physicians for human rights-israel: i am here, gender and the right to health in the unrecognized...

8/8/2019 Physicians for Human Rights-Israel: I Am Here, Gender and the Right to Health in the Unrecognized Villages in the

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I AM HERE

Gender and the Right to Health in

the Unrecognized Villages of the

Negev

April 2008

I AM HERE


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Gender and the Right to Health in the Unrecognized Villages

of the Negev

Author: Nora Gottlieb

Authors of Chapter 7: Na'amah Razon, Nora Gottlieb

Research: Nora Gottlieb, Naamah Razon, Orly Almi, Heiger

Abu Shareb, Yael Vidan, Raanan Forshner, Tal

Manor

Copy editor: Su Schachter

Photographs: Elisheva Smith (Cover picture: Khashm Zinna

Village)

Design: David Moskovitz

Print: Gafrurei Dafdefet

This publication was produced with funding from the European Commission

through Oxfam GB.

The contents of this document are the sole responsibility of Physicians

for Human Rights-Israel and can under no circumstances be regarded as

reflecting the position of the European Commission.

Acknowledgements

This report was made possible by the contributions, help and support of

Na'amah Razon; Orly Almi; Heiger Abu Shareb; Najah Abu Nadi and MaleehaEl-Nasasre and all the Health Rights Community Leaders; Suleiman Abu

Obaiyed, Yeela Livnat-Raanan and Ali Abu Sbaieh from the Regional

Council for the Unrecognized Villages of the Negev; Kathline Abu Saad;

Nadera Shalhoub-Kevorkian; Nadav Davidovitch; Shirin Batshon-Khoury;

Rowaida El-Sana'a; Hana'a Abu Khaf; Zenab El-Sana'a; Kamelia Abu Alheja;

and all the women and residents of the Unrecognized Villages who have

shared their stories, experiences and views with us.

Thank you!

The photographs in this report are taken from Elisheva Smith's

Exhibition: "The Unrecognized" which can be viewed online:

http://www.pbase.com/elishevasmith/the_unrecognized


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* Arabic: Look at me


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Table of Contents

Preface 7

Background 10Legal Background 10

Women in the Unrecognized Villages 13

FULFILL Womens Right to Acceptable 29

Health Care

Acceptability, Information Accessibility 29

and the Right to Health

Language Accessibility of Healthcare in the 30

Unrecognized Villages

The Impact of Communication Barriers 32

PHR-ILs Stand for Language Accessibility 38

of Health Services

FULFILL Womens Right to Accessible 40

Health Care

Background 40

Bedouin-Arab Womens Barriers to 41

Health Care

PHR-ILs Stand for Healthcare Accessibility 48

FULFILL Womens Right to water 52

The Right to Water in International and 52

Israeli legislation

Israel's Water Policy in the Unrecognized Villages 52

Water and Health 54

Implications for the Health of Women from 55

the Unrecognized Villages

PROTECT Womens Right to Live in Dignity 59

Background on Gender-Based Violence 59

Gender-based violence in Israel and in the 63


Denial of Protection, Support and Remedyn 67


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PHR-ILs Stand against Gender-Based Violence 71

RESPECT Womens Right to Housing 74

Background 75

Women and House Demolitions in the 79


PHR-ILs Stand against House Demolitions in the Negev 86

Conclusions and Recommendations 90

Summary 90

Conclusions 91

PHR-IL's "Community Health Rights Leaders" 93

Recommendations 95


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List of Abbreviations

ACRI - Association for Civil Rights in Israel

CEDAW - Covenant on the Elimination of all Forms of DiscriminationAgainst Women

CESCR - Covenant on Economic, Social and Cultural Rights

GC - General Comment

MCH - Mother Child Health

NHIL - National Health Insurance Law

NII - National Insurance Institute

OHCHR - Office of the United Nations High Commissioner

for Human Rights

OPTs - Occupied Palestinian Territories

PHR-IL - Physicians for Human Rights IsraelRCUV - Regional Council for the Unrecognized Villages

in the Negev

UN - United Nations

UNPF - United Nations Population Fund

UNHCR - United Nations High Commissioner for Refugees

WHO - World Health Organisation


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Preface

"The advancement of women is not a 'women's issue'. It is an issue for

all of society, for all people. There is a direct correlation between

the status of women in a particular society and that society's own

condition. The way a society treats its women is the way that asociety defines itself... States must do their utmost to promote the

advancement of women within their own borders...

Israeli Statement to the 59th UN General Assembly, Oct. 14th 2004

The lives of women from the Unrecognized Bedouin-Arab Villages in the

Negev are characterized by marginalization and disempowerment inflicted

on them by different agencies and on different social levels. They are

discriminated against as women in Israel, as members of a minority in

Israel and as women within their communities. The conflict between the

Unrecognized Villages and the State of Israel has specific and unique

implications for women in their respective communities, modulated by

their status and role in family and society. Too often, women ultimately

bear the major burden of health and human rights violations against the

villages' residents. In other terms, the State ignores the fact that its

discriminatory policies against the Bedouin-Arab population as a whole

not only harm primarily Bedouin-Arab women, but furthermore perpetuate

and reinforce gender inequalities. Additionally, Bedouin-Arab women are

being instrumentalized in the course of this struggle as symbols of

tradition, honour and motherhood by one side and as "demographic bombs"

by the other - to the detriment of their health and health rights. This

accumulation and interplay of numerous human rights violations

compromise Bedouin-Arab womens well-being. At the same time it deprives

them of resources to effectively oppose, protect themselves from, or

cope with rights violations and their health implications.

As an especially vulnerable group, Bedouin-Arab women deserve special

attention, protection and support on the part of the State.

Paradoxically the opposite becomes true; the State of Israel refuses to

fulfill its obligations to realize the health and human rights of women

from the Unrecognized Villages, as laid out in international human

rights instruments, on any of the three principal levels defined as

respect, protection and fulfilment. These are the States duties towards

Bedouin-Arab women identical to the States duty to any other person

living under its governance. Hence it is PHR-ILs mandate to compel the

State of Israel toward the realization of its duties according to the

principles of equality and non-discrimination.

Following the logic of marginalization and disempowerment, Bedouin-Arab

women play virtually no role in the public sphere. They are invisible

and silenced. One aspect of their invisibility is a lack of

comprehensive data on their living situation and health status. Women

from the Unrecognized Villages hardly appear in official figures. Many


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existing statistics and research studies tend to perpetuate the

patronization and stereotyping of Bedouin-Arab women by addressing them

solely in their reproductive role, and from an external, western-

biomedical perspective.

Large parts of this report are based on Bedouin-Arab women's

testimonies1 which were collected within the framework of PHR-IL

research and empowerment activities, as well as from case studies

compiled in the course of PHR-ILs long-term individual and principal

advocacy with the communities of the Unrecognized Villages2and their

representative organizations such as the Regional Council for the

Unrecognized Villages in the Negev (RCUV). This qualitative information

will be underscored with some statistical data. This report focuses on

thematic spotlights which are intended to contribute to a more faceted

picture of the complex health rights situation of women from the

Unrecognized Villages. At the same time they provide a platform for the

expression of womens experiences and perspectives and also and

importantly will serve as a resource for advocacy and awareness-raising

for Bedouin-Arab women and their communities.

This report begins with a summary of the international health and human

rights framework which constitutes the point of reference of PHR-ILs

mandate and activities. Chapter Two outlines womens living conditions

in the Unrecognized Villages. The following chapters (3-7) provide

examples of violations of Bedouin-Arab womens health rights. These

examples are divided into three categories, reflecting the three levels

of states obligatory action for the realization of human rights. They

illustrate how Israel not only refuses to actively fulfill the health

rights of women from the Unrecognized Villages but even denies them

protection and respect of fundamental health and human rights as well.

