physicians for human rights-israel: aggressively passive - the state of health of migrant workers in...

8/8/2019 Physicians for Human Rights-Israel: Aggressively Passive - The State of Health of Migrant Workers in Israel, October

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Aggressively Passive

The State of Health of Migrant Workers in Israel

October, 2002

Written by: Rami AdutTranslation: Shaul VardiTextual Editing: Michal RapoportCover Image: Miki KratsmanPrinted by: Arie Golan Printing Inc, Tel-Aviv, Israel

Some of the major conclusions are a product of our cooperation with Adv.Dori Spivak and his students in the Human Right Center, Tel-AvivUniversity.


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Contents

Introduction...... 3

Chapter One: Children

1A. The Current Situation..... 6

1B. Health Services for Migrant Children... 8

Chapter Two: Documented Migrant Workers

2A. Health Insurance for Visa Holders............... 12

2B. The Right to Health of DocumentedMigrant Workers ..... 13

2C. The Health Services Order to the New Law.... 14

Chapter Three: Adult Non-Documented

Migrant Workers3A. The Current Situation ... 20

3B. International Rights and Norms.... 25

3C. Possible Solutions..... 29

Chapter Four: Small Groups with Special Needs

4A. HIV Carriers..... 34

4B. Women Sold and Working in the Sex Industry 35

4C. Asylum Seekers and Refugees1 38

Conclusions.. 42

Responses...... 45

1 Wehave recently finished a full updated report on asylum seekers andrefugees in Israel together with Adv. Anat Ben-Dor of the Tel-AvivUniversity clinic for legal clinical aid. The report will be available in

our office and web-site as of November, 2002.

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Introduction

During the late 1980s and early 1990s, Israel saw the arrival of a

growing number of migrant workers2. As a result of the closurepolicy prevalent at the time, which prevented Palestinians from theWest Bank and Gaza Strip from working within Israel, thegovernment acceded to pressure from employers and issued them

permits allowing them to bring migrant workers into the country,mainly for construction and agriculture. By the end of 1997, thenumber of migrant workers holding visas was already at 85,000.3

Some migrant workers who initially held valid visas have since thenlost this status for various reasons. Workers who escaped theiremployers, either because of disagreements, extreme exploitation, adesire to secure increased earnings on the black market, or variousother reasons will automatically lose their valid visa. In addition tovisa-holding workers, a large number of workers have arrived andhave been working in Israel since the 1990s without visas at all.Most of these workers come from countries in which it is impossibleto obtain an Israeli working visa, such as Latin America, West andSouth Africa and Eastern Europe. All the while Palestinian workershave continued to enter Israel from the Occupied Territories

whenever the closure is lifted. While some return home at the endof the day, others will stay in Israel for a week or longer.According to figures of the Central Bureau for Statistics,approximately 240,000 migrant workers resided in Israel by the endof the year 2000, including those with visas and those without. Allof the migrant workers discussed here are not eligible for publichealth services, which are provided to Israeli residents4 under the

National Health Insurance Law (1994).

2 This document uses the internationally recognized termmigrant workers. In Israel, migrant workers are usually referred to asforeign workers.

3 From: Yitzhak Shanel, Guidelines for Policy toward ForeignWorkers, Social Policy Research Center, Jerusalem, 2001 (all workscited are in Hebrew unless otherwise noted.) The employers, andsometimes certain government ministries, refer to these employees asescapees.

4 The term resident is used here in its official sense, whichincludes permanent and temporary residents as well, of course, as

citizens.

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The National Health Insurance Law is one of the finestachievements of the Israeli welfare state. It establishes the

eligibility of any resident in Israel to a minimum 'basket' of healthservices as defined by the law. In other words, any person holding aresidents certificate (citizens are also residents) is entitled to healthservices through one of the HMOs. The HMO is not permitted toreject a member on the grounds of their religion, race, sex or state ofhealth. This eligibility is connected to the payment of health tax byall employees and self-employed persons, but is not conditioned on

payment. Even a person who, for whatever reason, fails to payhealth tax or is not a member of an HMO, but who holds aresidents certificate, is entitled to the full health basket. As noted

above, all migrant workers, by definition, are not residents. Theyhold working permits which far lesser status than those ofresidents. The National Health Insurance Law, consequently, doesnot apply to them.

It should be noted that the National Health Insurance Law includes aspecial clause that allows the Minister of Health to extend the scopeof applicability of the law to additional groups (also to those whoare not residents). The Minister may also determine the

composition of the health basket to be provided, and the means bywhich tax for these services is to be collected. In order to do so noexceptional legislation is required. If he so wishes, the Minister ofHealth (i.e. the Israeli government) can make public health servicesavailable to migrant workers, thus solving the problems detailed

below. However, the present Minister of Health, like all hispredecessors, has refrained from applying this clause, even in thecase of small groups with particular needs, such as children.

Thanks to lobbying activities initiated by PHR-Israel and other

organizations, progress has been made in recent years in theprovision of health services to two groups: children without civilstatus5 and adults who hold work visas. The laws and regulations

passed regarding these two groups have created a complex situationthat will be explained in detail in chapters one and two.

5 The progress secured regarding children did not include theapplication of the National Health Insurance Law to this population;rather, a special arrangement was introduced which will be discussed

below.

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The reality for adults who do not hold visas the largest groupwithin the population of migrant workers in Israel remains,however, the same as in the early 1990s. These workers have no

eligibility or access to health services and no attempt has been madeto provide them with such. Chapter Three will examine this groupand will include a number of proposals and conclusions.

The greatest problem facing migrant workers, as we see it, is thefact that eligibility and access to medical services preventativemedicine, primary and secondary care and hospitalization arecompletely ignored in the public debate and are non-existent on theagenda of decision-makers in the field of health policy.Accordingly, we encourage the Israeli public, policy makers and

media to initiate a public discourse on this subject on the basis ofthis report.

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Chapter One: Children

1A. The Current Situation

No information is available regarding the number of children bornin Israel to the families of migrant workers or brought into Israelfrom their country of origin. This lack of information is a by-

product of the fact that, from the standpoint of the Israeli authorities,these children effectively do not exist, even if they were born inIsrael and have lived in the country all of their life. They have nocivil status in Israel and do not appear in the States populationregistry. While Israeli hospitals issue a certificate testifying to the

birth of a child and the Ministry of Interior registers the child in the

population registry. These procedures do not apply to migrant'schildren.

The Municipality of Tel Aviv is the most prominent official bodythat has adopted significant and far-reaching policies (compared tothe situation in Israel in general), and has included these children inthe social service systems. Mesila ('The Welfare and AssistanceCenter for Foreigners' under the auspices of the Municipality of TelAviv) is currently preparing a more precise survey on the number of

children living in Tel Aviv. At present, approximately 1,500children of all ages are registered in the various systems associatedwith the Municipality. If one assumes that the number of children inTel Aviv, including those not registered in any system, isapproximately 2000, and assumes that hundreds of families live inareas outside of Tel Aviv (the Tel Aviv periphery, Haifa, Jerusalemand Eilat), one may cautiously estimate that the total number ofchildren of migrant workers living in Israel is between 3,000 to4,000.

Several social services are potentially available to these children.Israels Compulsory Education Law requires that any child living inIsrael for over three months be enrolled in an educational institution.Yet even this unequivocal requirement is not fully enforced, sincevarious agencies are often unaware of this community's existence.Local education authorities have had difficulties coming to termswith the concept of a child who lives in Israel but has no legalstatus. Here, too, the Municipality of Tel Aviv and a number ofschools in the south of the city, such as the 'Bialik School', have

played a pioneer role, taking various steps to welcome these

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children into the education system.

The second important service provided to the children of migrant

workers are development and preventative health services providedthrough the 'Mother and Child' clinics. The Municipality of TelAviv has opened these clinics to all migrant families. Followingthis example the Ministry of Health has opened all Mother andChild clinics under its auspices in Israel to the families of migrants,and has collected payment for these services as it does from Israelis.

