While staff members acknowledged an ethos of medical neutrality in which they were expected to treat all patients the same, they also recognized the differing health status of Arab patients. However, studies of medical neutrality have deconstructed claims to a position outside of politics. Many medical staff explicitly reproduced cultural stereotypes of Arab patients as alternatively highly respectful, on the one hand, or dramatic and violent on the other. Forces of compassion: humanitarianism between ethics and politics. The staff can engage in promoting varying structural-political solutions, according to their diverse perspectives, values, and beliefs. PubMed American funding cutback to East Jerusalem hospitals: a blow to the health of the city. Culture is perceived as unrelated to the conflict and therefore healthcare professionals feel comfortable using it. 2017;17(407):1-7. Multiple participants described the ethos of medical neutrality by invoking instances when a perpetrator and victim of a terror attack were brought to the same ED. EAA provided feedback and revised the manuscript. Midwifery. Physician 1 said, Even the stabber and the person stabbed can be lying in adjacent beds, separated only by the space necessary for providing treatment and they both receive the same level of treatment at the same time, without any difference, with the same degree of care. For this and other interlocutors who described similar scenes, it seemed to be a particularly meaningful way of communicating the power of biomedical and humanitarian ethics and differentiating this orientation from the "political," which may in this example involve a military or security response (cf. 2021;20(117):1-9. They target factors such as economic instability, limited educational and employment opportunity . They are served by the city's three major general hospitals as well as smaller Palestinian hospitals in East Jerusalem. In this context, some of the participants noted the fact that the language gaps prevent continuity of care between the ED and the community. With this institutionalization, the ED medical staff confront the effects of conflict in their everyday work while also ostensibly being positioned outside of it. When clinicians dismiss structural factors as peripheral, they not only miss opportunities to improve health outcomes, but may also "fail at medicines core responsibilities to diagnose and treat illness and to do no harm" [23]. N Engl J Med. The transportation infrastructures are insufficient and often unsafe, e.g., lack sidewalks and safety barriers [41]. Structural competency: curriculum for medical students, residents, and interprofessional teams on the structural factors that produce health disparities. Bruen C, Brugha R. A ghost in the machine? The official narrative of the hospital and the department is apolitical, neutral, striving to provide equal care to all, regardless of national identity or background. The authors declare that they have no competing interests. This naturalization entails ignoring the social and political origins of health disparities [57, 58]. Similarly, according to the accepted narrative, efforts are made to leave the Israeli-Palestinian conflict outside the hospital perimeters, and that policy is characteristically upheld. 2015;14(63):1-7. 2014;103:12633. Question: Compare and contrast how a structural-functionalist and a conflict theorist might approach the study of health and illness differently. The World Health Organization (WHO) describes social determinants as 'the non-medical factors that influence health outcomes. The unequal distribution of these indicators is further treated as the 'fundamental cause' of . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Metzl et al. ZO, EAA, and MDF conceived, conceptualized, and designed the study and created the interview guide. Metzl JM, Maybank A, de Maio F. Responding to the COVID-19 pandemic: the need for a structurally competent health care system. 2019;73(2):20723. Recall that social aging refers to changes in people's roles and relationships in a society as they age. The forces of production and the social relationship to this form the economic basis or infrastructure of society. These questions are examined in the context of the Israeli-Palestinian conflict. The research participants' reluctance to discuss structural-political issues goes hand in hand with their emphasis on cultural explanations, including in the case of HY. According to Physician 7, Arab women come into the ED as if they have fainted and are about to die. Nurse 9 noted that HY is more frequent among young Arab women. 2 The interpretative narrative analysis included several stages. Daoud N, Alfayumi-Zeadna S, Tur-Sinai A, Geraisy N, Talmud I. Denial and silencing of political conflict often divert attention away from the structural (upstream political, policy, economic, legal) causes of health inequalities and, instead, attribute inequalities to cultural and biological characteristics [2]. What are structural and social determinants of health? 