The situations described in these chapters exemplify the expansion of

health and health rights in the narrower sense, regarding healthcare-

related aspects, to their wider conceptualisation in relation to

underlying determinants of womens health. Each of these chapters

includes examples for PHR-ILs activities which specifically target the

health rights of Bedouin-Arab women. The report finishes with

conclusions and recommendations directed at the responsible authorities.

1

If not otherwise agreed upon with the interviewee, their names have beenchanged to avoid identification.2PHR-IL takes on individual cases only if the affected person, or someone

acting on her/ his behalf, turns to the organisation for help; that is,PHR-IL does not do outreach to individuals.


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Background

Legal Background

Womens Health Rights in International Human Rights Legislation

The right to health is enshrined in Article 25 of the Universal

Declaration of Human Rights (1948) (1). The International Covenant on

Economic, Social and Cultural Rights (CESCR, 1966) includes the most

comprehensive definition of the right to health as the right of

everyone to the enjoyment of the highest attainable standard of physical

and mental health (2). In 2000, the respective UN Committee set it out

in further detail in its General Comment (GC) No.14, which emphasizes

that the right to health is more than the right to health care. On the

contrary [it] embraces a wide range of socio-economic factors thatpromote conditions in which people can lead a healthy life, and extends

to the underlying determinants of health such as food and nutrition,

housing, access to safe and potable water and adequate sanitation, safe

and healthy working conditions and a healthy environment.

Signatory states are obliged to realize the right to health for all

persons under their sovereignty according to the principles of equality

and non-discrimination. Furthermore GC 14 enjoins the application of the

following four interrelated elements with regards to health-relevant

facilities, goods and services, those being availability in sufficientquantity; accessibility, including non-discrimination, physical

accessibility, affordability and information accessibility;

acceptabilityin terms of medical ethics and cultural appropriateness;

and qualityin terms of scientific and medical standards (Article 12a-

d).

In signing the CESCR, states commit themselves to take deliberate steps,

on three levels, to realize the covenant, The obligation to respect

requires States to refrain from interfering directly or indirectly with

the enjoyment of the right to health. The obligation toprotect requiresStates to take measures that prevent third parties from interfering with

article 12 guarantees3. Finally, the obligation to fulfill requires

States to adopt appropriate legislative, administrative, budgetary,

judicial, promotional and other measures towards the full realization of

the right to health. (Article 33)

Article 20 recommends that states adopt a gender perspective as an

inherent principle of their health-related policies, planning,

programmes and research. Article 21 is dedicated specifically to womens

3Article 12 guarantees refer to the availability, accessibility,

acceptability and quality of health and health-care facilities, goodsand services, as well as to the underlying determinants of health.


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right to health, calling upon states to implement comprehensive policies

and strategies for the promotion of womens health throughout their

lifespan. More concrete goals are, for instance, the reduction of women-

specific health risks, including gender-based violence and the

protection and remedy of harmful practices and norms as well as the

elimination of barriers interfering with health, health-care seeking and

related areas like access to education and information (3).

The right to health has been affirmed by various other human rights

documents, among them the International Covenant on the Elimination of

all Forms of Discrimination against Women (CEDAW). Its Article 12 and

the respective GC 24 call on states to ensure womens equitable access

to health and family planning services, to protect them during pregnancy

and lactation, to address distinctive features of especially vulnerable

groups of women, to take action against gender-based violence, to

eliminate access barriers to health care and to ensure acceptability of

services, with an emphasis on responsible, informed consent including

information, education and confidentiality (4).

Additional cornerstones for womens health rights are the Programme of

Action adopted by the UN Population Funds (UNPF) International

Conference on Population and Development in Cairo 1994 and the Beijing

Declaration and Platform of Action, which resulted from the Fourth World

Conference on Women in 1995 (5, 6). These documents underline the

supremacy of womens (health) rights over demographic and other

political goals. All of above documents highlight women's and

minorities' entitlement to special attention, protection and support on

the part of the State.

Womens Health Rights in Israeli Legislation

Israel ratified CESCR and CEDAW in 1991 (7)4. Gender equality is

enshrined in its Declaration of Establishment from 1948 (8).

Furthermore, the Israeli Authorityfor the Advancement of the Status of

Women, established under the prime minister's office in 1998, presents

the enhancement of Israeli Arab womens status as a highly importantgoal (9)

5. But so far none of Israels basic laws have incorporated

gender-equality principles (10). Meanwhile patriarchal institutions and

laws keep women, especially if members of marginalized segments of

4Yet Israel has declared its reservations about several CEDAW articles;

neither has it signed the Optional Protocol which would subject it to theInternational Court of Justices authority in case of disputes (4).5In its 2006 activity report, the Authority mentions Bedouin-Arab women

from the South as one of three specific target groups within the generalArab-Israeli population. Paradoxically, the described empowerment-activities exclude Bedouin-Arab women from the planning process and many

interventions are inaccessible to a large part of the target population,especially women from the Unrecognized Villages, due to the choice oflocations, methods and/ or media; e.g. internet-based resources, orcampaigns via radio, television and internet. The activity report itselfis available only in Hebrew.


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society, at disadvantage in a range of social areas, such as matters

concerning personal status (i.e. marriage and divorce).

The most important basis for Israeli residents' health rights within

Israeli health legislation is the National Health Insurance Law (NHIL),

enacted in 1994. As stated in its preamble, the law is based on the

ideological foundations of solidarity, social justice and equality. The

NHIL introduced universal health coverage by determining that every

Israeli resident, by virtue of his registration with the National

Insurance Institute (NII), is entitled to a "basket" of basic health

services. Four non-profit health funds provide health care. Insured

persons are free to choose at which health fund they wish to register.

One of the NHIL's drawbacks is that it binds health entitlements to

residency status. Furthermore, in the current trend to privatisation in

the Israeli Social and Health system, increasing co-payments and user-

fees undermine the original rationale of the NHIL (11, 12, 13).

Another foundation of health rights in Israeli legislation is the

Israeli Patients Rights Bill (1996). It applies principles of medical

ethics to the provision of health services, such as equal accessibility,

right to information, confidentiality and free and informed choice. The

law is explicitly valid for all patients, irrespective of gender, ethnic

or religious affiliation, residency, or any other status (14).

Women in the Unrecognized Villages

The Existence of a Woman Living in an Unrecognized Village

The difficult living conditions of women from the Arab sector and the

south in general, and in the unrecognized villages specifically,

constitute a genuine tragedy.

The unhealthy environment in which we live, including the lack of an

official, set place for dumping rubbish and the deep and unsupervised

wadi right behind the house, is a real danger to our lives and to our

childrens safety. The children also suffer from the lack of any

educational frameworks which would nurture their well-being and

development. The children are always outside playing, trying to find

something to do, some way to pass the time.

Add to that the problem of the houses not being connected to the

electrical grid, which causes great suffering to the residents. The women

must delay doing the laundry and the ironing until the generators are

turned on, and they run only 4 hours a night. Of course the refrigerator

doesnt work all day, so we cant keep medicines because were not

connected to electricity.

You can imagine the difficulties we have getting around where there are

no roads, when I want to go to the clinic in the next village. The

suffering from heat in the summer and cold in the winter is really


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awfulI have to walk half an hour in the heat of the summer and through

the mud in the winter just to get to the main road.

Our entire reality is very hard. I have nowhere to go in my spare time,

theres no club or meeting place, theres not even a playgroup for the

children.

I cant forget to mention the vast open areas around my village and the

cultivated lands of the Jewish settlers that are sprayed by plane with

all kinds of poisons which are a real source of air pollution and which

endanger our health.

Najah Abu Nadi, PHR-IL's Health Rights Community Leaders

What can I write to you; you, my own fairy tale

How can I begin, what can I write? Is there enough room in these pages

for your suffering, for your generous heartI asked the hills and I asked

the valley and they both know youI asked the paths and they answered how

can they not know you? You are she who always goes by foot, always

carrying a baby on her shoulders and a baby on her hip and yet another

baby cries trailing behind her, grabbing her skirts and asking her to

slow her steps.

