Social Science & Medicine 144 (2015) 119e126

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Social Science & Medicine

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The Israeli Medical Association's discourse on health inequity*

* Shlomit Avni a, , Dani Filc a, Nadav Davidovitch b a Department of Politics and Government, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva, 84105, Israel b Department of Health Systems Management, Ben-Gurion University of the Negev, P.O. Box 685, 84105, Israel article info abstract

Article history: The present paper analyses the emergence and characteristics of Israeli Medical Association (IMA) Received 9 December 2014 discourse on health inequality in Israel during the years 1977e2010. The IMA addressed the issue of Received in revised form health inequality at a relatively late stage in time (2000), as compared to other OECD countries such as 7 September 2015 the UK, and did so in a relatively limited way, focusing primarily on professional or economic interests. Accepted 8 September 2015 The dominant discourses on health inequalities within the IMA are biomedical and behavioral, charac- Available online 9 September 2015 terized by a focus on medical and/or cultural and behavioral differences, the predominant use of medical terminology, and an individualistic rather than a structural conceptualization of the social characteristics Keywords: Israel of health differences. Additionally, IMA discourses emphasize certain aspects of health inequality such as Health inequities the geographical and material inequities, and in doing so overlook the role played by class, nationality Discourse and the unequal structure of citizenship. Paradoxically, by disregarding the latter, the IMA's discourse on Social determinants health inequality has the potential to reinforce the structural causes of these inequities. Our research is Medical ideology based on a textual critical discourse analysis (CDA) of hundreds of documents from the IMA's scientific medical journal, the IMA's members journal and public IMA documents such as press-releases, Knesset protocols, publications, and public surveys. By providing knowledge on the different ways in which the IMA, a key stakeholder in the health field, de-codifies, understands, explains, and attempts to deal with health inequality, the article illuminates possible implications on health policy and seeks to evaluate the direct interventions carried out by the IMA, or by other actors influenced by it, pertaining to health inequality. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction The phenomenon of health inequality is both reflected in and reproduced by the diverse ways in which various actors explain and The publication of the “Black Report” on health inequality in the conceptualize inequalities in health. These conceptualizations in- United Kingdom in 1980 (DHHS, 1980), marked a new era in which fluence the choice of policies and ways of addressing the phe- awareness of health inequality (measured by indicators such as life nomenon. Since professional healthcare organizations play an expectancy, infant mortality, and morbidity), reemerged (WHO, important role in framing discourses on health inequality, it is 2008; Wilkinson, 1996; Marmot and Wilkinson, 2006; Dahlgren important to understand the ways in which they themselves un- and Whitehead, 1993). Inequalities in health are caused by the derstand inequalities. Thus the present study analyses the ways in unequal distribution of power and resources (income, wealth, sta- which the Israeli Medical Association (IMA) conceptualizes health tus, environment, and access to health care) and by the policies that inequality. The Israeli case is of interest due to the unique inter- sustain and deepen them, policies of exclusion and the economy of action between nationality, ethnicity, class, and gender in Israeli inequality (Farmer, 1999; Maru and Farmer, 2012; Mackenbach, society, and how they translate into health inequality. Moreover, 2012; McCartney et al., 2013). the analysis of the Israeli case demonstrates the paradox of how certain ways of understanding inequalities in health functions as a means of limiting awareness of their main causes, and in doing so, reinforce them. * This research was supported by the Israel Science Foundation, grant number This paper analyses the appearance and development of IMA's 566/12. * Corresponding author. Ben-Gurion University of the Negev, P.O. Box 653, Beer discourse on health inequality in Israel between the years of Sheva, 84105, Israel 1977e2010, exposing the main explanatory frameworks and E-mail address: [email protected] (S. Avni). http://dx.doi.org/10.1016/j.socscimed.2015.09.015 0277-9536/© 2015 Elsevier Ltd. All rights reserved. 