women afflicted with breast cancer. The survival rate of Jewish Israeli women for breast cancer is 70-75%, while among Arab Israeli women it is 60-65%, according to Physicians for Human Rights. Dr Raymond Menassa, the Director of the Breast Health Center in Nazareth has been quoted giving far more disparate numbers. The point is that survival rates indicate several things- access to health services, quality of diagnosis and treatment, access to information- and there is a serious differential here.

(Let’s keep in mind that in Gaza the breast cancer survival rate is around 30% or less, and I can’t find the numbers for the West Bank. I’m focusing here only within Israel’s internationally recognized borders, which places this into the context of an indigenous minority group’s health rights within the state where they are citizens. Cancer and access to treatment through checkpoints and across borders from the West Bank and Gaza is a whole other can of worms, though the people involved may end up in the same hospitals with the same doctors and may be related in some way....)

So there's the general cultural attitude toward breast cancer that makes prevention and awareness work so difficult: often women hide the fact that they are undergoing treatment, even from their own families. And as if stigma weren't enough, the Israeli Cancer Association insists on burying its head in the sand. The ICA recommendations, which determine what the Sick Funds (HMOs) will pay for, say that women should start getting mammographies at the age of 50. This recommendation is based on data showing that Israeli women tend to get breast cancer in their mid to late 50s.

Well, guess what. The physicians in Nazareth are saying, and have been for a long time, that Arab women tend to get breast cancer in their 40s. There's a reason why the American Cancer Society recommends that women begin mammogram screenings at age 40. And the CDC. While not always cost effective overall, mammogram screenings in a woman's 40s are so important, because if you get it younger it's likely to be more aggressive, and early detection will benefit you much more. You can find that information anywhere. Like here. And while it isn't a clear-cut issue (the American College of Physicians 2007 guidelines say you should just ask your doctor in your 40s when to begin mammogram screenings), it seems to me that if Palestinian citizens of Israel are likely to get breast cancer in their 40s, then the insurance should pay for screenings beginning at age 40, and the guidelines should be revised.

This whole situation is not unlike the good old U.S. of A. African American women tend to get more aggressive forms of breast cancer, and younger. African American women also wait longer for treatment.

Language is also a huge issue. While there is a ton of breast cancer awareness work that goes on in Israel, it's in Hebrew. I seriously doubt that's going to help most middle-aged and over Palestinian women who are Israeli citizens. At the study day, even though it was conducted in Arabic, every presentation but one was accompanied by a Hebrew language powerpoint. This is because you have to speak Hebrew to get anywhere in this country, and the doctors and nurses and nutritionists presenting who've clearly gotten somewhere have had to leave their Arabic in the dust and just couldn't be bothered to type out their notes bil Araby. One did. When her powerpoint came up in Arabic, the audience (mainly of the older non-Hebrew-speaking generations) reacted with exclamations of "What a bright girl!" "Bravo!" "She's so smart!"

I recently spoke with the product manager in the oncology branch of a major Israeli pharmaceutical company regarding some of this information, and he actually- and I still can’t quite believe this- said, “Now, explain to me why I should be interested in this?”

I’m sorry? Why should you be interested? Women in your country are DYING because they don’t have enough information in their own language to protect themselves, and you can’t muster up the teensiest ounce of interest? This issue is directly related to your line of work and product consumer base. I have a Susan G. Komen Race for the Cure San Diego t-shirt that lists the following general sponsors: Yoplait, American Airlines, Coldwater Creek, Energizer, Ford, New Balance, and Quilted Northern Ultra. TOILET PAPER, people! Yogurt, airplanes, weird yuppie clothing, batteries, cars, shoes, and TOILET PAPER are interested in breast cancer.

In spite of, and also because of, all this nonsense, many women showed up at the the Breast Health Study Day AND asked a ton of questions. Including the woman who stood in front of everyone to ask if in her 70s, she was too old for reconstructive surgery. Someone was quick to reply, "Not if you want to sing like Haifa Wahbe!"

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