The hills answered and said, how can we not know her? She is the one

carrying water jugs on her shoulders, she reaps the fields and helps her

husband to ensure life with dignity for her children and to safeguard her

lands

I have always written about you, oh you are the strong one and I have

filled pageseach page full of suffering. You do not complain to me of

your suffering, but I know, how can I ignore your suffering when I live

with you, I am one of you. You are strong, you never complain to anyone,

to whom could you turn? To the government authorities who steal your most

basic rights, the rights of your children? After all it is you who bears

their suffering. You who wait in line for hours for them, you who travel

in the heat of summer for their sakes, you who spend the nights next to

them worrying about their health and well-being. Add to that the worry

about contaminated water, which assures you your daily journey of agony

and suffering. You fulfill your obligations to children and to husband,

you guard the lands of your fathers

I am so proud of youyou live in the desert of the Negev with what is

hard and what is cruel, you suffer the iniquity of the oppressoryou are

stronger that the boulders of the hills around youin that desert where

even the chicken houses have the water and electricity you lack, you are

forced to teach your children by the light of the lantern. I salute you,

I am proud of you

Maleeha El-Nasasre, PHR-IL's Health Rights Community Leaders

Life in an Unrecognized Village


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Since the establishment of the State of Israel in 1948, the Bedouin-Arab

population of the Negev has been subject to a process of resettlement

and forced social transition. The government's policy of non-recognition

and systematic neglect reflects its agenda for concentrating the

Bedouin-Arab population in designated townships for the purpose of

turning their lands into (Jewish) urban development areas, agricultural,

industrial and/or closed military zones (15, 16). In pursuit of this

goal, the State (mis-)uses the provision of basic services and

infrastructure as leverage to oust the Bedouin-Arab communities from

their lands. Having labelled 45 pre-existing villages as illegal, the

authorities deny them the most essential prerequisites for a healthy

life, like access to potable water, appropriate housing, electricity,

sewage, waste deposal, roads and transportation. Environmental hazards

like chemical dumping sites, open sewage streams and air pollution from

industries that were established right next to Bedouin-Arab settlements

expose the population to serious health risks. Nevertheless,

approximately half of the total Bedouin-Arab population of the Negev,

more than 80,000 persons, persist in living in "Unrecognized Villages"

(15, 17, 18). The UNs treaty-monitoring bodies have repeatedly and

harshly criticized the Israeli government for violating the villagers

rights (19, 20, 21).

No social services are available in the villages. There are 21

elementary schools, only very recently have two high schools been

established, and these serve a population of whom about 60% are younger

than 19 years (22). For many Bedouin-Arab children, the path to taking

and passing the matriculation exam (bagrut) and hence to higher

education is thus barred (see 2.2.3).

Since 1994, 11 Primary Health Care Clinics and 8 stations for primary

Mother-Child-Health (MCH) care were established in some villages, partly

as a result of petitions to the High Court6. Three mobile immunization

units operate in the area. However, the new health facilities lag far

behind Israeli standards. They consist of large caravans which rely on

generators for supplying electricity. This makes the refrigerated

storage of drugs and vaccines impossible7. Opening days and hours are

extremely limited. A range of further health care delivery challenges

compromise women's access to services; communication barriers are among

the most prominent issues (23, 24). Emergency services are basically

non-existent because ambulances fail to find or refuse to enter the

villages (17).

6These petitions were filed by the Association of Civil Rights in Israel

(ACRI) and Adalah, the Legal Center for the Rights of the Arab Minority

in Israel on behalf of the residents of Unrecognized Villages and severalother organizations including PHR-IL.7PHR-IL has taken on the issue of the connection of these clinics to the

electrical grid a part of its principal advocacy, planning for a HighCourt Petition in 2008 (see chapter 6.3.3).


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In both government-planned townships and in the villages it has become

impossible for the Bedouin-Arabs to maintain their former lifestyle. The

deprivation of their lands has led to a loss of livelihood mainly from

herding and agriculture, which ultimately left most Bedouin-Arab men

little choice but to enter the labour market as unskilled workers. The

resulting involuntary, rapid transition of economic, social and cultural

structures implies a vital threat to heritage and the social fabric (16,

23 25). Today, the Bedouin-Arabs are one of the most impoverished

segments of Israeli society. The proportion of families living under the

poverty line is 66% in the townships and 80% in the Unrecognized

Villages (compared to 25% among the general Israeli population). An

estimated 22-36% of Bedouin-Arab men are registered as unemployed; for

the Unrecognized Villages this is probably an underestimation (26, 27).

Any of above-mentioned stressors impacts in a specific and unique manner

on Bedouin-Arab women's rights and well-being. The following paragraphs

outline their living situation and status, as modulated by an interplay

of factors from within and without. The subsequent chapters will then

exemplify how this detrimental interplay eventually makes Bedouin-Arab

women bear the burden of their communities' oppression and

marginalization.

Socio-Cultural Roles

Bedouin-Arab society puts a major emphasis on the individuals

affiliation to the extended family. Its hierarchical order, built on the

superiority of men over women and of elder over younger, is maintainedby loyalty and the subordination of individual needs to the common

cause. Within this framework a person is held accountable not only for

his own behaviour but also for the behaviour of other family members

(28, 29). On the other hand, socio-cultural norms cherish discussion and

joint decision-taking within the family (personal communication).

Having lost their productive role in agriculture and herding, Bedouin-

Arab womens responsibilities are now restricted to the household,

child-bearing and childrearing. Bearing a large number of children,

especially sons, enhances womens social status. Within the communitiessocial structure, (arranged) marriage and motherhood serve the functions

of strengthening inter- and intra-family bonds. This is one of the

reasons for the wide-spread practice of cousin marriages (50-60%) (27,

29, 30).

The designated space for womens lives and activities is the private,

domestic sphere (i.e. the familys compound). They hardly play any role

in the public sphere, which is reserved for men. Outside the family the

two sexes are not supposed to mix. This is partially due to the

conceptualisation of women as weak and untrustworthy, to be feared for

and feared. Many central norms that guide social behaviour and gender

relations ideologically charge the female body as a symbol and shrine


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for Bedouin-Arab traditions and norms, among them honour/dignity

(sharaf), shame/disgrace (ard) and modesty (hashma). Strict social

control is exercised via constant surveillance. Transgressions are

sanctioned by gossip, which discredit the individual's and family's

reputation, and can entail "social death" and/or actual femicide

("honour killing") (see also chapter 4).

Men's honour depends on their capability to control women's behaviour,

to guard and protect them. In return women are supposed to serve them.

In case a woman doesnt comply, if she complains, opposes, or becomes

ill, she has to fear that her husband will divorce her or marry

additional wives8. The rate of polygamous marriages is between 30% and

36% among the Bedouin-Arabs of the Negev (28, 29, 30).

Muslim feminists emphasize that womens oppression is not inherent to

Islam but the result of its biased interpretation by patriarchal

institutions, reinforced by colonialist regimes and other economic and

political processes9(28). However, given the current conflict between

the Bedouin-Arab communities and the Israeli authorities, Bedouin-Arab

women who call for gender equality and internal reform are at risk of

being accused of betrayal of the common, fundamental cause, of the

community and of religion itself (21).

Access to Education and Information

" Girls need to learn, they need to be educated, learn a profession,

get a job. Earn money. Who builds society?! Women are the ones who

build society. For this they need to be educated, also to bring up and

educate their children in the right way

Things in Bedouin society are changing. People start to understand,

but slowly, slowly. Some families are like this and others like that.

People say: "Why should a woman go back to study? She should pass her

knowledge on to her children, educate them."