120 S. Avni et al. / Social Science & Medicine 144 (2015) 119e126 policies applied to address these inequalities. The paper claims that There are a number of ways of conceptualizing and explaining the IMA addresses health inequalities mostly in bio-medical terms, inequalities in health. One way is by focusing on biomedical causes understanding them as a result of an individual's behavior, and in (i.e. biological differences, and more specifically, genetic differ- doing so, overlooks the role played by class and the unequal ences) (Gottfredson, 2004). A second approach explains health in- structure of citizenship. This approach reinforces health in- equalities as a result of cultural differences and the effect of these equalities, since it does not address the role of class and ethno- differences on an individual's behavior and life-style (Smith et al., national exclusion. As the 2010 Israeli Ministry of Health plan to 1994). A third conceptualization accentuates psycho-social mech- reduce inequality in health shows, failing to address these issues anisms, i.e. the deleterious influence of stress related to subordinate limits reforms to questions of individual access to health care. social status (Wilkinson, 1996; Marmot and Wilkinson, 2006). Another approach proposes a “materialist” explanation, which sees 2. Conceptualizing health inequality health inequalities as resulting from the unequal distribution of wealth, power, and other resources (Muntaner and Lynch, 1999). Discourses are ways of describing and conceptualizing the Finally, the integrative eco-social approach sees health as a dy- world. They shape institutional behavior, political and scientific namic product of the interaction between biological, social, eco- activity as well as day-to-day behaviors (Bacchi, 1999; Fox, 1997). nomic, and environmental factors (Krieger, 2001). The different Discourses have significant effects on the conceptualization of so- agents active in the field of health and healthcare adopt different cial issues and their transformation into problems that demand conceptualizations of inequalities in health, or more commonly, intervention. At the same time, they determine the manner in adopt different combinations between the abovementioned ideal which the policies proposed to address those problems are justi- types. fied, planned, and carried out (Lupton, 2003). Though there is a clear difference between discourse and policy, 3. The Israeli case discourse influences policy by shaping the conceptualization of social issues, by constituting those issues as ‘problems’, and by In Israel, inequalities in health status and among health in- marking the boundaries of possible solutions. The latter stem from dicators are grounded on class, ethnicity, nationality, religiousness, the alternative ways in which the phenomenon is explained education, profession, and place of residence. For example, infant (Chadwick, 2000; Crinson, 1998; Fairclough, 2000; Greener, 2004; mortality is more than twice as highamong Muslims than among Marston, 2000; Lupton, 2003). Few researchers have examined Jews, Diabetes is 3.6 times more prevalent among low income the influence of discourse on health policy. Among these, Annas households and the chances of women with lower levels of edu- (1995) and Malone (1999) have shown how the use of metaphors cation to die from a heart disease have risen in the past two decades from the military, the free market, or various metaphors used in the from two times to five times, compared with more educated health services sector, influence approaches and policies to reform women (Epstein and Horev, 2007; Horev, 2008; Averbuch and Avni, health-care services. Moon (2000) analyses the relationship be- 2014; Manor et al., 2011; Gross et al., 2007). tween discourses concerning safety, protection and risk, and the The tensions between universal citizenship as guaranteed by the development of a discourse of quarantine in the mental health Declaration of Independence and the definition of Israel as a Jewish services sector. Crinson (1998) analyses the way in which consumer state have produced and reproduce the unequal distribution of discourse informed Labor Party policies toward the NHS under Tony resources and power between Israeli Jews and Israeli Arabs. Thus, Blair. Greener (2004) adds a historical dimension to Crinson's Israel has been characterized as an “ethnic democracy” (Smooha, analysis by demonstrating the connection between the Fabian 1990), “ethno-republicanism” (Peled, 1993)oran“ethnocracy” movement which emphasizes “performance”, and “New Labor”, (Yiftachel, 2006). which accentuates consumer values. Finally, Kelle (2007) examines The complex interaction between the limitations of the Israeli the way in which international health organizations invoke the economy in the early 1950s, the adoption of a capitalist, state-led discourse of security. model of economic development privileging labor intensive in- Few attempts have been made to examine the influence of dustries and the euro-centrism that characterized the state's po- discourse on policy regarding health inequality. Carslile (2001) litical leadership, resulted in a dual labor market, built along examines the relationship between three discourses explaining national and ethnic lines (Krampf, 2015; Neuman and Silber, 1996). health inequality (poverty and lack, psycho-social stress, and in- Class inequalities created by Israel's early model of economic dividual deprivation), and the different policy proposals that seek development, significantly deepened since the transition to a neo- to address health inequality in England. Raphael (2000) examines liberal/post Fordist socio-economic model in the mid-1980s (see the absence of any mention of socio-economic inequality in the among others Filc and Ram, 2006; Gottwein, 2004; Ram, 2008). public health discourse on health inequality in Canada. Additionally, several scholars have depicted the ways in which Medical discourses on health inequality not only influence ethnic categories and racialization within the Jewish ethnic group policy, they also influence patient