The Municipality of Tel Aviv and the education system (followed by the public health system) have embarked on a process ofintegration, namely the inclusion of children of migrant workers in

the social service systems, without legalization, i.e. a change in theirlegal status. These children still lack a formal status, but they atleast have partial access to social services.

Until February 2001, the following health services were notprovided: family physicians, specialists, tests and hospitalization.As of February 2001 these services have become available to thechildren of migrant workers, yet the access is regulated through aspecial arrangement, not through the National Health Insurance

Law. The following section explains the difference and processinvolved.

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1B. Health Services for Migrant Children.

February 2001 February 2003

In 1999, PHR-Israel, together with The Association for Civil Rightsin Israel and The National Council for the Child, initiated a numberof lobbying activities. These included submitting a High Court

petition which stated that the National Health Insurance Law shouldbe applied on migrant children based on the UN Convention on theRights of Children which prohibits discrimination between childrenon various grounds, including their parents status and socialorigin6.

MK Tamar Gojansky (DFPE), Chairperson of the Knesset

Committee for the Advancement of Childrens Rights, contributedto the work of the lobby, as did MK Yuri Stern ('Israel Beitenu'

party) during his period of office as Chairperson of the 'Committeefor the Problem of Foreign Workers'7. Gojansky's proposed law,which stated the application of the National Health Insurance Law(and its public health insurance plan) to migrant children, was anadditional source of pressure on the various authorities.

The Ministry of Health responded to these pressures, to a certainextent, and initiated an administrative arrangement for the provisionof services through one of the HMOs- 'Kupat Holim Meuchedet'.This arrangement began to operate in February 2001. Since thenPHR-Israel has been monitoring the implementation of thisarrangement. Our findings show that 'Kupat Holim Meuchedet' hasspared no effort in facilitating registration and in providing services.The HMO has even waived, on its own initiative, the waiting periodfor children not born in Israel (a six-month period during whichonly emergency services are provided); in practice, these childrenreceive the full range of services from the moment of registration.

Dozens of children and babies whom we know to be suffering fromchronic and other illnesses have been registered for the arrangementand are now receiving full treatment. For these children, this is atremendous improvement of the health services they receive.

6 UN Convention on the Rights of the Child. Article 2.See http://www.unicef.org/crc/crc.htm

7 The two MKs come from the two extremes in Israeli parliamentary politics. DEPE 'HADASH' from the far left and 'Israel

Beitenu' from the far right.

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It is important to emphasize the great advantage of the arrangement:the basket of health services received by children from migrant

families joining the arrangement is equal in all respects to the basketof services enjoyed by Israeli children. The HMO cannot refuse toinsure a child on the basis of his medical condition or origin8. Thescope of registration, however, has been disappointing. No morethan eight hundred children have been registered out of severalthousand we believe to be living in Israel. The reasons for this areunclear, though we believe that there may be a number of problemswith the arrangement that may be the cause. These will be discussed

below.

The introduction of the arrangement is not identical to theapplication of the National Health Insurance Law (an action which,as noted above, is within the authority of the Minister and requiresno legislation). We shall illustrate the difference between these twosteps and review the problems related to the arrangement:

Free Choice for Parents: This is a voluntaryarrangement. Parents can decide whether or not toregister their children, and the provision of services

is contingent on registration and payment. This isin contrast to Israeli children, who are entitled toservices regardless of payment and registration.

Fixed Payment: A fixed payment of insurance feescontradicts the reality of migrant workers' life,namely constant uncertainty and a lack of economicand social stability.

High Payments: Insurance fees are 185 NIS permonth for one child, and 370 NIS per month fortwo or more children. People who supportthemselves from house-cleaning and other irregular

jobs find it difficult to commit to these payments.

Familiarity with the Concept of Governmental

Insurance: Some groups of immigrants areunaware of the distinction between private andgovernment sponsored insurance, since the concept

8 The only exception to this is a child who is ill on arrival fromabroad and immediately joins the arrangement. This exception is

intended to prevent medical tourism.

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of government insurance does not exist in theircountry of origin. They will express reservationsand a mistrust of insurance that is "a promise" to

cover future services if necessary. Some familieshave had negative experiences with private medicalinsurance schemes marketed in Israel and have lostconfidence in insurance altogether.

Despite all of these reservations, it is important to note that thearrangement represents a major step forward in terms of the attitudeof the Israeli authorities towards the children of migrant workers in

particular, and migrant labor in general. We hope the scope of thisproject will be expanded rather than contracted by February 2003, at

which time the pilot period will have ended.

It is our belief that the National Health Insurance Law should beapplied to these children. While the differences between this

proposal and the existing situation may seem slight, they are, as wehave pointed above, quite significant. Our proposal is that allchildren be eligible for health services by their right as childrenwho are not accountable for their parents actions and are entitled toservices comparable to those received by Israeli children. These

health services shall be provided regardless of the parents' ability tomeet arrangement demands. We believe that children should not bepunished for their parents failings, and that it is unacceptable thatin addition to their harsh living conditions they should be prohibitedfrom accessing reasonable health services.

This proposal will meet in full the requirements of the UNConvention on the Rights of the Child. A far less desirablealternative would be that the Health Ministry continues the paymentarrangement in its current format. In this case, it should include

amendments leading we hope to an increase in the number ofthose registering. These amendments should include flexibility of

payment sums, the establishment of criteria for social assistance,improved mechanisms for payments, and more.

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M. is a Colombian citizen. Her husband was deported from Israeland she is currently raising two children by herself. Her 11 year-oldson suffers from behavioral problems at home and at school. M. is

barely able to support her two children. Her son can undergodiagnosis within the education system, but cannot receive ongoing

psychological treatment, since he, like his brother and mother, doesnot have medical insurance. When we told M. about the possibilityof receiving full insurance through Kupat Holim Meuchedet, shereplied that there was no way she could meet the payment - shewould have to pay 370 NIS every month for medical insurance forher two children. PHR-Israel, through the 'Open Clinic for MigrantWorkers' has no funding available to help the family pay theinsurance9. 'Mesila' the Municipal Welfare and Assistance Center

for Foreigners is also unable to help, since it too has no specialfunds. There exists no procedure in which the Ministry of Labor andSocial Affairs or the Ministry of Health can provide support in sucha case. At the time of writing, these children are not insured with anHMO as part of the administrative arrangement.

In February 2001, the administrative arrangement for providing health services to non-Israeli children wasintroduced as a pilot program for two years. According tothe arrangement, the basket of services for these children is

the same as that for Israeli children. Yet, conditions andprocedures are different; any child who has been in Israelfor six months or more may be registered. His parentsmust pay the insurance fees. Children not born in Israelmust wait six months before receiving the full basket.

9 A description of the routine activities of the Open Clinic

appears on the next page, and in PHR-Israels website: www.phr.org.il.

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Chapter Two: Documented Migrant Workers

2A. Health Insurance for Visa Holders

Migrant workers who hold visas (Documented) continue to arrive inIsrael from Thailand (agriculture), China and Romania(construction), the Philippines (nursing), as well as from othercountries. Construction workers from Romania and Chinaconstitute the most exploited group of workers in Israel. Their workvisa, which should define their legal protection and their rights,actually chains them to a single employer who consequently hastotal control over their living and working conditions.

Since the 1990s work visas have been contingent on the purchase ofprivate medical insurance by the employer. This requirement hasallowed for the creation of a private market with an enormousturnover.10 Competition has led to reduced policy prices, but not toimproved standards. Indeed, the opposite is true: there has been aconstant decline in the quality of health coverage provided by theinsurance companies. In previous reports, PHR-Israel detailed thenumerous loopholes in these policies and described the typical

behavior shown by insurance companies and employers towardsworkers with visas who were misfortunate enough to become illduring their stay in Israel. Insurance policies not only excluded awide range of treatments (such as chronic and malignant illnesses),

but also included clauses designed to force insured to leave Israelonce they became ill (as in the case where treatment can be

postponed). It is no coincidence that insurance policies havebecome known as flight ticket policies. This was the situationprior to October 2001, at which time the Health Services Ordercame into effect. The order was intended to regulate the privatemarket and impose restrictions that would benefit the insured.