2018;108(12):16245. The SDH have an important influence on health inequities - the unfair and avoidable differences in health status seen within and between countries. Feminist theory aims to highlight the social problems and issues that are experienced by women. For example, higher levels of income inequality (the degree to which income in Int J Equity Health 21, 89 (2022). Pat-Horenczyk screened 1,010 adolescents in Jerusalem and nearby settlements who were subjected to intensive terrorist attacks in the context of the Al-Aqsa Intifada. This article contributes to the literature on depoliticization and structural determinants of health by analyzing how medical staff in a Jerusalem Emergency Department (ED) discuss the ethos of medical neutrality. Structural vulnerability: operationalizing the concept to address health disparities in clinical care. Raising the staff's awareness to additional conflict-related determinants that affect their Arab patients, determinants to which they are less directly exposed in the ED, can be an effective element in a structural competency training. Hamayel L, Hammoudeh D, Welchman L. Reproductive health and rights in East Jerusalem: the effects of militarisation and biopolitics on the experiences of pregnancy and birth of Palestinians living in the Kufr Aqab neighbourhood. Likewise, staff members recognized that Arab patients are more likely to experience poverty, and that poverty is detrimental to health, but did not make the connection to structural determinants. 2016;35(3):291304. The case of Jerusalem and the Israeli-Palestinian conflict contributes to bridging this knowledge gap. 2022;61(101131):1-7. These inequalities likely reflect residential segregation and can be reduced by changing government policies [30]. Participants mobilized multiple forms of explanation to account for distinctive health characteristics of Arab patients, generally without reference to conflict as a structural determinant. West Bank | East Jerusalem: key humanitarian concerns. Collier J, Kienzler H. Barriers to cardiovascular disease secondary prevention care in the West Bank, Palestine a health professional perspective. Provided by the Springer Nature SharedIt content-sharing initiative. Israeli medical teams often refuse to enter certain Palestinian neighborhoods in Jerusalem without a police escort due to fear of violence. "Many of our greatest global and social problems today - from health inequity to climate change to political and economic instability - have structures at their core: systems, institutions . 2019;380(25):23859. 2022;17(3):34162. Using a biopsychosocial approach to examine differences in post-traumatic stress symptoms between Arab and Jewish Israeli mothers following a childs traumatic medical event. When studying structural violence, we examine the ways that social structures (economic, political, medical, and legal systems) can have a disproportionately negative impact on particular groups and communities. 1. By 2017, 75% of the Palestinian families in Jerusalem were living below the poverty line, compared to 22% of Jewish families [41]. politics in global health policy. The ethos of medical neutrality, as well as the professional field of emergency medicine, have their origins in treating the war-wounded. We suggest that the normative demand for neutrality is an under-appreciated yet important aspect of how political conflict operates as a structural determinant of health. Seventy-Second World Health Assembly, 1 May 2019. Article But in my heart, I do feel that I am doing something with which I feel an internal dissonance. This staff member repeatedly emphasized that these opinions were personal and did not represent the state of affairs in the ED. Connecting between poor health and "problematic" cultural or behavioral traits implies a tendency to "blame the victim." [] They think that the condition will simply disappear; they can take a lot; they are strong and resilient.. During pregnancy, they are exposed to risky conditions and experience increased fear and anxiety. How is Society Constructed? Int J Equity Health. 2020;19(56):1-9. 