conduct, mainly through doctor/ structure not only economic inequality, but also inequalities in patient interaction. Foucault's concept of “governmentality” as the political power and cultural dominance through the exclusion of “conduct of conducts,” emerging from the interaction between the “Mizrahi” Jews (Swirksi, 1981; Shenhav, 2003; Shohat, 1991). “technologies of power” and the “technologies of the self,” allows Moreover, religion and religiousness also influence inequalities us to understand the dual influence of discourse (Foucault, 1988; in health. Researchers have shown inequalities between secular Fries, 2008). Policies and government practices belong to the and moderately religious groups and the very religious Jews or former; especially taking into account the increasing role medicine Muslims (Idler, 2014) in cardiovascular morbidity, general plays in the machinery of power (Foucault, 1980). The latter in- morbidity, and life expectancy (Friedlander et al., 1985; Kark et al., cludes the ways in which physicians conceptualize health in- 1996). Finally, gender inequalities pervade the economic, cultural, equalities and frame individual patients' “operation”“on their own political and juridical fields (Byniamin, 2006; Dahan-Kalev, 2001; bodies and souls, thoughts, conducts, and way of being”, in order to Herzog, 2000; Yzreheli, 1999). attain a state of health (Foucault, 1988). As Foucault (1997) argues, Inequalities in health due to the unequal distribution of re- the “techniques of the self” are integrated into hierarchical struc- sources along the abovementioned axes exist since the State's first tures of domination. days. However, the health establishment became aware of health S. Avni et al. / Social Science & Medicine 144 (2015) 119e126 121 inequity and began to develop more coherent policies that address social issues to be their main focus. What we are interested in is the these inequalities only recently, as exemplified by the IMA's pub- ways in which health, illness, and disease are conceptualized, and lications in the second half of the 2000s, and the launch of a stra- to what degree and to what extent is the social dimension taken tegic national plan to reduce health inequality in 2010 (Israeli into account. Ministry of Health, 2010, 2011). The search for relevant articles from the scientific journal “HaRefuah” was completed via the “Pubmed Medical online data- 4. The Israeli Medical Association base”, using fifteen “Mesh Terms”. The terms we counted included those dealing with different aspects of inequality in health and As the only institutional representative body of physicians in healthcare. The search for relevant materials in the two other da- Israel, the IMA has been operating since 1912 as a labor union tabases was carried out by a systematic review of all items in the protecting the rights and professional interests of its members. At years specified. Ethical approval for the research was obtained. the same time, it also functions as a scientific and professional or- The research includes a quantitative assessment of references to ganization working to preserve the quality of medicine in Israel health inequalities in order to assess their salience vis-a-vis other (IMA, 2012a,b,c,d,e,f,g,h). The IMA is responsible for the planning topics, as well as their development over time, and qualitative and supervision of the physician specialization system in Israel and analysis of the discourse contents and characteristics (the explan- for continuing education programs in medicine. Thus, it possesses atory framework). Critical Discourse Analysis (CDA) was used to significant influence over physicians' education and more broadly, describe, understand, and analyze the various discourses on health on health policy. inequality. CDA studies the relationships among discourse, power, Rozin and Davidovitch (2009) analyze the historical role of the control, and social inequality and examines the structures, strate- IMA in supporting a privateepublic mix, for the provision of health gies and characteristics of text, conversation, verbal interactions, care, using “public healthcare system” rhetoric to achieve legiti- and communicative events (Van Dijk, 1993; Fairclough, 2003). macy. Additionally, they point to the ways in which the organiza- tion has reinforced the interests of the liberal-capitalist elite and 6. Results the contradictions inherent in the tension between promoting public health agendas and supporting privately-run services (see 6.1. Latecomer and marginal discourse also Ishai, 1990; Cohen, 2010). This internal tension is to be ex- pected from a complex organization, such as the IMA, whose A general search of the “HaRefuah” journal applying the “Mesh membership is comprised of an amalgam of associations (family Terms” produced 197 articles out of a total of 11,063, or 1.78% of all physicians, surgeons, specialists in internal medicine, public health references. Among the articles found using “Mesh Terms,” forty- specialists, etc.), with differing,- even contradictory,- interests and eight relate to the topic of this paper. The search results describe agendas. differences between or within different social groups in Israel un- The IMA was the first institution within the Israeli health der one of the following parameters: health outcomes, health establishment to call for a comprehensive national plan for conditions, self-reported health, health behaviors