Hanan A. A., Umm Matnan

8It should be noted that polygamy is punishable under Israeli legislation

(see 2.2.5). The Quran permits polygamy under specific conditions; yet inreality many polygamous relationships breach the Quran's principles.9Several authors have observed a strengthening of patriarchal structures

in the Arab-Israeli communities, which may be ascribed totraditionalization provoked by the substantive threat that oppression andmarginalization pose to heritage and values; for example, perhaps therise of the importance of womens respectability serving as an emblem forthe familys honour can been related to the families loss of lands (28,

29). In certain cases the Israeli authorities did, intentionally or not,fuel rifts between different Bedouin-Arab families, to the detriment ofwomens health for example by naming MCH stations after a specificfamily, creating a situation where women from other families in the samearea could not use the health station.


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There are hardly any governmental kindergartens in the Unrecognized

Villages. For most children schooling is available only up to 9th grade;

pupils who want to complete high school (12th

grade) are required to

commute to a government-planned township. Yet it is considered

inappropriate for girls to leave their villages unaccompanied and mix

with male classmates outside the range of the family's surveillance.

This is one of the reasons that 60-77% of Bedouin-Arab girls drop out of

school early. In a PHR-IL research study10

the average number of womens

years of schooling was 6.3 opposed to 9.04 years among men. Graph 1

shows the distribution of educational levels in the sample as well as

the sharp decline in women's schooling after 9thgrade (24, 31, 32, 36).

32

11

4332

20

52

65

0

10

20

30

40

50

60

%o

fresponden

ts

0y 1-9y 10-12y >12y

Years of Schooling

Women

Men

Graph 1: Distribution of educational levels among residents

of the Unrecognized Villages according to PHR-IL's survey

This stands in contrast to the right to education which is anchored in

the Universal Declaration of Human Rights, in numerous articles of the

Convention on the Rights of the Child and in the CEDAW, the latter

directing national bodies to take action against any form of gender-

based discrimination in terms of educational opportunities (4). Israeli

law enjoins compulsory education until completion of the 10th grade

(33). However, the authorities forgo enforcing this law among the

Bedouin-Arab population (32).

The bagrut (matriculation) pass rate among Bedouin-Arab students is only

13% (compared to 56% for the Jewish and 33% for the general Israeli Arab

population) with a tendency to decline over recent years (32, 34, 36).

Especially among Bedouin-Arab women literacy rates and the level of

command of the Hebrew language are low. The predictable pathway without

schooling and further training leads towards early marriage and

motherhood11.

10This research was conducted among 176 women from Unrecognized Villages.

11

However, several experts have related a recent increase in polygamousmarriages to the fact that women, upon completing of their studies, areconsidered as "old" and "spinsters" and thus the only option left forthem to marry at all is entering into a polygamous relationship (21,personal communication).


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Education is more than a goal in itself. It also represents an essential

asset and tool for the realization of other rights. Its importance for

health, especially womens health, cannot be overestimated. Numerous

studies throughout the world have proven the protective effect of

women's education with regards to reproductive health, chronic non-

communicable diseases and mental health. It is associated with more

effective use of health services, especially preventive services; it has

been shown to improve the entire familys health status and children's

development (4, 5).

In the Israeli health systemHebrew skills are crucial to access health

information and services, even though Arabic is theoretically the second

official language in Israel. As a result many Bedouin-Arab women

encounter serious communication barriers when trying to seek health

care. For this reason a separate chapter of this report is dedicated to

the issue of health services language accessibility (see chapter 3).

It is true that educational levels rise among the younger generations

and that an increasing number of Bedouin-Arab girls finish high school

and enter institutions of higher education. Special programs, for

example that at Ben-Gurion University in Beer Sheva, aim at facilitation

and support of Bedouin-Arab women in their studies (29, 30), but hardly

any of these programs is a governmental initiative (19, 35, 36).

Employment and Access to Economic Resources

"Women do not have funds; they have to ask their husbands for

money. Another reason why girls should get educated, get a job

Child allowance used to be 3700NIS per month. Now after they cut

it down, I get only 1900NIS. Thats not enough!"


It is a far way to go to the [Mother-Child-Health station in]

Kseifa; sometimes I didnt have the money to go [ which is 10-

15NIS both ways]."

Ibtisam A. J., Albhaira

Social and economic transition affected Bedouin-Arab women in a

different manner than men; the shift to wage labor deprived them of

their economic power, limiting them to unpaid reproductive work within

the domestic sphere. Restricted mobility and restricted access to

education further exacerbate their deprivation. On top of this the

State's systematic neglect of Arab localities has led to a lack of work

opportunities, of public transportation and of local day care centres


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18

for children12. All of these factors contribute to women's unemployment

(25, 28, 32). Data for the general Arab-Israeli population shows that

Arab women make up only 5.6% of the female workforce in Israel (although

they represent 15.7% of the female population). In the age group of 15-

54 years, less than 25% of Arab women are employed, compared to 80.3% of

Jewish women (9). The Unrecognized Villages' situation is worse in all

of these aspects. Accordingly estimates on unemployment rates are

higher; only 0-9% of Bedouin-Arab women work outside the domestic

sphere. Those with paid jobs receive on the average salaries 50% lower

than Jewish women; often their income lies below minimum wage (26, 27,

32).

This also means that hardly any Bedouin-Arab woman has an income of her

own. Most women have to rely on their husbands, which leaves them

without decision-making power over the household funds. Many women have

nothing but their childrens allowance and welfare payments at their

disposal. This hasnt changed significantly over the last decade but

recent curtailments in social benefits additionally aggravate Bedouin-

Arab womens socio-economic disempowerment (24, 37, 38).

12Out of 1,700 governmental day care centers, only 36 operate in the Arab

sector, thus absorbing only 2% of Arab children (21). No governmental daycare services exist in the Unrecognized Villages (12).


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Legal Status and Social Rights

Naifes Story

Naife grew up in Gaza. In 1996, at the age of 16, she was married to a

Bedouin-Arab resident from an Unrecognized Village. Her husband suffers

from mental illness. The couple had three children. In 1999 Naife's

husband applied for family unification, so Naife would be granted legal

status and social rights, but they never received a reply to their

application.

In February 2005 PHR-IL intervened on Naife's behalf after the Ministry

of Health had attempted to operate on her and insert an IUD [intrauterine

device] claiming that Naife had given free and informed consent. Serious

doubts as to the veracity of this claim were raised, not only because

Naife does not speak Hebrew, but principally because she showed clear

indications of severe mental disorders. PHR-IL succeeded in forcing the

Ministry of Health to provide an appointment with a mental healthspecialist, Naifes first meeting with a mental health professional, who

confirmed that she suffered from schizophrenia and was possibly also

mentally retarded. But lacking legal status in Israel, Naife was not

eligible for treatment under the National Health Insurance Law and the

couple could not afford to cover the costs themselves. Accordingly PHR-IL

was also seriously concerned for the couple's children and appealed to

the Ministry of Health to immediately grant treatment to Naife.

In the beginning of 2006, the Ministry of Interior served notice that the

process of family unification was suspended because of Naife's husband's

criminal records; minor feloniesfor which he was never sentenced [itshould be noted that legally only the foreign spouse's criminal record is

relevant for the process of family unification]. In November 2006 their

seven-year-old son was diagnosed with muscular dystrophy. It was

recommended that the couple undergo genetic testing and counseling, but

could not afford it.

In February 2007 Naife was granted a temporary visa to stay and work in

Israel, which had to be renewed every three months and did not entail

social entitlements. Since this neither allows the family to live in

peace and security, nor enables Naife to receive direly needed mental

health treatment, PHR-IL is preparing an appeal to the High Court,demanding legal status and appropriate mental health care.

In 1994, the National Health Insurance Law (NHIL) introduced

comprehensive health coverage, based on the principles of social

justice, equality and solidarity. It binds health rights and

entitlements to residency status; only persons who are registered as

residents with the National Insurance Institute (NII) are eligible for

social benefits, including health insurance. Persons who lack legal


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status are thus denied a way to pay into the National Insurance and are

therefore excluded from most social benefits13(12, 39).