2021;20(89):1-12. We approached all the department's physicians, nurses, physician assistants, and student employees (approximately 130 staff members) and 24 (18.5%) agreed to participate in the research. The severe poverty in East JerusalemFootnote 3 derives from various structural determinants, including the West Bank barrier that separates many Palestinians in East Jerusalem from Israeli or West Bank economies, checkpoints, and other restrictions on Palestinians' mobility, planning and housing policies, the lack of citizenship status, limited access to social and welfare services, and discrimination in the labor market [41, 64, 65]. Physician 7 noted, I have more than a few cases of Arab patients who are re-hospitalized and it turned out that they simply did not comply with the treatment as directed after the first hospitalization; thus, their condition continues to deteriorate, which is something I noticed happens more frequently in this population than in any other. He attributed this difference to language gaps and to the fact that patients do not receive a proper explanation from the hospitals medical staff: Either they do not always receive an explanation or they do not always understand what they are told; it depends on the case. Nurse 5 emphasized the gaps in knowledge and perception as the reason for poor medical compliance: They do not quite understand how important treatment is. Interestingly, the staff did not address the issue of Arab patients' delayed arrival to the ED due to checkpoints and Israeli ambulances avoiding entering certain Palestinian areas in East Jerusalem, despite the direct relevance of this issue to ED practice. However, irregular migrants, migrant workers, asylum seekers, and other undocumented people are not covered by the National Health Insurance Law [26, 27]. In their most recent report published on May 25, the Safeguarding Health in Conflict Coalition and Insecurity Insight document more than 1900 incidents of violence against health care in war and situations of political unrest in 2022, a 45% increase compared with 2021 and the highest number since they began collating data 10 years ago. In the Ethnicity & Disease supplement "Structural Racism and Discrimination: Impact on Minority Health and Health Disparities" , the editors and authors highlight the need for a broader approachone that addresses the interconnected systems perpetuating racism and other forms of discriminationto reduce health disparities. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health. Nuseibeh RA. Pat-Horenczyk R. Post-traumatic distress in Israeli adolescents exposed to ongoing terrorism. Claims to neutrality in the medical sphere also operate as a powerful justification for ignoring unequal conditions that shape health for non-Jewish Israelis [15]. Ben-Gurion University of the Negev; 2020. [] This [catastrophic lifestyle] is evident also in the number of vehicular accidents: the way they drive is much more dangerous. In addition, participants associated Arab patients with traumatic injuries related to interpersonal violence and accidents. Louis M, Maertens L. Why international organizations hate politics: depoliticizing the world. These practices, in the view of participants, reflect poorer quality healthcare available for Arab patients in East Jerusalem and lower levels of knowledge about how to properly use the HMO. This is forbidden anywhere else in Israel, except for East Jerusalem [63]. Abuelaish et al. Some of the interviewees tried to explain what they perceived as aggressiveness, expressed by Arab patients, as well as the respect that they show the medical staff. ZO and MDF reviewed the literature. Critically assess these three theories. 2006;118(2):3839. For example, in these neighborhoods in North-East Jerusalem, there are no Family Health Centers (Tipat Halav)Footnote 1 [48]. When politics are sacralized: comparative perspectives on religious claims and nationalism. This includes how they view and address the limits of neutrality and how the boundaries of universal professional medical ethics are negotiated and even challenged. An analysis of social determinants of health and structural competency training in global emergency medicine fellowship programs in the United States. Those are terrible days. In Israel, the supposedly depoliticized approach is dominant. Holmes S. Fresh fruit, broken bodies: migrant farmworkers in the United States. Among other things, these women need to cross checkpoints to give birth in Jerusalem hospitals for their children to be eligible for permanent residency. All methods were carried out in accordance with the relevant ethical guidelines and regulations, including the Declaration of Helsinki. Refusal to be interviewed was usually explained by lack of time or unwillingness to discuss this study's issues. The language of culture is therefore preferred and prevails among most of the ED staff. They pretend to take the treatment seriously, but actually, they all know that this is how things are done., Nurse 9 also pointed out the risk of adhering to stereotypes during medical treatment: There were cases that were diagnosed as hysteria and turned out to be something completely different, such as hypoglycemia or things like that. Physician 6 reported that, among the ED staff, there is a stereotype of Arab women who complain of nonorganic symptoms. However, he too stated that this stereotype may lead to misdiagnosis that would risk the patient: Sometimes it is possible to miss serious diagnoses.. PubMedGoogle Scholar. 