and exposure to reducing health inequality. In light of its role in supporting the risk factors for ill health, or availability and accessibility to health agenda of the Israeli elite and the neo-liberalization of the services. These articles represent a negligible percentage (0.43%) of healthcare system it is especially interesting to understand how the the total number of entries in “HaRefuah” between 1977 and 2010. IMA understands inequalities in health and how this understanding Among the forty-eight relevant articles, only six address health influences its policies. inequality as a primary research topic. A search for items on health inequality in the two other IMA 5. Methodology databases yielded similar results: In “Zman Harefuah,” health inequality as the main topic of the paper appears only eight times. The research at the basis of this paper received ethical approval With regards to public IMA documents, only one booklet directly by the Ben-Gurion University's Helsinki Committee. This paper addresses the issue, as well as five surveys and four additional presents an analyses of IMA discourse on health inequality between documents. In other words, among thousands of texts published by 1977 and 2010, through the examination of three databases-public the IMA from 1977 to 2010, only a very small number of items IMA documents (press releases, position papers, protocols) and two address health inequalities. IMA journals e its scientific journal, “HaRefuah” [Medicine], and Moreover, discussion or research on health inequalities has “Zman HaRefuah” [Annals of Medicine] previously named [A Letter emerged only recently. For example, of the six articles in “HaRe- to the Members], a non-peer-reviewed publication which ad- fuah,” one was published in 1990, and the remaining five were dresses professional issues. The selected period begins in 1977, the published between the years 2008e2010. first time the Labor Party lost government since the founding of the State, ushering a long-term process of health care privatization. It 6.2. Dominant biomedical and behavioral discourses was also the year in which the IMA shored up its position as the representative body of physicians and as a professional, scientific Through critical discourse analysis of the relevant articles, we body (Ishai, 1986; Schwarts, 2000; Cohen, 2010). In addition, identified dominant discourses alongside alternative discourses inequality in health-outcomes and in healthcare in Israel grew “competing” over the conceptualization of health inequality. These deeper during the late 1970's and early 1980's (Ishai, 1990; Rozin include biomedical, behavioral, psycho-social, materialist, and eco- and Davidovitch, 2009). The analyzed period ends in 2010, the social discourses. year in which the Ministry of Health published its first official A content analysis of the six relevant papers published in report on health inequality. “HaRefuah” which address health inequalities as their primary The articles published in “Zman HaRefuah” reflect the positions research subject, reveals the dominant variables that the authors and perspectives of the IMA as an organization. The analysis of “take into consideration” in an effort to characterize, describe, or “HaRefuah” illuminates both the worldview of physicians in Israel analyze the existence of health inequality. These include education, and editorial considerations. Since the two analyzed journals are socio-economic background (only in terms of place of residence, not in the field of social sciences, we do not expect society and and only marginally in relation to income inequality), differences in 122 S. Avni et al. / Social Science & Medicine 144 (2015) 119e126 the availability of health-care infrastructure and public vs. private distribution system,”“the need for an appropriate intervention funding of the health system (namely, the economic barrier, as program,” or “awareness raising”). Only one-fifth of the papers represented by copayments for treatments and medication). Vari- reviewed included structural solutions to health inequality. In line ables such as nationality, ethnic background, religiousness, with the eco-social approach, it stresses the need for an approach employment, working conditions, housing, environmental factors, aimed at the complex interaction between all processes responsible power relations, and political voice and influence, are marginal in for health inequalities (“promoting women's accessibility to higher the corpus of the texts, mentioned in passing and only in some of education,”“a need for all social systems to become involved the sources. Structural factors that influence inequality in health, (finance, education, welfare, environment, etc.”)). such as characteristics of the socio-economic structure, the labor Between 1977 and 2010, “Zman HaRefuah” published only market, the social safety net, and the presence and strength of labor eight articles in which the main subject was health inequalities. unions (Navarro et al., 2006) are scarcely mentioned. Although the Three of those were published in a special issue (JuneeJuly 2006) authors refer to the role played by the various social determinants “mainly dedicated to inequality in the health system in Israel” of health while explaining inequalities and discussing possible so- (IMA, 2006a,b,c). Four major themes emerge while analyzing lutions, they focus on the healthcare system, the role of medicine, these