Diagnosis: poverty (1 of 2)
Aviv Lavie / Haaretz, 30.01.2004
The fact that infant mortality among the Negev Bedouin is the highest of all populations in Israel isn't news. The news is that the numbers
have been increasing at an alarming rate - more than 50 percent in the past six years. The Health Ministry is helpless in the face of
"A child who is here is just a small problem," says Sofer. "At least we know that he is getting the proper care. Our major
worry is that we'll receive a phone call informing us about a child in critical condition who is on his way here, and I
know that I can't accept him. Sometimes I beg to have him accepted to the adult intensive care unit (ICU), but often there is simply
no solution. At any given moment there are children in the regular wards who should have been in intensive care. That's what they've
allotted: eight beds for 400,000 children."
Sofer, whose white beard gives him the appearance of a guardian angel one moment, and a prophet of wrath the next, stops next
to the corner bed. A beautiful baby girl lies prone, with a plethora of tubes pushing air into her mouth; her abdomen rises
and falls at a rate dictated by the machines. Abed al-Hawashleh, the 25-year-old father, stands next to the bed waiting for his
daughter - usually a healthy and smiling child - to show signs of life. Her name is Shahad and next week she'll be six months
old, the only child of Abed and his wife Amina. Yes, he knows that she's in very serious condition, the professor told him;
and he also knows that in other circumstances, in another place, she wouldn't have reached this situation.
The visit to the ward took place two weeks ago; the nightmare of the Hawashlehs began two days earlier. Shahad's temperature
rose, and the couple turned to the clinic of the Kupat Holim Clalit Health Maintenance Organization (HMO) in their village,
an unrecognized Bedouin community on the Dimona-Be'er Sheva road. The doctor sent them home with some medicine. The fever
didn't go down and on Wednesday night two weeks ago it rose to 39 degrees Celsius. Her parents removed some of her clothes,
cooled her body with water and the child went back to sleep.
At 4 A.M., as he does every night, Abed, who works in a plant in Dimona, got up to check on his daughter. She was burning
hot, 41 degrees.
It was decided to take her to Magen David Adom (MDA) emergency medical service. Amina, Abed and his brother got into the car
and drove in the direction of Dimona. On the way he called the MDA headquarters and asked them to call a doctor. They told
him to first come with the child, and then they would call one.
He was angry, but there was no choice. When they arrived, they were astonished not to find anyone. They knocked loudly on the
door, they honked, no reaction. The child was burning with fever; they began to panic. They decided to drive at top speed to the
emergency room at Soroka Medical Center. At the entrance to Be'er Sheva the child went into convulsions and stopped breathing.
For three long minutes he drove like that, with his daughter wavering between life and death. She arrived at the hospital
with a fever of 42.5 degrees, in serious condition, and was immediately rushed to the pediatric intensive care.
Since then Abed hasn't budged from her bedside. The news at the beginning of this week was mixed: Shahad's condition had
stabilized, and she has now been transferred from intensive care to a normal pediatric ward, but the extent of the neurological
damage is still unknown. Abed knows that he is lucky: his daughter, apparently, will not become part of the death statistics of
the Negev Bedouin . Of eight children who were hospitalized that evening in intensive care in Soroka, one was Jewish, seven were
Bedouin . Not all of them will be returning home.
The fact that the infant mortality figures among the Negev Bedouin are the highest of all the population sectors in Israel is not
news. The news is that over time the death rate - only among the Bedouin - is rising at an alarming rate. The Health Ministry
is helpless to fight the phenomenon: According to official statistics published by the ministry recently, the number of infant deaths
among the Negev Bedouin has increased from 11.2 deaths per 1,000 births in 1996 (in the Jewish sector - 4.5) to 17.1 in 2002
(Jews: 4.0). An increase of over 50 percent in six years, somewhere between Syria (18 deaths for every 1,000 births) and Oman (16.2).
If the mortality rates had remained at the 1996 level, the lives of 130 Bedouin babies would have been saved.
"This is an insane dive into a Third World medical situation," says one pediatrician, who is worriedly keeping abreast of the
"If this were to happen in Tel Aviv," says Ibrahim Abu Sbeih, the deputy head of the Regional Council of Unrecognized Villages
in the Negev, "there would long since have been a government commission of inquiry."