10 The following calculation offers some idea as to the scope ofthe market: if each insured worker pays one dollar a day, and if thereare almost 100,000 such workers in Israel, all of whom are required bylaw to secure insurance, it follows that the private insurance companies

earn $ 100,000 a day for medical insurance policies alone.

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2B. The Right to Health of Documented Migrant Workers

Regarding Documented Migrant Workers, the Convention of theWorld Labor Organization (to which Israel is a signatory) states:Any member of this Convention shall implement, withoutdiscrimination on the basis of nationality, race, religion or sex, formigrants legally present within its territory (documented) treatmentthat is not inferior to that it provides to its citizens in the followingareas:[](B) National insurance (i.e., a legal means addressing injury at

work, motherhood, sickness, disability, advanced age, death orany other eventuality covered by local laws or regulations by anational insurance program), subject to these restrictions:2. Laws or regulations of migration countries may enact specialarrangements relating to benefits or parts of benefits paid in full by

public funds

On the one hand the convention establishes equality betweenDocumented Migrant Workers and residents in the provision ofhealth care, and raises the question of medical insurance. On theother hand, the convention permits countries to introduce specialarrangements regarding migrant workers. The duty to collectnational insurance fees and health insurance from migrant workersmay also be deduced from the convention. In return, the State will

provide them with equitable social services.

Israel has chosen not to include health services for DocumentedMigrant Workers in the same arrangement Israeli workers areentitled to. Instead, the State has also chosen to take advantage of

the option of providing special arrangements for these workers.This situation may be permitted according to the letter of theconvention, but is contrary to its spirit, which calls for equality

between local and legally employed migrant workers.

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2C. The Health Services Order to the New Law for the

Employment of Migrant Workers: A Happy End?

The amended law for the employment of migrant workers waspassed in the beginning of January 2000 and included a provision inthe matter of medical insurance for migrant workers. The Ministerof Health could choose between one of two possibilities included inthe law: either to issue an order regulating private medicalinsurance, or to apply the National Health Insurance Law toDocumented Migrant Workers. After considerable delay, the orderwas enacted in March 2001 and took effect as of October 2001. The

Minister of Health chose the former option an order regulating private medical insurance rather than imposing the NationalHealth Insurance Law on migrant workers (payment of health taxand the provision of services through the HMOs). Criticism of thisdecision was raised by PHR-Israel and reflected our extensiveexperience with the methods of operation of the private insurancecompanies. The Ministry of Health argued that the order issuedwould address the problems raised by imposing restrictions on theconduct of the insurance companies and by defining the basket ofservices.

In light of the current situation, the order certainly constitutes asignificant improvement at least on paper towards ensuringreasonable services for migrant workers. We shall, however,attempt to summarize the advantages and disadvantages of thisarrangement.

Advantages:

The order includes various mechanisms for appealing the

decision of the insurance companies, and protects the insured(at least on paper) against arbitrary decisions by the company.

The order includes most of the services in the basic basket ofservices received by Israelis.

Disadvantages: (see flow chart below):Since the enactment of the order, PHR-Israel has beenmonitoring its implementation together with the HumanRights Program at the Tel Aviv University. In dealing withthe insurance companies we have discovered their attempts to

return to the norms practiced prior to October 2001 and their

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endeavors to use various schemes to rid themselves of sickworkers.

We do believe, however, that the level of health services has

improved as a result of the order and of NGOs inspection.Experience has shown that migrant workers who enjoy the supportof their employers, and turn to us for assistance are often successfulin receiving the health services to which they are entitled.Unfortunately, the current situation has not provided a solution forwho will lose their eligibility for health services following the lossof their work permit for whatever reasons.

In our opinion, the following are the main problems encounteredsubsequently to the implementation of the order:

The exception clauses of former medical condition andloss of working capacity allow the insurance companies tocease the provision of insurance coverage. An insurancecompany may base its decision on the opinion of a specialist

physician (working on its behalf) who can determine oftenwithout documents or direct proof that the illness existed

prior to the insureds arrival in Israel, or that the patient willnot regain his capacity to work. In these cases the insurancecompany may cease insurance coverage and send the patient

to his country of origin. Fortunately, the worker has access toappeal mechanisms, which he may be able to activate if hehas the support of his employer and receives proper legalrepresentation.

The insurance policy is purchased by and belongs to theemployer. Accordingly, once the employee falls ill theemployer may nullify the policy and thus cancel theemployee's insurance coverage. The employee willconsequently lose his visa (namely his working and staying

permit). The fact that employers have such power overemployees makes it difficult to protect a sick employee facingan insurance company that is reluctant to pay for histreatment. This is one aspect of the consequences ofchaining employees to their employers11.

The insurance companies have recently reintroduced an old'favorite': when the period of insurance expires, the company

11 For other devastating aspects of the "chaining" policy, see Hot Line for

Migrant Workers publications www.kavlaoved.org.il

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will refuse to renew the policy even if it covered treatmentexpenses during the previous period. Without healthinsurance the employee is unable to renew his working and

staying permit and loses his official status.

Workers who cannot reach organizations that can providethem with legal aid face the greatest problems. Theseworkers are generally the most exploited. Romanian andChinese construction workers are rarely able to physicallyfree themselves of their employer and secure legal protection.In a number of cases we handled we suspected that workerswere being sent back to their country of origin withoutenjoying legal protection. Unfortunately, we usually

encounter Romanian and Chinese workers long after theirpresence in Israel has become unlawful and after they haveescaped from their employer. These workers have almostno chance of securing protection under the order or the law;in most cases the medical insurance paid by their employerhad been nullified at the time of their escape.

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o renew the policy for an additional period and states that there is no need to present a legal basis for t

ker contacts us, we will help. If he does not, or if the appeals period expires, insurance will be nullified.

nsurance period ends. The concept behind the Foreign Workers' Law is that health services are conting

ance company claims that the worker has a prior medical condition, or that he has lost the capacity to

The insurance company covers medical treatment.

e employer is repaid the insurance fee for the period pending the expiry of the policy. Since the emplo

ddddsssssssssssssssss

M., a Filipino nursingworker, came to Israel overfive years ago in order to carefor an elderly woman whohad cancer. Following her

A worker falls ill.Most workers, particularly manual laborers, try to avoid going to the physician due to theloss of working days it entails.

The sick worker contacts the insurance company healthThe employerdismisses theworker andnullifies theinsurance policy.

If the employerdies, the policymight also nullifyunless the man

The sick worker isdeported andflown back to hiscountry of origin.

Medical expenses are no longer

covered

The worker no longer has a valid

working permit.

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arrival in Israel she received a working and staying permit, and heremployer provided her with medical insurance through the 'Shiloah'insurance company. At the end of February 2001 she was diagnosed with amalignant tumor. 'Shiloah' announced that it would not renew the insurance

policy, but that it would be willing, beyond the letter of the law, to financeoutpatient services for a period of three months only. Since M. no longerheld valid medical insurance, the Ministry of the Interior refused to extendher staying and working permit (since the visa was contingent on a validhealth insurance policy). Not only did M. find herself fighting a terribledisease, but she had also become an illegal alien in Israel. On July 2, 2001,M. underwent her third chemotherapy treatment. However, since the three-month period set by 'Shiloah' had reached its end, and the company refusedto pay for the treatment. M. had no choice but to cover the cost ofchemotherapy (1,600 NIS ) by herself and she withdrew the limited

savings she had managed to accumulate during her years of work in Israel.It should be noted that two weeks after leaving her sick bed, and before shehad fully recovered from the operation to remove the malignant tumor, M.was obliged to return to work in order to earn the money needed to remainin Israel. On October 16, 2001 the day the new Medical Services Ordertook effect a hearing took place in the matter of the petition submitted byPHR-Israel to the High Court of Justice, demanding that M. receive atemporary working permit and medical treatment and calling for theamendment of the new order. The State's representative refused to agree toany compromise suggested by the Court, and the Court itself declined to

any compromise suggested by the Court, and the Court itself declined toprovide M. with any protection. M. was unlucky enough to fall ill duringthe period when the Ministry of Health was procrastinating before issuingthe new order. She received no help from the Supreme Court of Justice, afact that was criticized by attorneys from the human rights field. Whatwould have happened had M. fallen ill after October 16, 2001? Would shehave received all the treatments she required? Perhaps not. Our experienceshows that the insurance company could have raised various arguments(prior medical condition, loss of working capacity) and the employer couldhave fired M. and ceased policy payments.