eight articles: The first are material variables that influence and the physician. Examples include the emphasis on differences in health and access to health services, such as poverty, or out-of- availability of medical personnel and clinics, on inequality in re- pocket expenditures on health and medication. The second ferrals to healthcare services, and on the need to expand the im- theme is an emphasis on health inequalities between residents in munizations provided by the national health basket so as to reduce the geographic periphery and Israel's center. The third theme is inequality in infant mortality. an emphasis on inequality in access to and utilization of health In more than half of the forty-two articles in “HaRefuah” in services rather than inequality in health status. The fourth theme which a discussion of health inequalities is subordinate to another is the description of physicians' personal experiences when main topic (such as a specific disease or health problem) the encountering health inequality. The articles that focus on the first dominant explanatory framework is either bio-medical, behavioral, three themes stress economic obstacles in accessing treatment or a combination of both. These articles use words such as “char- and services (forgoing treatment and medications because of co- acteristics,”“patterns,”“profile,”“prevalence,” and “behavior”,to payments), inequalities in the availability of medical personnel describe health inequality. In other words, most of these texts (mainly physicians); inequality in the geographic distribution of employ a bio-medical discourse. In line with a dominant trend in hospital beds; and the unequal distribution of medical Western medicine, they examine and describe illness, a “harmful” equipment. behavior, the appropriateness and availability of medical services to Most articles in “Zman HaRefuah” that address health inequality patients, or the ways in which patients utilize health care services. as a main topic explained inequalities as having stemmed from Health inequalities are “discovered” in the process of diagnosing individual differences in socio-economic status and place of resi- illness, as a kind of “side effect” that comes up in the process of dence (highlighting the limited availability of health professionals describing and analyzing the phenomenon. Inequalities are and technology in the periphery). There were hardly any references described as a background feature among many other, more sig- to the structural causes of individual differences in socio-economic nificant ones. Moreover, variables used to measure inequality rarely status nor references to parameters such as employment and make reference to employment, nationality, or ethnicity. employment conditions (with the exception of one article which Few articles point to the presence of alternative materialist and addressed exposure to dangerous substances in the workplace), eco-social discourses, which compete with the biomedical and housing, access to water and sanitation infrastructure (excepting behavioral discourses. Among these are texts that address issues one article on air pollution), and to the wider political structures related to the structure of the health system, its funding, and the (discrimination, exclusion of minority groups, structure of the labor relationship between structural socio-economic characteristics market). The ethno-national dimension, a critical component of (such as relative income, the structure of the welfare system, Israeli society, is de-emphasized (Bedouin Arabs are only margin- characteristics of the political system, etc.), and health inequality. ally mentioned in an analysis of the southern periphery). As the For example, the papers “Challenges in the fair redistribution of following quote demonstrates, the focus is almost exclusively on health resources” (Ben-Basat, 2003)or“Medical ethics and health the spatial aspects of health inequality: economics in a time of shortage” (Afek and Ben Nun, 2009). Other “There are inequalities in almost all health indicators between texts address doctorepatient relations and the complex interaction different social groups, differences stemming from their socio- between social status, class and health or therapeutic outcomes. For economic status … one of the problems in Israel is the great example, the paper “The doctor and the poor patient” difference in public health between different geographical re- (Monnickendam and Monnickendam, 2010). Additional articles gions. [Concerning] infant mortality rate in Israel there is up to analyze the connections between a given medical phenomenon seven times the gap between different regions, not only be- (such as hospitalization or suicide) and its possible social causes tween the Jewish population and the Arab population, but (i.e. education level, employment, ethnicity, place of residence). For among different Jewish populations as well. In the south, infant example, “The impact of education and ethno-nationality of the mortality of Jews and Arabs is severely high. These differences mother on different health measures of children in the Haifa dis- stem mainly from differences in levels of education between trict” (Habib et al., 2005). groups”.