Because of pollution
A journey along the muddy dirt roads of the unrecognized villages illustrates how far Tel Aviv is from here. After a few days
of strong rains, the Negev is covered, as it is every year during this season, with beautiful green foliage. The sky is light
gray, there is a cool wind, and the brook that makes its way among the houses of the village of Umm Batin completes the pastoral
picture. "Europe, eh?" sighs Ali Abu Sbeih, an field worker in the council of unrecognized villages.
Not exactly. The stream in which the barefoot village children are treading is the water of Nahal Hebron, which contains little
rainwater and is composed mainly of the sewage from the large Palestinian city and the cluster of villages adjacent to it.
Even now, in the winter, a stench rises from the water, and on the bank, piles of disgusting-looking garbage accumulate.
That doesn't stop dozens of children, whose school is situated at the top of the hill, from gathering at the village attraction,
some on foot and some on rusty bicycles, to splash, to turn an old refrigerator into an improvised boat, to do everything
children do when a source of water passes at a stone's throw from their home.
In March 2002, a sample was taken from eight different points along the stream. The results showed that there was serious
bacterial pollution, coliforms at a level 16 times greater than that permitted for swimming, according to the requirements of
the Health Ministry, and microbes that "increase the danger of infectious diseases and other serious diseases," as determined
by Dr. Danny Filk, in an opinion that he added to a petition to the High Court of Justice that was submitted by the Environmental
Justice Clinic at Tel Aviv University.
Nearly two years later, the case is still pending. The piles of garbage are still there, and in the summer, the stench dominates
everything, together with the mosquitoes and the rats. The rats gnaw at the walls of the temporary buildings - and at the children,
too. Doctors at Soroka are already used to treating Bedouin toddlers who come with bleeding faces, clipped ears or bitten
hands. The treatment for rat bites doesn't end at the site of the bite. In most cases, all the body systems are infected.
The story of the Negev Bedouin is the story of a cruel battle, a battle declared by the state almost from the day of its inception,
against the tribes that lived in the south. After the establishment of Israel in 1948, the Arabs who were citizens, including the
Bedouin , were kept under a military administration. The Bedouin were forcibly transferred from all parts of the Negev to an
area defined as "the barrier region," which stretched over the area between Be'er Sheva, Arad, Dimona and Yeruham. In 1965,
the Planning and Construction Law was passed, and a national master plan was set. The Bedouin were in the area, but not in
the plan. Thus they became "unrecognized." The state began to concentrate them into urban communities. Between 1968 (when
Tel Sheva was established) and 1980, seven towns were built, which the Bedouin call "concentration towns" or "ghettos." Those
who moved to them were mainly Bedouin who in any case had been uprooted from their lands and had been transferred to the barrier
region during the first years of the state. Most of the others stuck with their lands. The state didn't like that.
The debate begins with the name: The authorities call the Bedouin who live in the unrecognized villages "the diaspora." A diaspora
is something that has to be gathered together. The Bedouin despise this name. At present the Bedouin Negev are holding about 240,000
dunams (60,000 acres) of land, 180,000 (45,000 acres) in the unrecognized villages, about 1.3 percent of the area of the
"The Bedouin are eating away at the last land reserve of the state," said Ariel Sharon in a speech he made two months before
he became prime minister. "In order to preserve the Negev, we have to operate through `individual settlement' or by `giving
land in custody.'"
Needless to say, the "individuals" who are invited to settle the Negev are Jews only. About a year and a half ago, the government
approved the Sharon plan for handling the issue of the area's Bedouin . Ostensibly, the plan was designed to provide a solution
to their distress; in effect, most of the budgets are channeled to enforcing the plans of the state relating to them and to
removing them from the open spaces. In this atmosphere, a group of settlers established a community near Rahat, "to establish
facts on the ground." Jews, of course.
The Bedouin are in no rush to do what the state expects. They are assisted by the fact that the process of urbanization has
been an utter failure. A study whose findings were presented by Middle East expert Dr. Yitzhak Bailey at the end of 2000
showed that the socioeconomic situation of residents of the towns is no better than that of those who remained in the unrecognized
villages. The infrastructure and services provided by the state remain at a very low level, unemployment is rising, the young
people are mired in crime and drugs, and the percentage of school dropouts is among the highest in the country.