M. is a Romanian nursing worker who worked for some two years for anelderly woman suffering from Alzheimer's disease. M. was insured throughthe 'Shiloah' insurance company. On November 6, 2001 ten days prior tothe introduction of the new order M. went to the physician, wasdiagnosed as suffering from cancer and began receiving treatment. At firstthe insurance company covered treatments, but subsequently it began tolimit medication payments, claiming that these costs were limited inaccordance with the policy. Fortunately, the new order had already takeneffect. After legal intervention by Attorney Dori Spivak from the Human

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Rights Program at the Tel Aviv University the insurance company droppedits case. M.s state of health is now satisfactory she is in completeremission and has an excellent chance of recovery.She now faces a second crisis. Her most recent insurance policy was

purchased for one year, ending October 2002. The insurance company hasalready announced that it will not renew the policy. This means that M.will be unable to receive additional medical treatment. Moreover, since shecannot receive a working permit without being medically covered, M. will

become an illegal alien and at risk of deportation. The elderly woman forwhom M. cares cannot manage without her help. On May 2002, PHR-Israel sued the insurance company in court, demanding that insurance berenewed and arguing that failure to do so strip the Health Services Order ofany meaning. We should emphasize that at least in this case the employeeis receiving real support from her employer. Were M.s employer to

dismiss her as other employers have done her chances would be muchworse.A few days after filing the statement of claim the elderly woman for whomM. had been caring passed away. We do not know now whether M. will beable to receive legal protection despite the fact that she has not lost hercapacity to work. At present M. still requires health services, but she hasno job and is at grave risk of losing her working permit.

On October 2001, a hearing took place following the HighCourt petition filed by PHR-Israel. The petition demandedthat medical services be provided to two documented Filipinowomen who had medical insurance and who had fallen illduring the period preceding the issue of the order by theMinister of Health. Their medical insurance had beennullified and their treatments were no longer covered. Theywere dismissed and therefore lost their working and staying

permit.The Court declined to grant the relief we sought - the

provision of medical services for these two workers, thereturn of their working and staying permits and theamendment of the order and the women did not recovertheir health insurance.

Chapter Three: Adult Non-Documented Migrant Workers12

12 We use different terms for the same population: without visas, non-

documented, illegally employed etc.

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3A. The Current Situation

Non-Documented Migrant Workers most likely constitute themajority of the migrant (non-Jewish) population in Israel. To date,

no law, regulation or arrangement has been issued in the purpose ofproviding health care services to this population and there is no realmigration policy e.g. there is no regulated way for the provision ofcivil status to a Non-Documented Migrant. As illegal aliens inIsrael, these migrants face the constant threat of deportation. The

principal authorities involved in their fate are the Ministry ofInternal Security (the police), the Israel Prison Service and theMinistry of the Interior, which is in charge of issuing deportationorders13. The number of Non-Documented Migrant Workers iscurrently estimated between 100,000 and 200,000 or more,depending on the source of the estimate. This number includesworkers who had a working permit but who lost their legal status,and others who arrived in Israel as tourists or with another kind ofstatus.

The rights of this population and ways by which to solve the problems they face have hardly been addressed up to now. Ourinvolvement to date has centered on humanitarian aid for patients,which we have attempted to provide through our voluntary Open

Clinic for Migrant Workers established in 1998. We shall discussthis population in particular detail and suggest various ways to solvethe problems we have encountered.

As a general rule though, none of the services available to Israeliresidents through the HMOs and the basket of services primaryand secondary medicine, therapeutic and preventative care,rehabilitation and hospitalization are accessible to migrants whodo not have a working permit. Despite this generalization, however,a small number of services are attainable or provided to Non-Documented Migrants:

1. PHR-Israel Open Clinic for Migrant Workers. The cliniccurrently provides a wide range of primary and secondarymedical services at little to no cost, and does its best to help

13 A new "immigration police" was initiated as of September 2002together with a deportation policy aiming at 50000 deportees. Untilnow, the new police managed to deport some 500 people a month.Meanwhile, at the pressure of employers, thousands of migrant

workers are entering the country every month!

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in more complex medical situations.2. Private clinics and medical centers. Costs at these clinics

are usually high, since they are intended for prosperous

Israelis seeking immediate, quality health care services.3. Hospitals and medical centers in East Jerusalem and theWest Bank. Due to the prevailing security situation, EastJerusalem provides the only possibility for receiving medicalservices at a low cost compared to Israel.

4. Private clinics and physicians in Israel offeringinexpensive services. These are generally physicians whoare doing a favor and earning relatively small sums inreturn for providing services to migrant workers. Often theseare physicians who speak the migrants language; in other

cases these are physicians attempting to survive in the privatemarket (e.g. chip dental services for the poor).

5. Emergency hospitalization: According to the PatientsRights Law, in a medical emergency situation, a person isentitled to receive urgent medical treatment withoutcondition.14 It must be pointed out that hospitals may try tocollect payment from patients following urgenthospitalization - emergency hospitalization is not free inIsrael and the hospital will not be reimbursed. The inevitable

result of this situation is that hospital administrators will putpressure on the medical staff in the emergency room andwards. Payment is often mentioned and even presented as acondition, in spite of the above-mentioned law that prohibits afinancial condition for the provision of a medical service. Anexcuse for that may be that the law does not clearly definewhat is considered an emergency. Our impression is that the

practiced definition of emergencies in emergency rooms is becoming increasingly narrow as hospitals face growing

14 Patients Rights Law, 1996, Article 3(B). As defined in theLaw, a medical emergency consists of circumstances in which a

persons life is in immediate danger, or when there is immediate dangerthat a person will incur severe and irreversible disability if he is notgiven urgent medical treatment. According to statistics from IchilovHospital in Tel Aviv, 'bad debts' in 2001 totaled 1.1 million NIS, andthe accumulated debt over the years totals almost 5 million NIS. Thesefigures have been provided by Ran Zafrir, Director of Intake Servicesat Ichilov Hospital, to Hamotal Barkan and Rinat Sagi, and appear in

their academic paper.

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financial pressure15. The cost of one days hospitalization fora tourist (i.e. a person who is not a documented Israeliresident) is approximately 3,000 NIS, 600$. Hospitalization

debts quickly transform into bad debts that cannot becollected from the patients.6. 'Mother and Child' clinics. Enforced by the Municipality of

Tel Aviv and subsequently adopted by the Ministry of Health,today any pregnant mother, regardless of her status, is entitledto register at the 'Mother and Child' clinics and to pay thesame fee paid by Israeli women. In return, she will be entitledto pregnancy inspection and immunizations of the infant.

7. The cost of hospitalization for birth should be covered byNational Insurance Institute, even if the mother is not legally

employed, provided that she has worked for more than sixmonths prior to delivery. In practice, however, hospitalizationcosts are covered only in cases where the employer has paid

National Insurance fees regardless of the employees' status.This entitlement is therefore accessible to Non-DocumentedMigrants, yet it is difficult to obtain.

As noted, all remaining medical services are inaccessible, either because Non-Documented Migrants are not residents or because

services are too expensive. Even if migrants are hospitalized inemergency cases in accordance with the Patients Rights Law, theyface mental anguish due to the enormous cost of hospitalization sums that are completely beyond anything they can imagine. Some

patients refuse emergency treatment and leave the emergency roomor ward, endangering their health because they have no idea howthey can cover the incurred expenses.