04/2017 on the subject of operating clinical services through external providers, October 18. While medical staff in the ED identified unique health risks for Arab patients, most did not associate these risks with the effects of conflict and instead explained them in depoliticized terms of culture and behavior. In recent years, there has been a revival of the term "structural violence (SV)" which was coined by Johan Galtung in the 1960s in the context of Peace Studies. 2018;75(2):1178. The supposed political neutrality of medicine is undergirded by the epistemics of biomedical sciences, which represent health, disease, and suffering through universal categories [4], which inflect medical education and practice with universalist assumptions [5, 6]. These forces and systems include economic policies and systems . They all get the same treatment. Physician 8 described the interpersonal interactions following the rare occurrence of snowfall in Jerusalem as a representative instance of coexistence in the city and compared this to the hospitals functioning: There are generally two circumstances when Arabs and Jews tend to get along with each other: in the hospital, because we're all in the same boat, [] and when it snows and people go sledding, then everybody gets along.. Nurse 3 said, We are no angels, but especially not on days following an attack. London: Routledge; 2021. Healthcare personnel, especially in the ED, should be trained in structural competency to better understand the fundamental influences on patients' health [71]. Neff et al. In certain Palestinian areas, the residents have to use the Palestinian Red Crescent Ambulance Service which provides Basic Life Support only. AEM Educ Train. BMC Health Serv Res. They come expecting to see that someone else is being treated better than them: Why is he in a bed inside the room while I am sitting out here [in triage]? I think that is one of the reasons patients become violent. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. This official narrative could be detected in the responses of several interviewees. While participants identified unique health risks for Arab patients, they usually did not associate these risks with the effects of conflict and instead explained them in depoliticized terms of cultural and behavioral differences. Which . The social detriment of health features a higher impact on population health than healthcare. Unger S, Orr Z, Alpert EA, Davidovitch N, Shoham-Vardi I. This training will allow them to move beyond the understanding of social determinants of health, such as poverty that was pointed out by many research participants, to comprehending the underlying structures that create and perpetuate the poverty of the Arab patients. The poverty, as well as the knowledge and language gaps, the lack of health education, and the poor treatment compliance described by the staff, are associated with a lower level of education in East Jerusalem that is caused by policy and conflict-related factors. In: Lock M, Gordon D, editors. Hyperventilation is a medical diagnosis of acute physical symptoms such as shortness of breath, chest pains, and loss of consciousness, which tend to occur in conditions of extreme mental stress, which is often referred to in the ED as hysteria. The ethos of neutrality has been credited with enabling healthcare to become one of the most diversely integrated sectors [6]. assert that although conflict always affects health, public health and health promotion experts have often failed to recognize the interrelations between health and peace [24]. Part of Orr Z, Machikawa E, Unger S, Romem A. Residential segregation, neighborhood violence and disorder, and inequalities in anxiety among Jewish and Palestinian-Arab perinatal women in Israel. This population of approximately 120,000140,000 residents constitutes 33%-39% of the citys Arab population of 359,000 residents. However, this "fiction of standing outside battle (hors de combat)" [3] may strengthen the naturalization of inequality as it attributes health disparities and inequity to the behaviors or innate characteristics of individuals or groups [53, 57, 58]. The politics of evidence: from evidence-based policy to the good governance of evidence. Inequities in health are socially determined, preventing poorer populations from moving up in society and making the most of their potential. Naturalizing inequality refers to the "ways in which health disparities are often attributed to the behaviors or innate characteristics of the individuals or groups of people most affected by these disparities" [53]. Moreover, the poor infrastructures in East Jerusalem impact peoples health and safety. Managing cultural diversity through multiculturalism