In the Israeli context, several pathways lead to "statuslessness"; many

of them primarily affect Arab women. The 2003 amendment to the

Citizenship Law prohibits family unification for spouses from the

Occupied Palestinian Territories (OPTs) and from countries that are

categorized as enemy states. It thus illegalized an estimated 25,000-

47,000 persons, most of them women, who consequently live in Israel

without any prospect of acquiring legal status and the related civil and

social rights. Often their children, too, are born into the same lack of

status and lack of rights (12, 39, 40, 41).

The NII revokes the residence status of Israeli-Arab women who marry a

partner from a neighbouring country, under the assumption that she will

live in her husbands country of residence. Likewise, the residency

status of Palestinians who happen to reside in East Jerusalem

(approximately 55,000 persons) is under constant threat of revocation

(42). Both the Citizenship Law as well as above-described practices

clearly violate human rights legislation and its underlying principles

of non-discrimination on the basis of ethnic or religious affiliation

and gender (43). For this reason national and international bodies have

criticized them as discriminatory (19, 20, 31, 41).

Another example of processes which deny status is that of women who

marry into polygamous relationships with Israeli citizens. In theory,

polygamy is illegal and punishable under Israeli criminal law. A prison

sentence of up to five years is supposed to deter men from marrying

several wives. Yet in fact, polygamous marriages are condoned by the

shariah (Muslim religious courts); the relationship and family status

receive certain recognition by the Israeli authorities. But on the basis

of a polygamous marriage a woman will not be granted legal status in

Israel, neither can she apply for family unification. Consequently she

is denied all social and civil rights, including social and health

benefits. For better or worse a statusless woman is completely dependent

on her husband and his family. The same destiny, revocation of legal

status, awaits women who have been granted residency after they have

married an Israeli citizen in case their husband is found to have

entered into (an) additional marital relationship(s) afterwards. In

other words, the Israeli system fails to deter or prosecute a criminal

offence - under the guise of cultural relativism - but instead punishes

its primary victim (12, 39, 40).

Up to 36% of Arab women in the Negev live in polygamous relationships;

several thousand of them lack legal status. The fact that hardly any of

13Excepting primary Mother-Child-Health Services and the birth allowance,

for which all women and spouses of Israeli citizens are eligible,regardless of their legal status.


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these women speak Hebrew and are not familiar with the Israeli social

and health system makes their reliance on their husbands families

complete. Apart from being a criminal offence under Israeli law,

polygamy often violates womens basic social and economic rights since

scarce household resources are being shared by too many to allow for an

adequate standard of living. The combination of polygamous relationship

and economic difficulties has been related both to high occurrence of

domestic conflicts and violence and to a great burden of mental ill

health on the women in question (30, 44). But again their lack of legal

status blocks these womens way to seeking professional help (39, 40).

Another, last, example of statusless people are the 600-1,000 members of

the El-Azazme tribe, who as a whole are granted neither legal status in

Israel, nor any other citizenship or national affiliation. In the course

of several expulsions and re-settlements between Egypt and Israel since

1948, they have been rendered completely stateless and any child born to

one of the approximately 100 families adds to the number of statusless

persons in the Negev (45).

Lack of legal status frequently lies at the core of the problems for

which persons from the Unrecognized Villages turn to PHR-IL for help.

Almost all of the appellants are women and their children. PHR-IL

estimates the number of statusless persons in the Negev as high as

3,000-4,000 (12, 45).

Health and Health Care Utilization

Living conditions in the Unrecognized Villages impact on Bedouin-Arab

womens health as well as on their health-seeking behaviour.

Availability and accessibility of the underlying determinants of health

as well as of health services are already problematic. Womens

deprivation of economic resources additionally hampers their autonomous

decision-making, as well as their options for putting decisions into

action. Beyond that, chances are low that household funds will be

allocated to womens needs, since these are commonly appointed low

priority (16, 24). In villages without local health services majoraccess barriers like lack of transportation, lack of childcare, the need

for the husbands permission and chaperoning in order to travel and lack

of funds for travelling continue to account for a high number of women

who forgo medical treatment. Even if health services are available

locally, some of these barriers persist and impede womens access to the

facilities. Language problems, socio-cultural divides, low service

availability and non-satisfaction with services potentially deter

Bedouin-Arab women from utilizing services even if they are accessible

in physical terms (23, 24, 32)(see also chapters 3 and 4).


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The combination of harsh living conditions and high fertility rates14

suggests a heavy burden of poor health among Bedouin-Arab women. However

Bedouin-Arab womens health is rarely brought to the public attention as

opposed to infant mortality15among the Bedouin-Arabs of the Negev, which

persists as a hot topic among health academics and authorities. But

they often seem to forget that Bedouin-Arab babies also have mothers

whose health and well-being may be closely, if not inextricably, linked

to the health of their babies16. One aspect of Bedouin-Arab women's

"invisibility is that hardly any disaggregated data on Bedouin-Arab

women's health status can be found in official statistics. As a result,

we can provide only sporadic information on life expectancy, general

morbidity or mortality. This despite the alarming results of the few

existing surveys, whose results hint at extremely high morbidity with

regards, for example, to the prevalence of anaemia (up to 47%), repeated

urinary tract infections (up to 53%) and respiratory diseases (27, 47).

PHR-ILs study accords with these findings; among its sample of

antenatal care users, 70% suffered from ill health, with anaemia,

infectious diseases and diabetes as the most widespread conditions (24).

In recent years, civilisation diseases like obesity, diabetes, high

blood pressure, heart problems and cancer have started to add

significantly to the Bedouin-Arabs disease burden. These diseases

rapid rise may be related to changes in lifestyle and to low socio-

economic status, as nutrition-related conditions like obesity, heart

problems and diabetes were basically unknown in the Bedouin-Arab

communities until recently. Today, prevalence rates have exceeded those

of the local Jewish population; especially among Bedouin-Arab women they

now show a significant peak. Other chronic non-communicable diseases are

not (yet) more prevalent compared to the Jewish population, but Bedouin-

Arab patients prognosis and survival rate is far worse. Similarly to

the general Arab-Israeli population, this can be partially explained by

later detection of disease and lower effectiveness of treatment17,

indicated for example by less controlled diabetes (23, 48).

14Fertility rates among the Bedouin-Arabs of the Negev are amongst the

highest worldwide with 7.6 children per woman in 2005, compared to 2.4for the local Jewish population (18).15Infant mortality rates among the Bedouin-Arab population of the Negevare consistently three times the average of the local rate; 14.2compared to 4.6 in 2005 (18, 46).

16 For example, iron deficiency anaemia (IDA) in infants is a publichealth concern of high priority. Rates have constantly declined over thelast decades, but IDA continues to be twice as prevalent among ArabIsraeli infants than among Jewish infants. However, infant IDA oftenresults from pre-existing maternal IDA. In the Bedouin-Arab population,maternal IDA has been related to multiple, closely spaced pregnancies,low socio-economic status and poor diet. Diarrhoeal diseases due toinadequate sanitation and food safety (due to the absence ofrefrigeration) increase the risk. 61% of Bedouin-Arab women in the Negevsuffer from IDA during their third trimester of pregnancy (56).17

For example, strokes are less frequent among Israeli Arab women(compared to Jewish women), but they are more likely to be fatal. Alsobreast cancer is less prevalent among Israeli Arab women (35.8 per100,000 population compared to 92.9 among Jewish women), but their deathrate is disproportionably high (29.1 per 1,000 cases compared to 48.9


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Several authors have noted Bedouin-Arab womens under-utilization of

health services; 47.3% of Bedouin-Arab women were found to forgo seeking

care in case of need (29). Preventive services are especially prone to

neglect. This can entail crucial delays in diagnosis and onset of

treatment, with potentially irreparable or fatal results (16, 24, 52,

53) (see also chapter 7). In the same vein the lack of antenatal care is

a significant contributor to low birth weight and infant mortality among

Bedouin-Arab women. It is also associated with out-of-hospital

deliveries, which obviously put both infant and mother at risk (54, 55,

79).