PHR-Israels clinic cannot possibly meet the medical needs of sucha large population, and it should not have to do so. Nevertheless,

our clinic is sometimes used by decision-makers as a fig leaf (and avery small one at that) in order to mask the broader issue.

The Open Clinic for Migrant Workers opened in 1998 and continuesto expand. Over the past years, the number of patients attending theclinic has risen sharply. We are greatly concerned that it will beimpossible to maintain a high level of services on a voluntary basisfor much longer. The Clinic consists of three treatment rooms

15 e.g. in cases where the immediate danger is not obvious,

hospitals tend to deny the service.

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staffed by one or two physicians and a nurse. It opens almost everyday of the week in the afternoon. Dozens of physicians, nurses andstaff volunteer in the Clinic, and dozens more provide additional

voluntary services. A number of medical institutions also provideservices, mainly consultations but also tests, for reduced fees, atregular private rates or for free. Since the Clinic's opening morethan 10,000 new files have been opened, yet the number of visitorsis even higher. In 2001 alone, some 2,500 new files were openedand approximately 6,000 patients attended the clinic (not includingreferrals to volunteer physicians). In other words, 40% of thoseattending the clinic were new patients. Every month, 60% of casesare seen by a family physician, approximately 70 patients see a

pediatrician and approximately 60 see a gynecologist.

Ichilov Hospital is the main contact for emergency cases involvingmigrant workers living in Tel Aviv. The hospital facilitates thisrelationship in many ways and the staff shows a very high level ofwillingness to help. Ichilov Hospital also provides a quota ofmedical services mainly consultations and laboratory tests forthe Open Clinic. On average, 37 tests of various types are carriedout at Ichilov Hospital each month. Assuta Hospital provides verysubstantial discounts for migrants referred by PHR-Israel as well,

and allows our volunteers to perform operations in its facilities atvery low rates. In some cases, an operation at Assuta Hospital is theonly way a migrant worker can receive treatment. Tel HashomerHospital also contributes specific tests.

The following referrals are for a random month during 2001:

Emergencyroom

Operationsand other

procedures

Voluntaryspecialists:ENT,surgical,orthopedist,urologist,gynecologist,etc.

Clinicsandhospitals- free

Clinicsandhospitals

reducedrates

Clinicsandhospitals

fullrates

Clinicof theLeagueAgainstTB(free)

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13 5 31 70 11 52 9

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3B. International Rights and Norms

Given the serious nature of this matter the right to health of Non-Documented Migrants we found much too few references to thissubject in the various international conventions to which Israel is asignatory. The matter is discussed in the UN Convention onEconomic, Social and Cultural Rights and in an ancillary note onthe subject of health. The following quotes may seem far-reaching,

but given the possible financial expenditure involved and the size ofthe population without visas in Western countries, they are actuallymodest and unduly vague.According to Note 14 to Article 12 of the UN Convention on

Economic, Social and Cultural Rights:Countries are obliged to refrain from imposingrestrictions or preventing the equal access of any

person including prisoners, detainees, minorities,asylum seekers and Non-Documented MigrantWorkers, to preventative, therapeutic and palliativemedicine; to refrain from implementing discriminatory

practices as state policy.16(Translation: PHR)

Elsewhere in the same note it is stipulated that public health servicesmust be available and accessible to all persons in a reasonablequantity:17

Medical installations, merchandise and services mustbe available to all. Payment should be based on theprinciple of equality.18(Translation: PHR-Israel)

The convention does not provide a clear policy, and accordinglycannot serve as the basis for demanding equal eligibility for healthservices for migrants and local residents. We will therefore turn tointernational norms: is there an international norm, or at least aWestern one, that requires health services to be provided to Non-

16 The notes to the Convention were made by the UN committeeresponsible for its implementation and constitute an authorizedinterpretation of the Convention, providing guidelines for the actions ofthe signatory states.

17 Article 12(1) (2) of Note 12 to the UN Convention onEconomic, Social and Cultural Rights.

18 Article 12(3) of Note 12 to the UN Convention on Economic,

Social and Cultural Rights.

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Documented Migrants?

Before drawing any conclusions we shall summarize the

information we have pertaining to countries in Western Europe:19

Britain is the only country, to the best of our knowledge,where public health services are effectively open to all

persons, with or without visas. Although in formal terms andaccording to court rulings the right to receive health servicesis confined to persons legally present in Britain, in practicecivil status, insurance coverage and economic ability andorigin are irrelevant at the general clinic where medicalservices are provided.20 In regards to hospitals, restrictionsapply according to status and to the type of illness, but these

are loosely phrased. In most cases Non-Documented Migrantsreceive free services. Emergency hospitalization (up to onenight) is free; beyond this period the hospital may, in

principle, request payment, yet there is a long list of types ofillness for which patients are exempted from payment.21

Asylum seekers may suffer due to the policy of dispersal,which requires them to live in specific areas around thecountry, sometimes removed from their own communities. Ifthese people move to other areas they are no longer

recognized by the authorities and lose their rights to specialassistance services. Sick asylum seekers whose applicationshave been refused and who are awaiting deportation maysometimes receive humanitarian residency permit.22

In Belgium, reimbursement may be received for emergency

19 Our information is based mainly on the publication HealthCare for Undocumented Migrants, published by PICUM: Platform forInternational Cooperation on Undocumented Migrants, De Wrikker-Antwerp, Belgium, June 2001. This source confirmed and added todata collected from other sources, such as NGOs, public reports, mediaarticles, the 'December 18' site (www.december18.net) and more.

20 The general practitioner receives payment from public fundsbased on the number of patients he sees, regardless of their status. Thephysician, however, may refuse to accept a person for treatment.

21 Such as infectious diseases, HIV and AIDS, and psychiatricpatients admitted in compulsory hospitalization. Patients with seriousdiseases who are facing deportation may request, and may receive, aspecial humanitarian residency permit.

22 Health Care for Undocumented Migrants, pp. 64-74.

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medical services through a government agency (CPAS23)whose objective is to ensure a decent existence for any

person present in Belgium.24 It is important to note that the

definition of emergency in Belgium appears in a royal edictfrom 1996, and also includes preventative and therapeuticmedical assistance that may be provided in an ambulatoryframework and in a hospital/institution. In contrast to the

process we have identified in Israel, the definition ofemergency reflected in daily use by Belgian physicians hasextended rather than narrowed the legal definition.

The situation in Germany is similar to that in Israel.All foreigners unlawfully present (between half amillion and one million) are entitled to receive servicesfor infectious diseases (particularly tuberculosis, butalso infectious STDs, with the exception of drugs forAIDS), and preventative medicine for babies andemergency treatment (through payment).25 As for theGerman equivalent of the provision requiringemergency hospitalization (albeit for payment), thesituation may actually be worse than in Israel. Intheory, a hospital can claim reimbursement from the

Social Welfare Center for the emergency hospitalizationof a person without a visa. In practice, this involvesendless red tape. Worse still, a clause in the GermanAliens Law imposes on any public institution theobligation to report suspected illegal aliens to theimmigration authorities. It is all too easy to imagine theserious effect this has in terms of access to medicalservices. Although it is uncertain whether or not thisobligation applies to hospitals, some hospitals believethis to be the case, and therefore grossly violate medicalethics by transferring information about patients that

23 Centre Publique pour Aide Sociale.24 Health Care for Undocumented Migrants, p. 23.25 Illegal migrants suffering from serious diseases, post-

traumatic syndrome or AIDS can, in theory, apply for a specialtemporary visa (Duldung). This status one step above that of no visa

is usually awarded to asylum seekers who have been rejected but whocannot be deported. The special visa entitles the migrant to highlyrestricted eligibility among which is reimbursement of expenses from

the Social Welfare Center.

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can lead to their deportation.