"The government's policy was to invest as little as possible in the Bedouin communities," wrote Bailey in his study. "Almost
no thought was given to the economic welfare of the residents, and no steps were taken to find sources of employment and livelihood
for the communities ... The state must invest in order to eliminate the shameful cynicism with which it has defrauded the Bedouin
since its establishment."
The fate of the Bedouin who remained in the unrecognized villages is not much better. Today about 57,000 people live in 46 such
communities, 60 percent of them children. The villages are not connected to electricity, water or sewage systems, they don't
receive garbage collection services, and often kilometers of dirt paths separate them from the main highway. This is the
bottom of the barrel of the State of Israel: Tens of thousands of human beings who live in tin sheds and plaster huts. "In
articles about Jewish poverty, they always write about the empty refrigerator," says one of them. "Here a large percentage of
the families don't even have a refrigerator."
These conditions - combined with cultural customs such as consanguineous marriage (40 percent are between first cousins), a large number
of children (a high natural growth rate of 5.3 percent annually) and a tendency to avoid abortions for religious reasons - have
been the cause of the fact that infant mortality among the Bedouin has always been higher than among other sectors in Israel. The
infant mortality rate among the Arabs in the north of the country, for example, was 7.8 for every 1,000 births in 2002, less than
half that of the Bedouin (for statistical purposes, this includes infants who died up to a year after birth). Over the years there
was a certain improvement among the Bedouin , too. Progress crawled slowly up the dirt roads leading to the villages. From over
20 deaths per 1,000 births in the early 1980s, the number dropped to 11.2 in 1996. Since then there has been a renewed climb,
up to the hair-raising statistics of 2002.
People involved with the population have far more questions than answers. Prof. Ilana Shoham-Vardi heads an intervention
project to prevent birth defects and hereditary illnesses among the Bedouin , which is run jointly by the Health Ministry, Soroka
Medical Center and Ben-Gurion University of the Negev. When asked if she has an explanation for the dramatic increase, she
replies: "I really don't have an answer, and it's not that we aren't trying. If one cause of death were to increase dramatically,
we would have a clue, but the increase is on all fronts. If an explanation is found, I'll be happy to hear it."
Because of poverty "What - are you joking? Read my article from last year. Everything
was foreseen." Dr. Mohammed Morad, a Bedouin , director of the Be'er Sheva municipal clinic and a lecturer on disability and
retardation at Tel Aviv University, doesn't mean to brag. He simply doesn't understand what's not clear here.
In March 2003, in the wake of the publication of the National Insurance Institute poverty report, which made waves, he published
an article together with two colleagues (Prof. Joav Merrick and Dr. Eli Carmeli), in which they drew a straight line between
the economic situation and the level of poverty among the weak populations.
Morad: "The reason Bedouin children die more is very simple - poverty. Infant mortality is a direct function of income,
the quality of food, and which devices are available in the home to protect the infant. In traditional populations, when
there is competition for limited resources, the man is the one who receives the lion's share. When there are many children
in the house, the babies are exposed to infectious diseases, and today standard antibiotics no longer work for most types
of diseases. Seeing a doctor is a mission - someone has to drive, someone has to watch the children at home, the doctor has to
be paid. Fewer and fewer mothers nurse. Many babies are born with a low birth weight, because of poor nourishment of the
mother and stress that results from the family's economic situation.
"The Health Ministry can treat illnesses, but not social ills. This is a matter of policy. It's like the policy toward people
with handicaps - the ministry can help them, but if the state stops the allowances for the disabled, it's not the ministry's
responsibility. The treatment has to be global, the spotlights have to be turned on the government. There was an assumption
that the social damage would not cause damage to health, because we're a developed country, after all. We thought we were protected
because we belong to the enlightened world. Now look what we've come to."
"I encounter the socioeconomic situation every day," confirms Dr. Yunes Abu Rabia, the first Bedouin doctor in the Negev.
"Today, when a mother with 10 children needs milk, she makes a selection. There isn't enough for all of them. Only this week
a woman with several sick children came to me, I wrote her a prescription for five medications. She said to me, `Which is
the most important? No way do I have the money to buy all of them.'"
