Global health CASE REPORT Ethiopian-Israeli community Jonah B Cohen Medical School for SUMMARY had matrilineal Jewish roots. These individuals were International Health, Ben- The Ethiopian-Jewish community in Israel is an unable to legally immigrate to Israel until this reso- Gurion University of the Negev, 8 Beer Sheva, Israel immigrant population numbering 131 400 as of 2012. lution. Concerns regarding the Jewish character of Many arrived from 1980 to 1992 by airborne operations this group and political pressure on the Rabbinate Correspondence to coordinated by the Israeli government. Immigration was prevented their earlier absorption with other Jonah B Cohen, prompted by Israeli recognition of the community’s Ethiopians.2 According to a 2012 census, the [email protected] Jewish citizenship eligibility status. This period in Israel’s Ethiopian-Israeli population in Israel reached 9 Accepted 18 August 2016 history saw the First Lebanon War, the First Intifada, the 131 400 members. Gulf War and the beginning of Soviet Jewish During the waves of Ethiopian immigration, immigration. The Ethiopian community faced difficult Ethiopia harboured environmental, political and integration, cross-cultural misunderstandings and the social turmoil; famine in Ethiopia led to food inse- development of chronic disease, due to lifestyle changes curity in the region.5 Militant rebel groups led a and differences in cultural beliefs. These factors violent insurrection to overthrow the Marxist significantly affect the community’s health. Governmental Ethiopian government. Prior to Operation and non-governmental organisations have sought to Solomon in 1991, the militant groups marched improve the quality of life for Ethiopian Israelis through towards and sought to conquer the government- empowerment and education. Enhancing societal controlled area around Addis Ababa, where many integration, augmenting cross-cultural communication Ethiopian Jews happened to be located. The and understanding and instituting community-based Ethiopians (as well as members of other minority health projects are essential in improving the health of groups) experienced marginalisation by the ruling this community. Successful healthcare intervention regime and faced restrictions on religious worship. requires a biopsychosocial model of analysis and usage With these conditions and the threat of continued of a culturally appropriate context. violence, the Ethiopian-Jewish community sought to leave Ethiopia in hopes of a better life. Israel, the embodiment of modern Zionism and a demo- cratic state harbouring Jewish values, became the CASE PRESENTATION clear destination. The Ethiopian-Jewish community in Israel is a Differences in cultural beliefs and practices posed unique segment of the Israeli population that largely challenges for integration into Israeli society and immigrated in waves from 1980 to 1992. high-quality provision of healthcare. The immi- Approximately 50 000 Ethiopian Jews arrived in grant Ethiopian-Israeli community presented with Israel during this period.1 In 1984, many Ethiopian symptoms of illness and perceptions of health, Jews traversed from Ethiopia to Sudan under hygiene and medication that varied from the Israeli demanding and deadly circumstances in hopes of biomedical norm.10 Western medicine was an reaching Israel.23Those who had escaped famine in unfamiliar concept to the Ethiopian immigrants.5 Ethiopia and survived the journey to Sudan faced These issues, coupled with the difficulties experi- malnutrition in Sudanese refugee camps. Many suc- enced by Israeli clinicians in recognising health con- cumbed to illness.4 Earlier in 1975, the Chief cerns and treating Ethiopian patients, highlight the Rabbinate of Israel ruled that Ethiopian Jews were value of effective cross-cultural communication and eligible to immigrate to Israel under the Law of understanding. The prevalence of diabetes, a result Return, Israel’s Jewish immigration policy. The of stark changes in physical exertion and dietary Rabbinate has influence in certain political and social conditions, was shown to be markedly higher functions of Israeli government, as they relate to trad- within the Ethiopian-Israeli community in compari- itional orthodox religious law.5 The ruling, coupled son to the greater Israeli population.11 The overall withreportsoffatalitiesintherefugeecamps, health of the Ethiopian community changed on prompted Israel to covertly exfiltrate Ethiopian Jews immersion into Israeli society. to Israel in a mission called Operation Moses.2 The second large-scale airborne operation that brought Ethiopian Jews to Israel, titled Operation Solomon, GLOBAL HEALTH PROBLEM LIST was conducted in Addis Ababa, Ethiopia, in 1991. ▸ Challenges in societal integration