In the Netherlands, the ability of Non-Documented Migrants

to access health services was recently impaired because of theenactment of the Linkage Law a law that links the right tosocial services with possession of a residency visa. However,Dutch law provides for free emergency treatment, and public

pressure has led to an increasingly broad definition of whatconstitutes an emergency. Pressure has led the Minister ofHealth to broaden the definition of an emergency, allowing

physicians more leeway in their work. The Linkage Lawalso established a public fund, which compensates physiciansfor the costs of emergency treatments (again, the practical

definition of the term is quite broad) for Non-DocumentedMigrants, although it is far from easy to overcome the

bureaucratic hurdles and to secure reimbursement. In mostcases, general physicians still demand insurance or payment.Mental health services, on the other hand, are covered by a

public fund and are open to all, including Non-DocumentedMigrants. A residency visa in the Netherlands (entitling theholder to health services) may be requested on variousgrounds; for example, any minor who arrives in the country

on his own is automatically included in the process ofrequesting asylum a status entitling the minor to almost fullhealth coverage. Residency visas may be granted anddeportation may be postponed for humanitarian reasons, suchas illness and the need for treatment.

On the basis of this information and data gathered from othercountries, one may depict a reality in which persons without visas those who are outside of the legal framework and are not includedin any migration category are not entitled to equal access to the

public health service. Access may even endanger them. However,there does seem to be a norm whether of a legal nature or of a

public and ethical one according to which emergency treatmentshould be provided to all persons while minimizing the financialobstacle or simply stating that emergency treatment is given forfree. Some Non-Documented Migrants can begin a process leadingthem to special residency status, which will entitle them to healthservices.

In some places, institutions (religious or secular) provide

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humanitarian medical services for those who cannot access thepublic health system. In Los Angeles, for example, we know thatthere is a network of clinics similar to our own, but operated by the

local authorities. These clinics provide health services for groupswithout medical insurance. In Barcelona, 'Doctors Without Borders'(MSF) operates the Fourth World project a clinic serving Non-Documented Migrants as well as homeless people and drug addictswho do not have access to the public health system.

3C. Possible Solutions

The following proposals are new to the Israeli public debate in the

matter of health care for migrant workers. Some contradict eachother, while others are complementary.

1. Free Emergency Hospitalization.

2. Legalization A: A Temporary Work Visa Followed By

Departure from Israel.

3. Legalization B: Residency Leading to Naturalization.

4. The Provision of a Minimum Health Basket of Services,

provided through an Insurance Arrangement.

5. The Provision of a Minimum Health Basket of Services,

provided through a Open Community Clinic.

1. Free Emergency Hospitalization: The price of one dayshospitalization for a tourist (in the absence of any otherdefinition, Non-Documented Migrants are currently definedas tourists) is approximately 3,000 NIS. It is hardlysurprising that in the Emergency Room financial pressure

becomes yet another concern for patients and medical staffalike. This pressure can lead to tragic results, such as in cases

where patients refuse to be hospitalized or when hospitalsrefuse to admit them. Financial pressure can cause delays inhospitalization; some patients avoid being hospitalized due tohigh costs and eventually require emergency hospitalization.It is important to emphasize that free emergencyhospitalization would not necessarily cause an additional

burden on public funds. The burden already exists, sinceessential emergency hospitalization already takes place evenif the patient cannot pay the fee. Substantial debts on accountof emergency hospitalization have been accumulating and

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remain unresolved in the hospitals accounts. As notedabove, Ichilov Hospital in Tel Aviv, for example, notes thatthe debt for 2001 was in excess of 1 million NIS an

increase of 70% over the figure for 1997. Cumulated debtover the years now totals 4.8 million NIS. The prevailingprinciple of paid emergency hospitalization seems to causemore damage than good. It endangers patients who refrainfrom obtaining treatment; hospitals may break the law byconditioning treatment on payment; emergency rooms mayface undue pressure due to the financial considerations; andthe practical definition of the term emergency may benarrowed, influencing the entire system. For a comparisonwith the situation in European countries regarding emergency

hospitalization, see section above.

2. Legalization A: Legalization in varying forms has alreadybeen at the focus of public discussion as it applies to Non-Documented Migrants. The main interest from the part ofdecision-makers was on how to insure that Non-DocumentedMigrants leave the country. On the part of Human RightsOrganizations, legalization is also considered to be adesirable proposal in principle. Indeed, a person who

receives a work visa will be covered by the new ForeignWorkers Law, which includes a minimum level of medicalinsurance and offers legal protection. However, as explainedin Chapter Two, today working visa means chaining themigrant workers to a particular employer and severelyimpairs their standard of living and working conditions26,damaging also their state of health.27 Our response to thisdilemma is to oppose legalization as long as it means

providing undocumented workers with chained workingvisas. In other words, as long as the chaining arrangement

persists, and the living and working conditions of workerswith visas are not significantly improved, Human RightsOrganizations and the Israeli public should opposelegalization proposals of this type.

26 As noted, the health services to which documented migrantsare entitled have improved on paper. For more information and detaileddepictions of the working conditions of documented migrants, see thewebsite of Hot line for Migrant Workers:www.kavlaoved.org.il.

27 Excessive working hours, lack of safety precautions at work,

emotional and physical stress, and more.

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3.Legalization B: The second possibility for legalization is toallow for the option of temporary and permanent residency

status, which may even lead to naturalization. Such a stepwould be a real revolution in Israeli immigration policy.Proposal of this type will no doubt create shock waves in theIsraeli mainstream media. Natural candidates for such anarrangement might include families that have been in Israelfor many years, particularly those with children who were

born, raised and reached maturity in the country, and forwhom Israel constitutes the center of their lives. This is, ofcourse, a relatively small group, but it might be the first stepin the long road for immigration policy in Israel. We should

recall that once a person is recognized as a resident (even atemporary one), he is entitled to social services and above all to national health insurance. For the present, it is probablyrealistic to demand legalization (residency) at least for adults,who came to Israel as children or were born here, raised andhave reached maturity in Israel, and who are not familiar withany other society. Let us give one example of legalization:On January 22, 2000, Belgium initiated a process of"regularization" through which all Non-Documented

Migrants could apply for a visa. One of four categories forapplying for a visa was "serious illness" - a criterion - acriterion currently included under the heading of"humanitarian reasons"28.

4. The Provision of a Minimum Health Basket of Servicesprovided by an Insurance Arrangement: A specialarrangement could be introduced by which one or more of theHMOs would offer medical insurance to Non-DocumentedMigrants based on a basket of services as determined by the

Ministry of Health. This arrangement could be applied eitherthrough legislation (including secondary legislation), orthrough an administrative arrangement (as with the currentarrangement for children). HMOs might consider itreasonable to accept the migrants, who are generallyrelatively young and healthy. Naturally, this populationwould be required to pay a special tax whether to the HMOor to a governmental body - in return for the limited health

28 Health Care for Undocumented Migrants, p. 28.

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services to which it would be entitled. Interestingly,insurance companies consider Non-Documented Migrants asa potential market and have already made efforts to market

their private insurance policies in this sector; one of theHMOs recently joined the race in an attempt to penetrate thisuntapped market. This situation suggests that, at least as faras the private market is concerned, insurance for migrants isconsidered to be a viable economic proposition. Yet, in ouropinion, official arrangement supported by legislation orregulation must be the basis for any insurance program.Otherwise, it will be impossible to supervise the actions ofthe insurance providers (private companies or HMOs), andthey will, therefore, continue to apply the unacceptable norms

that have characterized the private medical insurance marketfor migrants before October 2001.

5. The Provision of a Minimum Health Basket of Servicesprovided through a Community Clinic: PHR-Israels cliniccould provide a possible model for a municipal orgovernmental body. One of the HMOs recently offered tooperate a similar project budgeted by a local authority andsupported from abroad. While this seems to be a positive

idea in principle, the HMOs proposal was rife with loopholesand ambiguities. Nevertheless, it does seem that such an ideacould be acceptable to one of the HMOs if support wereforthcoming from the Ministry of Health and from themunicipal authority, and if the project were to operate incooperation with a local hospital. The HMOs proposal leadsus to believe that this idea is feasible.