The apocalyptic descriptions by the pair of doctors are realized in the home of Salameh and Maliha Gebua. They live in Al-Fura,
an unrecognized village on the outskirts of Arad. On the way down from the main highway to a bumpy dirt path, it seems for
a moment as though someone has been joking: On a rusty pole, three stripes are painted in orange, blue and white, which indicate
that the Israel National Trail passes here. The residents of the village had hoped to take advantage of the marking of the
trail, and posted a sign directing those en route to the village.
That was already too much. The unrecognized villages are not allowed to post signs, an anonymous emissary of the establishment
passed through and threw the sign on the ground, and there it remains. The law gives the state the authority to destroy; it
doesn't require it to clean up.
Salameh Gebua, 28, a native of the village, works in a plant for pesticides in Arad. Pleasant, shy, he earns about NIS 4,500
per month. Meliha, also 28, whose attractive face peers out from a black scarf, grew up in Baka al-Garbiyeh and moved to
the south with her husband. No great wealth awaited them there.
Their toilets are a hole in the floor, they operate the generator a few hours a day and fuel is expensive - NIS 20 for six to
seven hours. Most of the time they heat their home with wood, but that's not enough to overcome the freezing cold of the desert
winters at an altitude of 600 meters above sea level. They don't heat at night, they can't afford it.
"We cover the children very well," says Salameh, "but sometimes I get up and see that one of the children has moved his hand
out from under the blanket at night, and it's completely blue."
Tragedy hovers over the house. In mid-March 2002, the youngest of their four children, 1-month-old Saba, fell ill. Salameh
took her to the Arad B clinic, a code name for a clinic for "minorities," which is located in the industrial zone, in the
Paz gas station. The doctor checked the child, said it was the flu and gave them medicine. At night Salameh left for his shift
at the factory. Saba's temperature rose, reaching 39 degrees, and Meliha gave her medication to reduce the fever. At about
2 A.M. the baby fell asleep. At about 6 A.M. Meliha awoke, approached the baby's cradle and saw that she was not breathing.
The parents describe with hair-raising lack of emotion how she called her husband crying, how he rushed from work, and how a
relative took the little body to the doctor so he could determine death and sign the death certificate. Salemeh was furious -
he accused the doctor of negligence, spoke with reporters from the local paper, and even the district head of the Kupat Holim HMO
called him - but what had happened was irreversible.
After a few difficult months, the couple decided to bring another child into the world; three months ago Iba ("Gift") was born.
They have four children in all, two girls and two boys, "and there won't be any more," they say. Salameh has no idea how
they'll manage with the cut in insurance allowances: "Once I received NIS 1,400, now NIS 600. As it is, everything goes for
fuel and food." In order to give the children a bath, they boil water on a portable gas burner, dreaming of running water and
electricity, but the electricity flows in cables that pass above their house on the way to the Jewish communities, "and even
if we ask, we won't get."
Another dream: to have a clinic in the village, within walking distance, so that Meliha can go with the children without being
dependent on her husband to drive her, because every time he leaves the factory, he has to punch a time card, and then his
salary decreases. But the matter of the clinic has been pending in the High Court of Justice for three and a half years.
Diagnosis: poverty (2 of 2)
Because of the budget
The past years have been marked by many battles between, on the one hand, the Bedouin and a series of human rights organizations
who support their cause and, on the other, the Health Ministry.
Most have revolved around the quality of health services provided to the Bedouin population. In recent years a series of Tipat
Halav well-baby clinics have been built in Bedouin communities, in most cases after repeated intervention of the High Court
of Justice. Serving all the unrecognized villages, each with a population of 500 to 5,000, are only seven such clinics; there
are also nine HMO clinics. For the sake of comparison, in Lehavim, a community of 5,000, there are three HMO clinics.
Ambulances don't always enter the unrecognized villages. During the period following the Arab riots of October 2000, they sometimes
refused even to enter the recognized towns, such as Tel Sheva.
Today, the drivers who don't know the way often refuse to travel along dirt paths that don't appear on any map. Anyone who needs
an ambulance has to bring the patient on his own to the meeting point on the main road. By the time a heart-attack patient arrives
at the gates of the hospital, at least 45 minutes are likely to pass, enough time to depart from this world.