When it comes to mental health, the situation of Bedouin-Arab women is

just as worrisome. Several authors describe high rates of psychological

distress whose most common manifestations (with prevalence rates around

30%) are anxiety, somatization, low self-esteem, hopelessness and

depression (29, 44). However, few women from the Unrecognized Villages

are aware of the option to seek mental health services and hardly any of

them do so (only 49% are aware of the option and but 2% utilize

services). The lack of Arabic-speaking mental health specialists in the

Negev poses the question whether the women truly have an option to

obtain adequate mental health care (17, 29, 57).

Gender-based violence is another weighty health issue among Israeli Arab

women in general; it has been pointed out that the situation of Bedouin-

Arab women is the worst. Their exposure to physical violence is

estimated at up to 66%. Women in polygamous relationships, especially

first wives, are at significantly higher risk (69%). Also, women with

low educational levels suffer more often from abuse (78% compared to 59%

of high school graduates) (29, 44, 47). Gender-based violence goes to

extremes in the form of femicide (honour killing). Each year 20-30

women in Israel are murdered for the sake of preserving their familys

reputation. We do not have an exact distribution of these figures, but

allegedly femicide is more accepted among the Bedouin-Arab communities

in the South and the laws and policies that are meant to protect women

against gender-based violence are not seriously enforced (28, 32) (see

also chapter 6).

Altogether Bedouin-Arab women provide a textbook example of the sad

irony of the "Reverse Care Law", which says that those populations who

among Jewish women) (32). This correlates with an uptake rate of breastcancer screening and mammography of only 20% among Arab Israeli women,one third the rate of the general Israeli population (49, 50, 51). Acomparable picture is seen with cervical cancer: While Arab and Jewishwomen show similar prevalence rates (10.2 and 9.2 per 100,000 populationin 2000), there are vast discrepancies between their use of screening

tests. Only 8.3% of 35-44 year-old Arab women and 18.5% of 45-54 year-oldArab women have ever done a PAP-smear test, compared to 65.3% and 70% ofJewish women respectively. The utilization rate for Bedouin-Arab women iseven lower; 6% (32).


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are most in need of a (health) service have the least access to it. This

emphasizes PHR-IL's central appeal that women from the Unrecognized

Villages not only deserve respect, protection and fulfilment of their

health rights, in equal scope and manner just like any other person

under Israeli governance. The State must show accountability for the

dire consequences of its non-recognition of the villages for the health

rights of the female residents. Therefore, they deserve special

attention, redress and support from the authorities.


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FULFILL: Womens Right to Acceptable

Health Care

They told me that the head of the baby is up [ in breech position].

But I knew that it was still early and thought that maybe it will turn

by itself by the last weeks of the pregnancy So I didnt go for the

check-ups they didnt explain to me how urgent the situation is...

The doctor asked me if I wanted an operation [caesarean section]. I

said if I have a choice I want to deliver naturally. Nobody wants an

operation, no? I didnt know what to do! In the end they wrote in my

file Wanted to deliver by operation. Do you know what that did to

me?! Who wants to deliver by operation?! It hurt me a lot to do the

operation!

Rania A. A., Umm Matnan

The previous chapter put language barriers in the context of Bedouin-

Arab womens physical access to health care. This chapter elaborates on

further language- and communication-related obstacles and deterrents

with which the Israeli health system confronts Bedouin-Arab women.

Acceptability, Information Accessibility and the

Right to Health

The right to health is an inclusive right beyond the entitlement to

health care alone. GC (General Comment) No. 14 to the CESCR defines how

it extends to underlying determinants of health including accessibility

of health-related information and education; the right to seek, receive

and impart information and ideas concerning health issues. The

principle of Acceptability stipulates, all facilities, goods and

services must be respectful of medical ethics and culturally

appropriate; i.e. respectful of the culture of individuals, minorities,

peoples and communities... as well as being designed to respect

confidentiality (). An additional, related issue is the right to

participation in health-related decision-making on all levels (3).

In the context of womens health rights, both CESCR and CEDAW especially

emphasize the importance of access to information, (The)realization of

womens right to health requires the removal of all barriers interfering

with access to health services, education and information. Consequently

the State is to provide education and to foster knowledge and awareness

of health- and health-service related issues, to enable women to decide

and act on this information (which includes ensuring availability of the

necessary resources), and to guarantee cultural appropriateness and

training of medical staff in relevant capacities (CEDAW GCs No.14, 37and 44) (3, 4).


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The above principles are reflected in the Israeli Patients Rights Bill,

which enjoins ethical principles like the right to confidentiality, and

free and informed choice. More specifically the law determines that,

before beginning any medical treatment, a patient is to be provided with

all relevant information in appropriate length and in a way that will

enable his/her full comprehension so s/he can make an autonomous,

willful and independent decision. Furthermore, caregivers are bound to

preserve their patients' confidentiality towards third parties (14).

Language Accessibility of Health care in the


Language, Communication and Health

"I read Hebrew, also instructions and leaflets. And signs. It is a big

advantage. Otherwise you can get lost."

Hanan A. A.. Umm Matnan

Smooth communication is a precondition for a positive rapport between

caregiver and patient and is thus the basis for effective and good

quality health care. But the interaction between medical professionals

and patients is more than simple transfer of objective information, and

it has to overcome more than common linguistic and cultural divides.

Communication problems on a linguistic level obviously make it more

difficult to bridge conceptual divides like educational discrepancies,

different jargons, and divergent conceptualizations of health, sickness

and healing.

In Israel, Arabic is the official second language; Israeli Arabs

constitute 19% of the general Israeli population (18). Nevertheless, the

Israeli Health System is largely Hebrew-dominated.

Previous research has concluded that communication problems are among

the most salient barriers that Bedouin-Arab and Arab Israeli women face

in the Israeli health system (23, 102) and that linguistic, cultural,

and educational divides contribute heavily to Israeli Arab women's

under-utilization of health services (16, 38, 52, 53).

Most health facilities in the Unrecognized Villages are staffed by

Jewish personnel whose command of Arabic is very basic at best18. It is

not uncommon to find written information like signboards with the

facilities opening hours or health promotion materials in Hebrew only.

18 These findings contradict the claims of the health providersregarding comprehensive enrichment programs for their medical staff,ensuring appropriate levels of competence in Arabic, and their efforts torecruit and employ Arabic-speakers in the villages health facilities(personal communication).


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The lack of material in Arabic causes grave diminution of the Arabic-

speakers right to health and related information.

The following chapter presents Bedouin-Arab womens perspectives on the

communication barriers with which they are confronted by the Israeli

Health System. They inform conclusions on how language inaccessibility

of health services specifically violates womens right to information,

to acceptable health services and to informed, autonomous decision-

making. Interview excerpts and most statistical data are taken from PHR-

ILs research on access to antenatal care in the Unrecognized Villages

(24).

Access to Information and Education

The first chapter of this report has outlined the educational situation

of women from the Unrecognized Villages in general. In PHR-ILs surveysample 35.3% categorize themselves as illiterate (in any language) and

62.4% as illiterate in Hebrew. 48.6% neither understand nor speak Hebrew

(24). However, different villages show different profiles. 43.4% of

interviewees from village A were literate in Hebrew, while 39.6% didnt

speak Hebrew. This contrasts with village B, which has a reputation of

being more "traditional", where none of interviewed women knew how to

write Hebrew and 59.3% had no verbal Hebrew skills (24).

The Impact of Communication Barriers

Health Care Effectiveness and Compliance

Sometimes women do not understand the nurses and the nurses

do not understand the women. And sometimes the women do not know

how to care for their baby, so the nurses give guidance and

recommendations but the women do not understand exactly.

Nadja A.K, Um Bateen

Some might have done one television [ultrasound] and so they

think that there is no need for another one. Maybe the nurse

explained but the woman did not understand exactly what the

purpose of the television [ultrasound] is.