This operation occurred concurrently with the start ▸ Cross-cultural misunderstanding of the wave of Soviet Jewish immigration.6 ▸ Diabetes and chronic disease Throughout this period of Ethiopian immigration, To cite: Cohen JB. BMJ Case Rep Published online: Israel faced the First Lebanon War, the First Intifada GLOBAL HEALTH PROBLEM ANALYSIS [please include Day Month and the Gulf War, when scud missiles fell in Israel.7 Challenges in societal integration Year] doi:10.1136/bcr-2016- In 2003, a resolution to the Law of Return granted The difficulties encountered by Ethiopian-Israeli 216074 citizenship eligibility for Ethiopian Christians who citizens are indicative of challenges faced by Cohen JB. BMJ Case Rep 2016. doi:10.1136/bcr-2016-216074 1 Global health immigrants, refugees and communities that have undergone a was eligible for immigration under the Law of Return, the dramatic shift in their geographical and cultural context.1 emphasis on conversion was an attempt to fully embrace the The change in lifestyle from Ethiopia to Israeli absorption community as Israeli Jews, as the Israeli orthodox religious sect centres and cities led to culture shock and social upheaval in the specifically perceives Jewish identity.25Tension soared when the community.11 The extended family support structure that public discovered that from 1984 to 1996, blood donations existed in Ethiopia shifted into the nuclear family model, cul- from Ethiopian Israelis were being eradicated by the Magen tural rifts emerged between younger and older generations of David Adom (MDA) Israeli blood bank. According to MDA, the Ethiopian Israelis and traditional physical and dietary habits goal was to protect donation recipients from infectious blood- eroded. Ethiopian men, who historically performed agricultural borne diseases that were prevalent in Ethiopia. Many in the work in Ethiopia and were considered the head of the family in Ethiopian community felt as though they were perceived as the traditional Ethiopian patriarchal system, became second-class citizens that posed a danger to Israeli society. unemployed or worked in low-income jobs.10 The absorption Efforts to conceal the practice of blood donation rejection centres, coordinated by the Israeli government, sought to orient added insult to injury. Initiatives to successfully integrate Ethiopians to Israeli society and address health concerns such as Ethiopian Israelis into all levels of Israeli society while encour- infectious diseases.6 Ethiopian Jews were sent to these centres aging the maintenance of Ethiopian heritage and identity are on arrival in Israel. crucial. Efforts were made to further integrate Ethiopian Jews into Despite successes with efforts to integrate Ethiopian Jews into Israeli society, with variable success.5 The Israeli government Israeli society, socioeconomic gaps still exist.12 Statistical data promoted settlement into apartments and permanent living were collected by the Joint Distribution Committee and pre- facilities following a period in the absorption centres. In order sented in a 2012 report on the status of Ethiopian Israelis. to prevent clustering and ghettoisation of Ethiopian Israelis in Discrepancies in economic, educational, employment and family specific locations, and in the hopes to better integrate the status between Ethiopian Israelis and the greater Israeli popula- Ethiopian community within the broader Israeli society, the gov- tion were prevalent. This leaves room to strengthen pre-existing ernment encouraged settlement in various cities and provided initiatives and create novel programmes that address these grant and lone incentives. However, likely due to the Ethiopian issues. population’s strong family and community structure, extended families tended to settle together in the same location. This Determinants of health of the Ethiopian community in Israel highlights the issue of governmental integration efforts in con- Social determinants of health flict with immigrant community structure and psychosocial Shavu Banim is an Ethiopian cultural centre in Beer Sheva, health. On one hand, the distribution of Ethiopian Israelis Israel, that provides social and cultural services to the among non-Ethiopian Israelis may promote and hasten immer- Ethiopian-Israeli community.13 This organisation seeks to cele- sion into Israeli society, with increased interaction with presid- brate and preserve Ethiopian heritage, bring together and ing Israelis and greater familiarisation of cultural nuances. On empower the Ethiopian community in Beer Sheva and enhance the other hand, disruption of the traditional Ethiopian commu- the integration of Ethiopian Israelis, all of which can be sup- nity structure, undoubtedly a protective factor in mental health portive in