The Bedouin have accused the health care system and the government of serious discrimination concerning the budgeting and availability
of health services. The Health Ministry has preferred to blame Bedouin society, and to remind them that about a third of infant
mortality is caused by birth defects, a result of consanguineous marriage. There is justice to the claims of both sides, but
now a third front has appeared, a new player on the field, about whose influence there is broad consensus among all those concerned:
the economic situation.
Dr. Ilana Belmaker is the Health Ministry's southern district doctor. A few months ago she infuriated the Bedouin and human
rights activists when, in response to a detailed and critical report published by Physicians for Human Rights (PHR), she claimed:
"The infant mortality rate in the Bedouin sector in the Negev is lower than the infant mortality rate in any Arab country
in the Middle East."
"Your reply indicates that the Health Ministry considers `Arabs in various countries in the Middle East' to be a control group
for residents of the unrecognized Bedouin villages," said Tomer Feffer, executive director of PHR, in response. "Can you accept
a scenario in which the the United States Secretary of Health would take a similar stand toward arguments regarding the health
of Afro-American citizens, and compare their situation to `the rest of the African countries' rather than to the rest of the
citizens of the United States?"
Today Belmaker says that "in the area of consanguineous marriages and birth defects among the Bedouin , there is no increase on
previous years. On the other hand, there is an increase in all the indexes related to poverty. It's true there's no diagnosis
that says a baby `died of poverty,' but more and more we are encountering a phenomenon where people don't have money for
medicine, and they don't have money to reach the emergency room or a doctor, because the trip costs a few shekels. They don't
have money to operate a refrigerator, and then it's no wonder that the food and milk are contaminated. About 80 percent of
the children who come to Soroka with diarrhea and vomiting are Bedouin ."
Has the Health Ministry presented these statistics to the government?
Have you warned that the economic policy is taking the lives of dozens of infants every year?
Belmaker: "I'm not at Jerusalem headquarters. I presented the statistics to the ministry. It's important to explain something
about the budget: The budget of the HMOs is determined according to the number of insured, and if the number increases, their
budget increases as well. The budget for public health such as well-baby clinics, on the other hand, does not depend on
the number of those receiving services. There is no mechanism for updating manpower and budgets in accordance with the number
of patients - on the contrary. Every year there is an increase of over 5 percent in the number of patients in the Bedouin population,
but there is a decline in manpower and in the budget devoted to treatment.
"My nurses and doctors are working harder and harder, with less and less ability to help. When a nurse is sick, there is nobody
to replace her, the clinic is closed. A large part of the work with the Bedouin has to be counseling, to encourage mothers
to nurse so that their children won't drink contaminated milk, but there is less and less time, money and manpower for such
counseling. The loss is twofold: both the lives of the babies and in the long run, the waste of money as well. Preventive
medicine is always more economical."
Nevertheless, every small Jewish settlement has a well-baby clinic, whereas among the Bedouin there is a serious problem
of the accessibility of services.
"It's not true that every Jewish community has a clinic - the moshavim don't have, and they go to a district center. I'm in
the process of closing down clinics in the Jewish sector as well. I have closed five or six, and I have plans to close another
three, in order to transfer resources to the Bedouin sector, but there are lots of problems. For example, there are another
three well-baby clinics that are ready, and I just want to set them up, but meanwhile I'm not getting permits and everything
is stuck. The doctors and the nurses work and work, invest their all, and then when they see the results it's very frustrating."
Frustration is also the lot of Prof. Yona Amitai, director of the Department of Mother, Child and Adolescent Health in
the Health Ministry, who signed the report on infant mortality.
"All over the country there are 490 well-baby clinics for about 85,000 babies, about one clinic for every 200 babies. Among
the Bedouin the numbers are completely different. Their dispersion creates a problem of accessibility, but that's a two-way problem.
We have a serious problem of manpower, there are three new well-baby clinics that have been dedicated and are still not manned. We
made an effort to train nurses for the Bedouin sector, we allocated three classes of nurses in the school for practical nurses in
Ashkelon, but the graduates preferred to go to Soroka and the HMOs, because the salaries are higher there. They pay much less
in the preventive services. Why?"
Because of policy
The offices of the Regional Council of Unrecognized Villages are located in a building in the heart of the old city in Be'er
Sheva. It's a ghost council: The residents of the villages elected their representatives, but the state doesn't recognize them.