Mona A. K., Um Bateen

Health education and counseling are essential components of primary and

preventive health services. They rely on successful information transfer

and a trustful staff-patient rapport, which in turn require functioning

communication. Thus it shouldnt be surprising that many Bedouin-Arab

women recounted to PHR-IL that they do not benefit from the medical


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staffs explanations. This also raises serious doubts whether

sensitive issues like mental health problems or domestic violence can

be addressed at all. In such circumstances primary health services are

supposed to serve as entry points to a system of more specific health

and support services. But in the given setting we have to assume that

they fail to fulfill this function. Language-specific health services

like speech therapy or mental health care are hardly available at all to

Arabic-speakers in the Negev.

The above quotes illustrate that communication failures lead to

misunderstandings and delays in seeking health care and/or provision.

Statistical findings underscored the association between communication

barriers and health care utilization: Most of the interviewees who

hadnt gone for antenatal care (ANC) and who hadnt adhered to referrals

for antenatal screening tests, many of them because they reckoned that

these tests were useless, came from aforesaid village B19

(24). These

findings hint at how communication barriers jeopardize the effective

utilization of preventive services and hamper the delivery of curative

care, leading to faulty treatment in worst case.

Emotional Experience of Health Care

Most interviewees expressed frustration about the inability to

understand and to make themselves understood by the medical staff. Some

described being scolded by the nurses for their unwillingness and

non-compliance with recommendations and referrals. Situations which

are characterized by communication failures between them and the medicalstaff cause embarrassment and frustration as they demonstrate the

womens deficiencies in terms of Hebrew and literacy skills and their

incapability to properly take care of their children.

"Some women maybe feel shy; they do not want to ask questions.

Maybe they will not understand, or look down on you as if you

were simple-minded. If you do not speak a language well, there

are lots of problems.


I get along with them [the nurses], but not a lot. Sometimes I

have a problem and I do not manage to explain myself. The nurses

and the doctors give counseling and explain the tests, but in

Hebrew

I felt very bad because I didnt know to explain that [my babys

problem] to the doctor. I had to wait until my husband comes and

explains in my place. I understood that there is a problem with

19 59% of women who lacked all ante-natal care, and 48% of women whohadnt seen a gynecologist even once during their pregnancy wereresidents of B. Likewise 57% of women who had foregone antenatalscreening because they considered it pointless from village B.


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the girl and it hurt me a lot that for such an issue, too, I

need to wait for my husband to do it. For a simple thing like

explaining my daughters pains.

Sabreen A. A., Bir Hadaj

In earlier PHR-IL surveys, medical consultations in the local clinics

were referred to as veterinary examinations (17).Evidently, this does

not exactly meet common notions of good interaction between patient and

caregiver, which is generally considered paramount in quality health

care.

Confidentiality and Privacy

"We expect our clients to take responsibility for their health and -

in case that the clients have difficulties with [the] Hebrew

[language] to ensure that they come with [being accompanied by] a

relative who can translate for them, as it is done among the Ethiopian

and Russian-speaking population as well."From a letter by Clalit

Health Fund to PHR-IL

Many female Bedouin-Arab patients bring translators along; otherwise the

medical staff occasionally recruits interpreters ad hoc out of the

waiting area or around the health facility. However this well-intended

solution seems to only exacerbate communication problems. Both patients

and translators describe bashfulness and shame, which silence them

rather than facilitate better communication.

In case I need to talk with the doctor about something delicate, I

take my husband along to translate for me, or my older son. I feel

humiliated if other women explain for me.

Tamam A. J., Albhaira

Sometimes the nurse runs out in the middle of the examination to find

a translator, somebody in the clinic or walking outside. Of course,

this is a problem with privacy. It is not convenient to talk about

something personal, about a problem, when there is some other person.


Several times they asked me to translate for other women, but I

hardly manage myself in Hebrew. Our village is small and everyone

knows each other. Therefore it is very hard for me when they ask me to

translate for women I know, because it is always about intimate

issues. It bothers me to see how much these women get embarrassed in

front of the nurses.

Hadije G., Umm Matnan

This also has to be seen in the context of the womens lives in small,

cohesive communities. If information on a womans health issues leaks


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through to the community it can have dramatic consequences for herself

and her entire family. Gossip, especially about a womans reproductive

health problems, is a viable threat to her and her relatives' marital

prospects and social status within the community (see also 7.3.6). In

this context, many Bedouin-Arab women voiced outright rejection of

Bedouin-Arab male doctors, because they suspect them of breaching

womens right to confidentiality and of mixing family surveillance and

politics with health care. This accords with other researchers findings

that Arab Israeli women eschew the social exposure and interference with

family politics associated with medical consultations with a male doctor

(35, 102).

Staff-Patient-Relationship

Many Bedouin-Arab women rated their relationship with the medical staff

positively. Nevertheless they demanded for more Arabic-speaking staff,reasoning that this would enable better interaction and rapport. Thus

Arabic thus turned out to be the crucial key-capacity for medical

professionals who work with Bedouin-Arab patients, rather than gender

and/ or religious-ethnic affiliation.

It doesnt matter if she is Arab or Jewish. Most important is that

she will understand me. I feel more comfortable if a woman gives me

treatment. But I know that, in case I receive treatment from a man,

that it is his profession. Hence I deal with him in his role as a

doctor. Most important is that he will understand me.Amal A. J., Albhaira

I would prefer a female doctor. We Arabs are shy in front of a male

doctor About Jewish or Arab, I do not care - the most important thing

is that she should speak Arabic.

Mona A. K., Um Bateen


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Conceptual Divides and Stigmatisation

Communication barriers between medical professionals and patients can be

the result of both linguistic and conceptual differences. In order to

prevent or rectify misunderstandings and discords both sides

considerations and beliefs have to be respected and negotiated in a

constructive, non-hierarchical discourse. At the same time this enables

caregivers to better understand patients potential dilemmas between the

medical and other paradigms. But such a discourse obviously requires a

common language at least on the linguistic level. The following

paragraph provides a few examples of conflicting concepts and their

interaction with communication barriers in the context of Bedouin-Arab

womens reproductive health.

The first example is the issue of conflicting timescales. While the

medical establishment recommends to start ANC as early as possible inpregnancy, socio-cultural norms prohibit making a pregnancy public

earlier than around the second trimester. Many antenatal screening test

results are available only at a relatively progressed stage of the

pregnancy, at a time when medical interventions or abortions are banned

on religious grounds (24, 52, 53).

Another example is the stigmatisation of certain antenatal screening

tests, which is partly due to the failure to explain the concept of

statistical risk to patients and their families. It may not take more

than the referral for a certain antenatal screening procedure for aBedouin-Arab woman to be branded within her community as problematic

and unable to bear healthy children. This is an enormous social risk,

not only for herself but for her entire family.

The last example is the false alarms anecdote, which is widespread in

the Bedouin-Arab communities of the Negev. Several interviewees

recounted it about their relatives or other community members. The story

goes that a Bedouin-Arab woman had been recommended to perform an

abortion on the basis of abnormal screening results. But she had decided

to carry out the pregnancy and eventually gave birth to a healthy baby.Her family's conclusion is that evidently the medical staff tries to

make Bedouin-Arab women abort healthy babies. Apart from a failure to

communicate the concept of statistical risk, this narrative also

reflects deep mistrust of the medical establishment and its role in the

demographic struggle in Israel (16, 24). In general, medical gossip and

anecdotes among the Bedouin-Arab communities of the Negev reflect

misunderstandings and distorted information; they spread and reinforce

stigmas, vital fears and suspicion towards the medical establishment

which are products of a combination of conceptual divides and the

inability to clarify these due to language barriers (16, 103).


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The above examples provide some ideas about the factors that a Bedouin-

Arab woman has to weigh against medical risks and guidelines. Her cost-

benefit-calculation differs from the considerations most medical

professionals are familiar with and may lead her to decisions which,

from the latter perspective, seem incomprehensible and self-defeating

(16, 24).