(IMA, 2005a,b). Most of the papers the IMA's medical journal propose biomed- ical or behavioral solutions to health inequalities. Some texts un- derscore treatment or medical solutions such as “safeguarding by Two interesting themes arise from our look into “Zman Hare- medical staff,” or “screening and early diagnosis” and solutions fuah.” The first is the disregard for egalitarian approaches to health focused on improving health services, such as “checking the inequalities, for example the claim for equal access to health care, availability and accessibility of the health system.” Other papers as utopian or “Bolshevik”. This approach appears mostly in articles emphasize the need for behavioral changes within the population discussing private medical practice, articles that support private or among health-care providers (“changing behavior patterns healthcare services as a legitimate complement to the public sys- among women and their physicians,”“changing the information tem, and support various forms of private/public mix. The S. Avni et al. / Social Science & Medicine 144 (2015) 119e126 123 possibility of equal access, availability, and utilization of health financing of health services; a booklet entitled, “Medical Ethics: services is presented as an unreal, utopian dream. For example, Guidelines and Position Papers,” which includes a chapter on “Inequality in Medicine,” focusing on the role of the physician in “… [B]ut unfortunately, in the present public discussion the addressing inequality; “The Israeli Health Folder” (“Ogdan HaB- terms have gotten mixed up and it was penetrated by more than riut”), includes a chapter describing health inequality in Israel; a few emotions, apologetic overtones, a miniscule level of finally, “Circles of Action,” a brochure summarizing the activities of honesty and any real desire to solve the problem, and a second the IMA between 2005 and 2009 includes a chapter on IMA actions helping of demagoguery. This article does not pretend to in addressing health inequality. address the serious problem at hand … but rather at the Some prominent re-occurring themes appear in these texts: a demagogic aspect that frequently borders on hypocrisy … It is a special emphasis on geographic inequality of the center vs. the fact that “equitable healthcare” has never existed. In the field of periphery; a focus on inequality in provision, availability, and medicine, as in other fields, there has developed in recent years accessibility of health services; and a reference to material causes of a Bolshevist attitude that maintains equality for “the common health inequality (i.e. differences among high and low-income people,” alongside the privileges of the ruling “nomenklatura” groups). The following quote exemplifies the first theme: (IMA, 1986). “Last July, at the IMA's initiative, the Periphery Sub-Committee chaired by MK Miri Regev held a special session on the severe The second theme is the emphasis on “freedom of choice” e i.e. inequality in the periphery … In the session, the IMA presented access to private medical care e over equitable access to health up-to-date data on health inequality and suggested proposals care. The IMA's commitment to promoting the medical elite's in- for reducing inequality between the center and the periphery in terests leads to an emphasis on liberal values emphasizing the accessing health services” (IMA, 2012a,b,c,d,e,f,g,h). patient's individual autonomy and liberty (Rozin and Davidovitch, 2009). Demands for equal access to health care are subordinate to support for private medicine: How does the IMA explain inequality in health? The Associa- tion's key 2008 document suggests an eco-social view of inequality. “Even those opposing the private medical care in hospitals don't It references specific parameters such as socio-economic status, wish to prevent private medicine, and most likely, prevention level of education and of employment, housing, access to water and would have been against our founding principles, mainly the sanitation infrastructure, and access to health services. While these right to try and achieve the best for one's health.” (IMA, 2000) points are indeed applicable and relevant, the IMA falls short of addressing mechanisms of social stratification such as class, citi- These references exist in parallel and in contradiction to articles zenship, national belonging, or ethnicity. Moreover, each of the dealing with obstacles in access to health care services. On one texts mentioned above, focus solely on the individual. The social hand, the IMA criticizes the existence of economic barriers that determinants of health are presented as neutral “characteristics,” hinder access to the public health care system and warns about the eluding any reference to the ways in which unequal access may be connection between individual deprivation and limited access to the result of power relations and structural injustice. Furthermore, health care services. On the other, the IMA justifies the existence of the texts primarily emphasize healthcare system issues considering private healthcare services, and firmly supports forms of private/ health services as the main locus for intervention. For example, in public mix, which result in unequal access to the public health the publication “Medical Ethics: Guidelines and Position Papers,” system. While inequalities in health convey a challenge e even in a the ethical guidelines laid out in the chapter entitled, “Inequality in fully public system -, the fact that the Israeli health care system, Medicine” emphasize “inequality in the accessibility to means of which historically was