Sometimes government representatives speak with some of the members of the council, but they emphasize that "they speak
to us as private individuals, as though we had returned to the period of the mukhtars (Arab village heads)," says Ibrahim Abu
Sbieh, the deputy chair of the council.
The only thing that encourages Abu Sbieh is the solidarity shown by several dozen organizations, most of whose members are Jews,
including the Association for Civil Rights in Israel, which, together with the Bedouin council comprises the Yahad (Together)
forum, and helps them in their struggle for existence. Since October 2002, just as in the Galilee, the Negev has been abuzz
with cooperative efforts of Jews and Arabs.
"This time it's not hummus coexistence, but a common struggle,"says Orly Almi, PHR coordinator of the health project in the
Abu Sbieh has no doubt that government policy has a direct influence on the rising mortality: "The roads are the key. A woman about
to give birth, or a child who is very sick, sometimes has to travel seven or eight kilometers in the middle of the night
on a dirt road, just to reach the highway. If the wadi is full of water and floods the road the trip is postponed until the
morning, and by then who knows what will happen. Now it's winter, and everyone is talking about the cold, but the heat in the
summer is no less dangerous.
"I am personally familiar with a case of a child who arrived at the hospital with a high fever. They stabilized him, sent
him home, and the next day he came back. They went to check what was happening, and reached the conclusion that he was simply
living in a hothouse. The heat in the tin sheds in the summer is inhuman."
That was all true 10 years ago. What has changed now?
Abu Sbieh: "The economic situation has deteriorated. This was even before [Finance Minister Benjamin] Netanyahu, because even
before him there were four waves of cutbacks in the various allowances. I would estimate that there is about 90 percent
unemployment in the unrecognized villages, and the cutting of the allowances is a death blow. In both senses of the word."
He notes several other innovations of recent years: For example, the spraying of the fields. For years, the authorities used
to dig up the fields that they claimed were illegally farmed by the Bedouin . Since 2002, a new method has been used, which
is much faster and more effective, but also violent and dangerous: spraying the fields. On the morning of February 15, 2002, chemical
spraying planes belonging to Chim-Nir appeared over the wheat and barley fields without advance warning, and began to spray
herbicides. Among other things, they sprayed near the Al-Amal school in the village of Hirbet al-Watan, which is located southeast
of the Shoket junction. At the time the children were in school, and they inhaled the chemical that was sprayed from the planes
and was carried by the wind to the school itself. Many of them were hospitalized. In other cases, it turned out that the substance
being sprayed was the herbicide Roundup. Studies published in recent years have shown that there is a connection between Roundup
and higher rates of birth defects.
Because of geography
Ilana Shoham-Vardi is not at all convinced that the catastrophe will end with the Bedouin . "In light of the steep rise among
the Bedouin , it has gone almost unnoticed, but during the past three years there has been an increase in infant mortality among
the Negev Jews as well. I am convinced that when we sum up 2003, it will turn out that the increase was even greater. That's
what happens when people are poor."
"The entire population in the south is quite badly off," agrees Prof. Shaul Sofer, "but the Bedouin are the worst off. Slightly
above them you can see Mitzpeh Ramon, Yeruham, Netivot, and above them Be'er Sheva. At the top of the pyramid are Omer,
Meitar, Lehavim. When my house in Omer is broken into - and, of course, I can't prove that it's Bedouin - it's very annoying,
but I can understand it. With the budget of one family in Omer, you can heat 100 huts among the Terrabin tribe on the other
side of the fence."
Sofer's mood doesn't improve when he tries to sum up the processes that the Negev has undergone over the past 30 years. "I have
been here since the 1970s. What a difference. The Bedouin population was friendly then: It was a pleasure - `sit, have a drink, ahalan
we'sahalan [an Arab greeting],' we would talk. Now the suspicion and hostility are all there is. We declared them to be collaborators
with the Palestinians, the standard bearers of drugs and violence; we have attached all the labels to them. We always think that
everything will be solved by force, and if not, then with even more force. In the end everyone will understand that no problem
is solved by force."
If you were the health minister, what would you do tomorrow morning?
Sofer: "I would go to the prime minister and bang on his desk It's not a matter of cosmetics here. Not to provide infrastructure
for a population group in 2004 is like declaring that a person is neither alive nor dead. It's incredible that a country that
considers itself advanced denies its citizens the elementary right to health. They exist - you can't run away from that."