We believe that all those living of Israel have a stake in solving

the problem of access to health services for hundreds of

thousands of Non-Documented Migrants living in the country, ifonly because of the inevitable connection between the health of themigrants and the health of the public as a whole. A network of

primary and secondary care would also partially reduce emergencyhospitalization costs, which are, as noted above, a source of ever-growing debts incurred by hospitals. In other words, it is bothmorally and financially sound to provide preventative primary andsecondary medical care. Migrant workers will naturally be requiredto contribute to the cost of these services through the payment of

reasonable insurance fees; the municipal hospital, as well as the

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local authority and the government, should also partake in funding.

A. came to Israel from Ghana. He is married, and the couples 7 year-oldson was born and raised in Israel. A. has suffered from diabetes for the

past four years and can barely cover the cost of treatments. He comesperiodically to our clinic to be checked by our volunteer physicians. Forover a year he suffered from cataracts in both eyes. We suggested hereceive treatment in a private medical institution and checked the costs forsuch treatment. We discovered that the cost inside Israel is over 6,000

NIS, while in East Jerusalem it is approximately 2,200 NIS. A. cannot paysuch sums. On a subsequent visit to our clinic it became apparent that thecondition of one eye was deteriorating, increasing the danger that A. maygo blind. We have lost contact with A. and do not know whether hemanaged to collect enough money to pay for at least one eye operation.

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Chapter Four: Small Groups with Special Needs

The Non-Documented Migrants community is highly diverse.Within the large group a number of small groups with special needscan be identified. These groups require a wider breadth of healthservices than those required by the majority of migrant workers.

4A. HIV Carriers

According to official records approximately one-fourth of new HIVcarriers in Israel in the year 2000 were migrant workers; 29 the exactfigures may be even higher. The Israel AIDS Task Force cares for

dozens of non-Israeli HIV carriers and AIDS patients, some of alsovisit our Open Clinic. Seemingly, there is no difference betweenthese patients and other undocumented patients, yet they faceintense mental pressure due to the social isolation they endurewithin their community. Loneliness and a lack of support areserious problems for Israeli HIV carriers, even more so formigrants. It must be emphasized that the community is vital to thesurvival of migrant. Carriers must undergo tests and, from a certainstage, integrated treatment, all of which are very expensive. The

drug cocktail prescribed for carriers and AIDS patients costs severalthousand shekels a month far beyond the ability of a migrantworker in Israel. AIDS centers in hospitals and the AIDS TaskForce have been treating foreign carriers and patients who were, inmost cases, diagnosed only when they were already ill. Within thehospitals the AIDS centers have managed to circumvent the fact thatthese patients do not have any insurance by including them inresearch programs, by providing personal favors and thanks to theconstant support of the AIDS Task Force.

Over time, the number of diagnosed carriers and patients has risenand available slots in special programs have been filled. Physiciansand the AIDS Task Force volunteers fear that they will no longer beable to guarantee proper help for foreign carriers and patients.

This reality served as the backdrop to our publication last year of areport comparing the situation in Israel with that in other countries.The report included specific demands addressed to the Israeli

29 The total number of foreign HIV carriers known to the Ministry of

Health is several hundred.

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government, and suggested possible ways of solving the situation.

Working in cooperation with the AIDS Task Force and supported

by part of the medical establishment, we urged health authorities tolearn from positive European models.

We demanded that children and pregnant women be providedwith the full range of treatment given to Israeli citizens,regardless of their civil status.

We strongly opposed the deportation of AIDS patients totheir country of origin in cases when no medical treatmentwould be available to them there.

We insisted that Documented Migrant Workers shouldreceive the same treatment as Israeli workers, as noted inChapter Two.

We stated our belief that special health services and treatmentshould be provided to Non-Documented Migrants who areHIV carriers or AIDS patients, as is the case in Europeancountries. This could take place by means of a humanitarianresidency visa (if no treatment is available in the country oforigin), or through a national project providing treatment, onewhich would not distinguish between Israeli and foreign

patients. Such a decision would be a clear statement that

humanitarian considerations and public health are being put atthe forefront.

4B. Women Sold and Working in the Sex Industry

It is estimated that thousands of women work in Israel inprostitution and in similar jobs, which accounts for a significant proportion of the whole sex trade. Some of these women areemployed in prostitution under coercion; others were brought to

Israel with the promise of better living conditions. Today there isextensive evidence of trading in women and of employment under

poor conditions. In cooperation with the Assistance Center forForeign Workers, PHR-Israel recently contacted the AttorneyGeneral through Adv. Dori Spivak of the Human Rights Program atthe Tel Aviv University, and demanded that full health services be

provided to women being held by the police in order to givetestimony against their former pimps. This small group (a sub-setof migrant women traded and employed in the sex industry in Israel)

who have been victims of violence, trading and many other offenses

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in the past and are now being held forcibly by the Israeli legalsystem, should receive full health services preceding the trial.In October, 2002, the state attorney replied prior to the court hearing

stating a plan for almost full medical insurance to 50 migrantwomen that were brought to Israel, traded and victimized are nowpart of the testimony project.

PHR-Israel Press Release, January 31, 2002:

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Press Release

January 31, 2002

The police have reneged on their responsibility to provide

medical care for women appearing as witnesses in the

prosecution of pimps and sex traders, despite the fact that the

women are held in police custody.

Two women held in police custody in the south of Israel, who areserving as witnesses for the state in the prosecution of sex tradersand pimps, are not receiving medical treatment. The Israel Policehas reneged on its responsibility to provide medical care for these

women, and asked PHR-Israel to find them a physician. Theinstruction to contact NGOs with this request came from seniorsources in the national police headquarters.

This is not the first time that the Israel Police has refused to financemedical treatment for women held in its custody. In the past, PHR-Israel and the Assistance Center for Detained Employees have seenwomen in a serious medical condition due to procrastination anddelays in referral to a physician by the police.

The police is legally obliged to provide medical treatment for allpersons in its custody, and all the more so in cases when thesewomen are endangering their lives by providing testimony; theywould surely prefer to return to their home country. The AssistanceCenter for Detained Workers and PHR-Israel are engaged in a

protracted legal battle against the police in order to oblige it torecognize this obligation. Indeed, we believe that there is anobligation to provide these women with a series of medicalexaminations and treatments due to their special situation and the

legacy of injury and abuse they bear.

4C. Asylum Seekers and Refugees30

The number of people that are living in Israel and seek political

30 We have recently finished a full updated report on asylum seekers andrefugees in Israel together with Adv. Anat Ben-Dor of the Tel-AvivUniversity clinic for legal clinical aid. The report will be available in

our office and web-site as of November, 2002.

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asylum is estimated in the hundreds. Processing of asylum seekerswas recently transferred from the UN Commission for Refugees to adomestic Israeli inter-ministerial body. This body is to be guided by

the UN Convention on the Status of Refugees (1951) and theappendices thereto, to which Israel is a party. Refugees form a smallgroup of people in Israel. Most of them have undergone suffering,turmoil and sometimes torture before reaching Israel.Currently, an asylum seeker (i.e. a person who passed the first stageand his application for refugee status is under investigation) issupposed to receive a work visa, which legally enforces theemployer to arrange for medical insurance. In practice, nothingworks. Asylum seekers encounter extensive bureaucratic problems,for reasons that are unclear to us, some of them appear as

deliberately planed. Approval the working visa is conditioned on payment of a fine for illegal entry into Israel; the work visa islimited to specific professions (nursing, construction, agriculture),and so on. In short, this entitlement of asylum seekers does notsolve any of their problems, including the problem of healthcoverage. Asylum seekers are just like any Non-DocumentedMigrant.Despite the numerous restrictions imposed by Western Europeancountries on the entrance of refugees, many of these countries have

made sure that asylum seekers (in the investigation stage) enjoysome access to health services:

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The Situation in the West31

Germany: When an asylum seeker arrives at the absorption centerhe undergoes a medical examination. During the first 36 months theright to health services is limited to serious or painful diseases. Thisdefinition also includes chronic diseases that cause pain. TheGerman courts have ruled that expenses incurred by an asylumseeker for psychotherapy are to be covered by the State. After thewaiting period, if there is no final answer, the asylum seeker isentitled to the same medical services as a German citizen.