founded on the principles of a strong public diagnosis and medical care,” and inequality in “medicine, especially system, has been exposed to strong and effective privatization in the geographical periphery.” They do not note any of the deeper forces, worsens the situation. societal or systemic origins of the issue. Since 2003 and through to 2007, a growing number of IMA's The IMA public documents that focus on health inequalities public documents have addressed heath inequality, mainly acknowledge social determinants as key health influencers. Refer- focusing on inequality in healthcare. At the same time, other public ring to the need to decrease health inequality, public documents IMA documents address specific issues, which influence health include proposals to develop a national strategic plan supported by inequality, such as co-payments and reforms in the national health- a coordinated effort among various ministries. In these documents, care system. the IMA also proposes making concrete advances in the provision of In 2007, the IMA established a committee to examine the ways healthcare services (improving the geographical distribution of in which to address health inequality in Israel. In 2008, the IMA services, decreasing co-payments, improving the cultural compe- published the Committee's Report, the IMA's key text on health tencies of health care providers, etc.). inequality. The report asserted that “health inequality in Israel is However, and in contradiction with these suggestions, the IMA rising, and with it morbidity and mortality rates.” In 2010, the IMA claims that dealing with the social determinants of health is not the promoted a hearing in the Knesset Finance Committee's Subcom- physician's responsibility, nor is it within the physician's scope of mittee on the Periphery on the prevalence of inequality in the action. It is acceptable to assume that individual physicians are not periphery (The Israeli Knesset, 2012). responsible for intervening in concepts and conditions relating to The IMA also distributed a number of additional publications the social determinants of health. However, as an organization, addressing health inequality, as follows: five surveys on the educating about the importance of social determinants, and col- accessibility of health services in Israel emphasizing economic lective action for a more equal distribution of these determinants, obstacles for the poor in accessing healthcare, access to health care are options that the IMA does not sufficiently consider. Moreover, for residents in the periphery, children and the elderly; a paper in suggestions mentioning the need to address the social de- which the IMA suggests the adoption of an “Israeli National Health terminants of health (such as education, income, and political Index”, with a section on health inequality that includes sub- structures) remain abstract and general (“a need to reform social/ sections on health conditions, accessibility of health services, and economic policy”), and do not translate into concrete policies. With regards to the IMA's public documents that address health 124 S. Avni et al. / Social Science & Medicine 144 (2015) 119e126 inequality as a secondary topic, we find two re-occurring themes: This contradictory dual stance influences IMA policy on health The first is a dual approach towards the privatization of healthcare inequalities. This is reflected in the way the IMA practices and systems. The IMA opposes privatization of some healthcare services promotes two forms of public campaigns. It campaigns for the such as mother and child centers and primary-school health ser- expansion of the national health basket, against privatization of vices (where care is provided mostly by nurses). On the other hand, motherechild centers and against the privatization of medical it strongly promotes forms of private/public mix, such as the pro- services in pre-schools, issues that do not clash with the medical vision of private medical services in public hospitals and the community's professional or economic interests. At the same time, deregulation of private health care. The second relates to its sup- it counters campaigns dealing with issues which threaten physi- port for the different forms of private medicine and includes an cians' professional or class interests, such as its campaign against emphasis on liberal and individualistic values, such as the right to the inclusion of dental care, as well as mental health services, in the choose a doctor, the right to bodily autonomy - even at the expense national health basket. In these cases, the IMA's main priority is of increased inequality in access to healthcare services. protecting the professional and economic interests of its members (fewer patients will buy dental care and mental health care services 7. Discussion from physicians in the private market following their inclusion in the national health basket), even at the expense of deepening in- The analysis of the various journals and documents demon- equalities in access to health care services. strates that all of the main frameworks used to explain inequalities The characteristics of IMA discourse on health inequalities in- in health, bio-medical, behavioral, psycho-social, material and eco- fluence the construction of inequality in health as a social problem, social frameworks, are indeed employed, with bio-medical and the the phenomenon's interpretation, its limits and boundaries, the behavioral discourses taking a much more central and significant interpretation of its causes, and the proposed solutions (Bacchi, role than the others. 