The Politics of Health Care

The New York Times published a troubling article this morning: "Palestinians Pull Patients from Israeli Hospitals." http://www.nytimes.com/2009/02/10/world/middleeast/10patients.html?hp

This article profiles a rather dramatic shift in the policy of the Palestinian Authority, which has previously supported Palestinian patients seeking care in Israeli institutions.

Every day, hundreds of Palestinians cross the border into Israel with special permits granting them day and sometimes overnight access to an Israeli hospital. In 2006, according to the WHO, tens of thousands of permits, averaging 200 patients per day, were issued to Palestinians, allowing them to cross the border from the West Bank or Gaza and be treated within an Israeli health facility. Approximately 60,000 Palestinians from the West Bank were treated in Israeli, 2/3 of whom received received ambulatory care and 1/3 of whom were hospitalized. 2500 of these patients were children. Patients crossing the border are generally looking for specialized care for a condition such as cancer or diabetes, for which expertise in terms of both human resources and specialized facilities is generally lacking in the Palestinian Territories.

For a range of reasons, related in large part to the history of the development of the Palestinian health system when health care in the Territories was administered by Israel, the Palestinian health system is built predominantly around primary care and community health services. While access to these services can be quite good, secondary and tertiary health care services are largely lacking in the Palestinian Territories. While the Palestinian Al-Quds University Medical School in East Jerusalem trains Palestinian physicians, Palestinian health facilities generally do not have the capacity to offer specialized residencies. And while Israeli hospitals are open to Palestinians seeking residencies and fellowships, these training positions are often too lengthy, inadequately funded, or unattractive for Palestinian applicants. Furthermore, given the already competitive and squeazed Isreali medical education system, the few positions available to Palestinian applicants fall far short of what would be required to truly build capacity in a systematic way. Palestinian students can also look for training in Jordan and elsewhere abroad, but again barriers abound.

What's left is a situation which, for better or worse, demands cooperation and requires codependence. At the time being, the Palestinian Territories do not have the facilities and expertise to provide treatment to most of the patients being seen in Israeli hospitals, the majority of whom are there because those institutions offer best-in-the-world specialized care for a complicated longterm health condition. Withdrawing these patients as a political statement may indeed sacrifice their lives to politics. And as usually occurs, it will be the children and the most vulnerable who suffer the most.

The Palestinian Ministry of Health does spend about 16% of its budget in paying for the treatment of Palestinian patients in foreign institutions, including those in Jordan, Egypt, and primarily Israel. For a cash-strapped heath system, this amount is not insignificant and the expense of treatment in foreign facility may contribute to slowing the development of a self-sufficient Palestinian health system. Yet, it is also true that Israel subsidizes much of the care for these patients. Often Israeli hospitals themselves soak up much of the cost of treatment for Palestinian patients. In many cases, their care is subsidized by an Israeli NGO such as the Peres Center for Peace or Save a Child's Heart. Call it what you will, these cooperative efforts save lives. That these lives are Palestinian or Israeli is unimportant. Talk to any physician, for instance, at Israel's Hadassah Hospital in Jerusalem and they will tell you that when a person enters that hospital they are no longer Palestinian or Israeli or anthing else. They are a person in need of care, and they will be given the best care possible. Politics stop at the door.

I know Dr. Fathi Abu-Moghli, the Palestinian Minister of Health, and I know that he is a good man who cares deeply about the people for whose health he is charged. I hope that the way forward beyond this controversy can result in a new kind of cooperation -- cooperation in building a sustainable, independent health system for Palestine, the kind of institutions and resources that will be required in order for a two-state solution to be viable. The peace process is also an institution-building process: a two-state solution means that each must have institutions and systems that can stand on their own two feet and operate independently, though with some necessary ties. My experience has shown me the benefits of Israeli-Palestinian cooperation in health, medicine, science, and academia for both sides. These cooperative efforts build trust and bonds of mutual respect while benefiting both sides involved. They also increase capacity and create the civil society ties that two states living side-by-side in peace will require. I beleive that this kind of cooperation can encompass the politics that Dr. Fathi is expressing here rather than fall victim to it. The goal of building a Palestinian health system that is strong, advanced, and independent is a extremely worthy and viable one. Cooperation with Israel, as well as the neighboring Arabic nations, can and should help it get there.