Greece: Asylum seekers are entitled to free medical servicesincluding examinations, medication (one prescription a month), andhospitalization, as established in the Aliens Law amended in 1996.

Britain: Asylum seekers and their children are entitled to freemedical care under the National Health Service. Services are

provided for asylum seekers by the general practitioner in the areaof residence. Asylum seekers are also entitled to an interpreter to be

paid for by the physician or through the local health authorities.Asylum seekers supported by the NASS (a governmental agencyproviding assistance for impoverished asylum seekers) may receiveadditional services, including prescriptions, dental care and paymentfor travel to the hospital, etc. all for a period of six months. Thereare also special reductions and exemptions for the purchase ofmedication.

D is an asylum seeker who has not yet been recognized as a refugee. As aresult he is not presently eligible for the medical services he requiresneither can he be employed legally. The following is a summary of his

31 The information in the box is quoted from the above-mentioned report. See comment 29. For additional information on the

situation in Europe, see Chapter 3B.

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story;"In my country, I was a Red Cross employee and a political activistopposing the Communist regime. While I was at university, I met somefriends my own age and we founded a group [the political situation

began to deteriorate and a number of armed militias were formed PHR]If you give weapons to people, to youngsters, you may think that they will

protect you, but they already sense the power they have and they try to usetheir weapons to get things. I tried to persuade people at least in our

province not to take weapons and not to send their children to themilitias. One night the militias came and took my uncle and murderedhim. He left behind two wives and children. I wanted the murderers to be

put on trial, but I didnt have any evidence. Then the militias took controlof the capital city. There was shooting during the day and curfew at night.In May 199*, after the elections, we planned a large demonstration in the

capital in favor of peace and social progress. When we reached the square,a car suddenly pulled up and militiamen began to shoot into the crowd.Three people were killed and eight wounded. I felt that I mustnt remainquiet. I had to go out to the public and tell them what I had seen. Iidentified the people in the car and wrote down its number. Two yearslater, some people came to my house and told me they were police officersand wanted to investigate the events at the demonstration. They arrestedme forcefully in front of my family. My little daughter began to cry andone of the policemen pushed her with his foot and knocked her over.They handcuffed me and put a black hood on my head. Since that day I

have not seen my family or my little daughter. She should be 14 years oldnow. They took me to the cellar in the home of one of the commandersand I began to realize that they werent the police, but one of the militias. Ispent about two weeks in the cellar. They shot my leg and cut me with aknife on my lower back. They wanted to humiliate me because I was kindof sophisticated and educated. During the two weeks they brought a

political friend of mine and told me that they were going to show me howthey would execute him, and they would do the same to me. I had to watchthem beating him. I was naked the whole time. Anyone could come inand do whatever they wanted to me or watch me. They told me: Youregoing to die anyway, but we want to torture you so you die slowly. They

treated me like dirt, and did not give me any food or water. One of theguys was my special torturer. I was half dead. I came from an educatedfamily, and I myself was an educated man. I had never been hungry, and Ihad never even performed hard work. My father was an important man,with possessions and houses. Suddenly everything fell apart. They toldme that they wanted to exchange me for friends of theirs who were in jail

but I was in the opposition, why would the police want to exchangesomeone for me? One day they came and told me there was no point, theywouldnt be able to exchange me. They should just kill me, but they werewaiting for the order. They sent someone to me who said he was a doctor.

He put me into bed and then left, leaving the door open. I managed to get

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up and found an open window. I jumped out and ran away. I went back tomy home, which was completely abandoned. I just took some documentsand money and then ran to the home of my nephew, who was a policeman.He hid me. They made me forged documents and he took me to the airportin his car. I flew to a neighboring country where I tried to begin a new life.I even bought an apartment and married a young woman I met there. Shehardly knew anything about my past. Sometimes I used to remember whathad happened to me. Everything went black. My brain got mixed up. Iwent to a psychologist and began to have therapy. On the anniversary theyinvited people from all the countries in the region, and people also camefrom my country. Until then I had used a different name. I had to leavethe second country. I took my original passport and looked for anembassy. By chance, completely by chance, I arrived at the Israeli embassyand asked for a visa. I arrived in Israel in 1997 and my wife joined me

later. I went to the central bus station and made contact with otherimmigrants from the same area. They found me a cheap apartment and acleaning job. Suddenly my wife was arrested for being an illegal alien andshe was put in Neve Tirzah prison. Since my previous job had arranged awork visa for me, I tried to get her released. I went to attorneys and courts,and eventually they let her out, but she wasnt allowed to work. One daythe police came and arrested me. They told me that my visa was no good,forged, and put me in jail. It was very hard for me in jail. At night I saw

black faces, like my torturers. It took me back to it all. I began to behavestrangely and talk to myself. Suddenly I remembered the worst torture, the

sexual torture, the pain and blood. The staged executions. I could actuallysee the face of my torturer and feel him strangling me with an electriccable. The physician in prison spoke to me like everyone else, for oneminute, and then said he had no time and gave me tranquilizers. I spent 20days in jail. They wanted to send me to my country, because I had myoriginal passport. I told them that I had worked for the Red Cross, andthey sent a woman from the Red Cross and contacted the UN Commissionfor Refugees. Only then, when a representative came from the UNCommission for Refugees, did I finally manage to tell part of my truestory. When they released me, I was in a bad state. My wife also had ahard time with me. She left home and moved in with friends. I used to

wake up at night with flashbacks, and I was sure I was in prison again [theCrisis Center for the Victims of Sexual Violence and PHR-Israel helped D.receive basic psychological assistance R.A.] I really like Israel and Iwant to stay here, despite the problems. Life isnt easy here, but I couldstay and live a reasonable life, but our problem is that were all the timescared because of the documents. I still dont have any idea what happenedto my large family and I havent seen my daughter."

Conclusions

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This report addresses a single key question: how can we ensureaccess to health services for a population, which, by definition, lies

beyond the scope of Israeli social services? These men, women and

children live and work in Israel, but are not defined as residents andare, therefore, unable to enjoy equal eligibility and access to healthservices.

We believe that the presence of such a large population that doesnot have residency status must be the subject of public debate inIsrael. Israeli society must accept their existence as a fact andrecognize that the State bears at least a minimum responsibility fortheir health.

Major steps lie ahead. The greatest challenge lies in the ability ofIsraeli society to cope with the problem of Non-DocumentedMigrants who already constitute the majority of the migrant workers

population that, according to various estimates, totals between200,000 and 300,000. Israeli society must recognize someresponsibility to provide essential health services to people whocontribute their working power to the Israeli economy.

The following steps need be taken in order to allow for a real

change: The public, as well as decision-makers, must accept the

existence of migrant workers as an inevitable feature inIsraels integration into the global economy, rather than a

phenomenon that can be eliminated by violent means.There must be an immediate end to the attempts to deflectsocial and economic unrest in Israel upon the migrants, andan end to efforts to use the difficult situation of theseworkers in order to justify attacks on minimum wage,unemployment benefits and social services. Some

politicians and high officials accuse both the migrants that

They cause unemployment and the Israeli unemployed thatthey do not want to work and deserve no state allowance"32

32 We refer again to note 3 in the summary to this report. OhadMarani, director-general of the Ministry of Finance, was quoted inMaariv on August 15, 2001 as saying: The number of foreignworkers is far too high higher than the number of unemployed []

We should take drastic action against foreigners who damage salary

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Part of the population of migrant workers can and should beincluded in Israeli social systems on an equal basis

(integration), and should receive work or residency visas(legalization). T

physicians for human rights-israel: aggressively passive - the state of health of migrant workers in...

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