1999; Weedon, 1999). Because of the central role physicians' play Of the IMA texts that deal directly with health inequality, most in the healthcare system, the IMA's discourse on health inequality consider a wide-range of conditions that affect health. We found influences not only the organization's own policies, but also those references to the impact of individuals' level of education, socio- of other key stakeholders, namely, the Israeli Ministry of Health, economic status, and place of residence, on health. However, where physicians hold many of the top positions. Thus, although as those issues are framed by the centrality of an individualized gaze stated above, there is a difference between discourse and policy, that stresses biomedical and behavioral characteristics. More IMA discourse on health inequity has served as a key influencer of importantly, when addressing and explaining inequalities in health the Israeli Ministry of Health's approach to inequalities in health, as only a minority of references mention class and the ethno-national well as on policies regulating private practice. divide, though these are dominant causes of inequalities in health We can confirm this influence by looking at the Ministry of in Israel. Moreover, there are only a few mentions of education, Health's first report on health inequalities, published only in 2010. housing, employment, religion and religiousness, and gender. Its similarities with the IMA's conceptualization of the issue are When the medical profession addresses questions of poverty or worth noting. As in IMA documents, socio-economic causes of in- socio-economic status, it considers both at the level of the indi- equalities in health and the effects of class or the structure of citi- vidual, without accounting for the social structures and social zenship that discriminates against Israeli Arabs are addressed processes that produce them. This approach is especially striking indirectly, mainly through universal actions that have the potential with regards to IMA discourse on measures to decrease inequality. to affect these axes. The Ministry of Health report also focuses While references refer to the need for different government mainly on health care services as the way to deal with inequalities agencies to work together (such as the Ministries of Welfare and of in health. As IMA publications, the MOH report tends to overstate Education) and point to the need for broader policies that address the role of culture and behavior, and emphasize the geographical health inequalities, the main tendency was to suggest a medical divide between center and periphery as a major axis of inequality. solution: changing behaviors at the individual level, modifying Thus, the proposed policies include culturally sensible services, the practitioner behavior, and redistributing health-care personnel and expansion of the national health basket to include dental care in the infrastructure. health basket; the restriction of private health expenditure; Another characteristic of IMA discourse on health inequalities is reducing inequality in the availability of infrastructure in the its contradictory approach towards the role of private practice and geographical periphery, reducing co-payments, and adding a the private/public mix. As we saw above, the IMA opposes priva- geographical parameter to the resource allocation formula that tizing certain public services, while strongly supporting the private distributes funds among the health funds. provision of medical services within public facilities. The IMA's Summing up, we can see that the Israeli medical profession's approach to questions related to the provision of healthcare ser- conceptualization of health inequalities that individualizes and bio- vices that affect health inequality is defined, constituted, and medicalizes its causes, blurs the contribution of the class structure limited by its commitment to the medical community's profes- in neo-liberal Israel, and applies the hierarchical structure of citi- sional and economic interests. Thus, the IMA stresses freedom of zenship that discriminates against Israeli Arabs, to inequalities in choice and individual autonomy over a more equitable redistribu- health. Consequently, the proposed policies do not include mea- tion of medical services. sures to address these power relations “head-on”. Thus, the Israeli The contradiction between the IMA's call to address health case exemplifies the ways in which certain discourses on health inequality, coupled with its strong support for private healthcare inequality, while bringing public attention to the topic, have the stems from its dual role as a professional organization committed potential to paradoxically contribute to the perpetuations of these to the profession's ethical framework of defending the interests of inequalities, or at the very least, contributes to the status-quo. all patients on one hand, and its commitment to physicians' interest in preserving their professional freedom and their economic op- portunity, on the other. This tension is reinforced by the IMA's References dynamic and complex character as an organization that includes an Afek, A., Bin Nun, G., 2009. 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