Summary

On the basis of the preceding paragraphs we can say that the language

inaccessibility of health services impacts on two levels: 1) on a

technical level, it compromises the effectiveness of health service

utilization and delivery. 2) on a (inter-) personal level it turns

medical consultations into a negative experience for the patients,

tainted with feelings of frustration, inferiority and shame. The

involvement of non-professional interpreters does not solve but on thecontrary aggravates the problem by violating the patients right to

confidentiality. Furthermore, language inaccessibility jeopardizes the

patients right to free and informed choice. How can it possibly be

realized if the relevant information couldnt be made clear to the

patient? Which decisions can a Bedouin-Arab woman realistically make,

reckoning with the norms and values that dominate her social

environment? Which decisions can she indeed put into action, in light of

her living conditions? And what do the responsible governmental bodies

do, beyond medical treatment, to support a Bedouin-Arab woman in a

critical situation and open up realistic options to her?


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PHR-ILs Stand for Language Accessibility of Health

Services

Advocacy with Health Authorities and Providers

PHR-IL constantly advocates with health funds and with the Ministry of

Health for better language accessibility of health services. The case

study cited above exemplifies PHR-IL's interventions on behalf of

individual pleas. However, much of PHR-IL's advocacy regarding language

accessibility and acceptability of health services in the Unrecognized

Villages is comprised of advocacy on a principal level. It is based on

PHR-IL's demand for the realization of the right to equal availability

and accessibility of language-specific health services for the Bedouin-

Arab population of the Negev.

For example, PHR-IL has maintained correspondence with the Israeli

Health Funds regarding language accessibility of written health-relevant

information like clinic signposts and educational materials like

information sheets and leaflets. Another focus is the delivery of

language-specific health services like mental health services, speech

therapy and also mother-child-health care (in light of the fact that the

latter is based on counselling and guidance). At the time of writing,

PHR-IL is corresponding with the Israeli Health Funds, the Ministry of

Health and the Ministry of Education with the purpose of ensuring speech

therapy for Bedouin-Arab children who have received a cochlea (hearing)

implant. This costly operation does not make any sense for the patient

in question, if s/he does not undergo appropriate rehabilitation

afterwards. PHR-IL considers taking this matter to the legal level in

the event that its current efforts shouldn't bear fruit.

Facilitating Dialogue

As part of PHR-IL's principal advocacy, it encourages exchange and

dialogue between the Unrecognized Villages residents and health funds

and authorities. Face-to-face meetings give members of the unrecognized

communities an opportunity to express their needs and demands, and to

address them directly to the responsible institution. Since Bedouin-Arab

women are usually not part of the public or political discourse, PHR-IL

finds it especially important to provide them a platform for presenting

their perspective. These activities serve the long-term goal of a

sustained discourse between the authorities and the communities of the

Unrecognized Villages, and the latter's participation in planning- and

policy-making processes.

The policy of establishing discourse led to a meeting between

participants of PHR-IL's course for Bedouin-Arab Women Community Health

Right Leaders with representatives of the Ministry of Health (see also


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Chapter 8). The course participants seized the opportunity to raise,

among many others, the issue of language accessibility. They addressed

communication barriers between medical staff and Bedouin-Arab patients

in general, and within the framework of preventive and primary health

services specifically. A list of recommendations and demands was handed

over to the Ministry of Health representatives, who invited the course

participants to submit their suggestions for concrete interventions and

projects in the field of health promotion and primary health care for

the Bedouin-Arab communities. The dialogue which was opened by this

initial meeting is to be continued by a series of follow-up meetings.

Awareness-Raising and Research

In 2006 PHR-IL and the Israeli Institute for Advancement of the Hearing

Impaired have jointly initiated a project that involves students from

Ben Gurion University of the Negev in the mapping of the needs of thepopulation of hearing-impaired Bedouin-Arab adults who reside in the

Unrecognized Villages. Beyond the "by-product" of raising awareness

among the local student and academic community, the results of this

needs assessment will serve as a basis for PHR-IL's principal advocacy

in this matter.


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FULFILL Womens Right to Accessible

Health Care

I went with my first two children to [the Mother-Child-Health

station] when they reached the age of almost two years, in order to

have them immunized. Because of the difficulties to get there I

couldnt go [for antenatal care]. Back then there was no road to our

village so I couldnt use transportation. My husband couldnt take me

there because he had neither a drivers license nor a car.

I didnt have the awareness of how important it is to go It happened

many times to me that I missed tests and appointments because I didnt

have anybody to drive me sometimes I didnt have the money to go.

Tamam A. J., Albhaira

A woman is not supposed to leave the house alone... Here, a woman can

walk all the way [to the Mother-Child-Health station] on foot. With

the baby on her arm. So everyone will see her walking and will know

where she goes. But to Beer Sheva thats more difficult. The woman

has to go to the highway and when she takes a taxi from there she

disappears. Nobody can see where she goes. My husband is a bit strict.

He would not accept that.

Asma A. A., Wadi Ghwain

Background

This chapter deals with access barriers that hinder women from the

Unrecognized Villages from physically reaching health care. As explained

in the first chapter of this report, it is incumbent upon the State to

ensure equal accessibility of health services as part of its core

obligations according to binding human rights treaties (see 2.1.1). The

Israeli National Health Insurance Law also enjoins the provision of

primary health care to a needy person within reasonable distance and

time. Yet the first few primary health clinics and Mother-Child-Health

(MCH) stations in Unrecognized Villages werent opened before 1994. In

many cases, their establishment was accomplished only by means of

petitioning the High Court20. Today eleven primary health care clinics,

eight MCH stations and one mobile MCH unit operate in Unrecognized

Villages (17, personal communication). On the one hand this represents a

positive step on the part of the authorities, which has greatly eased

access for the residents of the respective villages. On the other hand

the newly-established facilities provide an absolute minimum of

services, just enough to comply with the High Court rulings but not

enough to accord with Israeli standards of care, and their staff

struggles with numerous service delivery challenges.

20 In June 2000 a High Court Petition (4540/00) was filed by theAssociation of Civil Rights (ACRI) on behalf of the residents of threeUnrecognized Villages, the Regional Council for the Unrecognized Villagesin the Negev, and other organizations including PHR-IL (17).


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Furthermore it has to be born in mind that most villages remain without

local provision of primary health care until today. Their residents are

required to travel far and under harsh conditions in order to seek

health services. Access barriers to second- and third-level health care

remain unaltered. Low geographic accessibility of health services has

unique and especially severe implications for Bedouin-Arab women. In the

following chapter, the interplay of women-specific determinants of

physical access to health services in the context of the Unrecognized

Villages will be described and analysed. This section is mainly based on

findings of a recent PHR-IL research study, which assessed access to

antenatal care among women from Unrecognized Villages21(24).

Bedouin-Arab Womens Barriers to Health Care

It happens that women do not go [for antenatal care] because of thedifficulties to get there. If her husband cannot take her there. Or

because of money. Also because of the children.

Nadja A. K., Um Bateen

Before they opened here, I went to the Tipat Halav in Dimona on

foot... On the dust track to the highway, sometimes with a little

child, in the heat or rain. From there you can take a Transit. It is

far. It takes a long time. It is also expensive; the Transit costs 10

NIS one way.


A whole range of interrelated issues challenge Bedouin-Arab womens

physical access to health services; distance, unavailability of

transportation, restrictions on womens autonomy and mobility,

transportation costs, lack of childcare, and difficult travel conditions

related to climate and the absence of roads (23, 24, 37, 38, 99). The

following paragraphs illustrate in what way many women-specific access

barriers are relevant depending on whether or not health services are in

walking distance from the women's homes.

Distance, Transportation and Travel Time

Before they opened the villages MCH station, I depended more on my

husband to drive me. When he was at work or not free, Id postpone the

appointment. It happened a lot that I wanted to go , but I couldnt

because I had pro

physicians for human rights-israel: i am here, gender and the right to health in the unrecognized...

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