in NGOs for social change: an Israeli case study. Medical neutrality describes an ethos in which medical personnel and their patients are positioned outside of the field of politics. Structural family therapy (SFT) is a type of family therapy that looks at the structure of a family unit and improves the interactions between family members. The interviewees did not discuss these structural determinants. The Israeli-Palestinian conflict, directly and indirectly, affects the life and health of Palestinians living in East Jerusalem in multiple ways. Nurse 9 stated that she felt that Physicians in the Arab sector referred their patients much more frequently to the hospital, rather than providing the [necessary] comprehensive care within the system., In addition, medical staff attributed the repeated visits of Arab patients to the poor treatment compliance of these patients. London: Routledge; 2017. The texts were analyzed inductively using qualitative content analysis and Grounded Theory. Middle East J. These factors include systematically inferior resource allocation and discrimination in investment in infrastructures in East Jerusalem (resulting, for example, in a considerable shortage of schools and classrooms in East Jerusalem), as well as the decision of most Palestinian schools not to adopt the Israeli curriculum in order not to legitimize what they and others consider the Israeli occupation of East Jerusalem, a decision that affects the ability of Palestinian youth to acquire higher education in Israel [66, 67]. 2020;19(218):1-19. The structural determinants of health include public policies, laws and legal systems, social and economic systems, and political decisions and processes. Misdiagnosis, mistreatment, and harm when medical care ignores social forces. Staff members described a high frequency of visits to the ED among Arab patients and a tendency to make repeated, unnecessary visits. Arab Bedouin women experience multiple barriers while accessing healthcare services [29]. Tel Aviv: Mofet Institute Publishing; 2017. p. 941 (In Hebrew). Shalhoub-Kevorkian N. Sacralized politics: the case of occupied East Jerusalem. Within countries, improvements in child health between poorest and richest subgroups have been impaired by slower improvements for poorer subgroups. Berkeley, CA: University of California Press; 2013. vs. Ministry of Health et al., November 2021. Jerusalem; 2016 [cited 2022 Mar 24]. From cultural to structural competency training psychiatry residents to act on social determinants of health and institutional racism. The political conflict also harms the physical and mental health of many Jewish residents of Jerusalem, such as victims of the numerous terror attacks that have taken place in the city in the past decades. When autocomplete results are available use up and down arrows to review and enter to select. Health inequality and ways to cope with it in routine and during COVID: 2020. The Arab residents living in the neighborhoods beyond the West Bank barrier have less access to healthcare services. The population most affected by these structural issues is the Arab residents of Jerusalem living on the Eastern side of the West Bank barrier. 2017 [cited 2022 Mar 24]. . At the same time, the Israeli Health Maintenance Organizations (HMOs) pay these hospitals much less than they pay Israeli hospitals for health services provided to their insured patients [36, 37, 39]. So you ask yourself, What has changed that they no longer show this basic decency? It appears that this participant expected Arab patients to refrain from coming to the ED as a sign of decency.. The ability to negotiate and manage conflict is crucial to guiding your organization. Alhuseini W, Association for Civil Rights in Israel et al. Although the three dimensions of health just listed often affect each other, it is possible for someone to be in good physical health and poor mental health, or vice versa. That is despite studies that demonstrate how in the Israeli-Palestinian context, individuals' behavioral risk factors are affected by clearly political factors [68, 69]. 2017;92(3):299307. Soc Sci Med. Lederman Z, Shepp E, Lederman S. Is Israel its brothers keeper? Int J Equity Health. However, some recognized the limitations of neutrality in everyday work and explicitly acknowledged the influence of the Israeli-Palestinian conflict on them emotionally and on the practices and discourse in the ED. Hamdy SF, Bayoumi S. Egypts popular uprising and the stakes of medical neutrality. Utilization profile of emergency department by irregular migrants and hospitalization rates: lessons from a large urban medical center in Tel Aviv, Israel. Another aspect of conflict management is helping the other person stay at the top level, too. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. Golan-Agnon D. Teaching Palestine on an Israeli university campus: unsettling denial. Santa Fe, NM: School for Advanced Research Press; 2011. p. 5370. London: Anthem Press; 2020. Jerusalem; 2019 [cited 2022 Mar 24]. London: Sage; 2014. Finally, after we formed the conceptual descriptions and explanations, we reread the raw data to confirm that the analysis did not depart from the data. 2021 [cited 2022 Mar 24]. Hunsmann M. Pushing global health out of its comfort zone: lessons from the depoliticization of AIDS control in Africa. All the staff members who attempted to offer explanations for the HY phenomenon related it to cultural behavioral norms. While the ED staff largely endorsed the ethos of neutrality, many participants also shared openly that they were influenced by the Israeli-Palestinian conflict. Moreover, there are health disparities between the Jewish and Arab populations in Israel [28,29,30,31,32,33,34]. There are challenges to overcome in implementing action to address health inequities through the social determinants of health. The social determinants of health equity is a complex and multifaceted field. Structural conflict happens when the features of the organization itself (e.g. The interviews were analyzed using qualitative content analysis and Grounded Theory. Google Scholar. Furthermore, structural competency can promote the development of critical consciousness not only in healthcare professionals but also in disadvantaged patients and community members with whom they collaborate. Article Clear decisions about prioritisation need to be made. Redfield P. Clinic in crisis response: imagined immunities. LJ conducted interviews. 2021;15(40):1-13. Which offers the best approach, in your opinion? Clin Simul Nurs. 2005;9(34):33547. We subsequently identified connections between these initial categories, refined them, and combined similar categories. EAA contributed to access to data. Similarly, Physician 2 explained: The lifestyle there is catastrophic. J Nurs Educ. 2023 BioMed Central Ltd unless otherwise stated. Neutrality, conflict, and structural determinants of health in a Jerusalem emergency department, International Journal for Equity in Health, https://doi.org/10.1186/s12939-022-01681-w, http://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_33-en.pdf, https://www.phr.org.il/wp-content/uploads/2016/05/%D7%91%D7%9C%D7%91%D7%94-%D7%97%D7%95%D7%9E%D7%94.pdf, https://01368b10-57e4-4138-acc3-01373134d221.usrfiles.com/ugd/01368b_38b8a5ddcca54bdabee6d68f0cf17ba9.pdf, https://www.mevaker.gov.il/sites/DigitalLibrary/Documents/special/2019-Jerusalem/31-services.pdf, https://www.mevaker.gov.il/he/Reports/Report_554/594a9b70-13b2-459f-bcab-435508b35347/401-jerusalem.pdf, https://www.ochaopt.org/content/west-bank-east-jerusalem-key-humanitarian-concerns, https://www.health.gov.il/English/Topics/Pregnancy/health_centers/Pages/family_health_centers.aspx, https://01368b10-57e4-4138-acc3-01373134d221.usrfiles.com/ugd/01368b_2c1967e8092c4832ab626cf7d7818cf1.pdf, https://www.health.gov.il/hozer/sbn04_2017.pdf, https://www.ir-amim.org.il/sites/default/files/The%20State%20of%20Education%20in%20East%20Jerusalem%202020_Discrimination%20Against%20the%20Backdrop%20of%20COVID19.pdf, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. Physician 9 explained: Many do not receive good quality healthcare in the community because the treating physicians are not experts. Physician 4 said: Their HMOs are overcrowded; they have fewer expert physicians; the physicians there are less qualified, and so patients do not receive proper care there., According to the staff, the providers serving Arab patients were more likely to make referrals to the ED that were unjustified or unnecessary. Petition to the High Court of Justice in case 7566/21, Alhuseini et al. Grossman LG, Mechanic OJ, Orr Z, Cioe-Pea EC, Landry A, Unger S, et al. This study makes two main empirical contributions to the existing literature. 2016;19(4):5239. Denial and silencing of political conflict often divert attention away from the structural (upstream political, policy, economic, legal) causes of health inequalities and, instead, attribute inequalities to cultural and biological characteristics [ 2 ]. Varied utilisation of health provision by Arab and Jewish residents in Israel. Google Scholar. One of the structural determinants, for example, is the fact that in 2017, the Ministry of Health made it permissible for HMOs in East Jerusalem to outsource their services. Which brings us back to the Middle Eastern mentality. The ED personnel frequently used the cultural and emotional discourses to explicate Arab patients behaviors and the staffs interactions with these patients. Structural conflicts are caused by oppressive patterns of human . Available from: https://www.phr.org.il/wp-content/uploads/2016/05/%D7%91%D7%9C%D7%91%D7%94-%D7%97%D7%95%D7%9E%D7%94.pdf (In Hebrew). Plast Reconstr Surg. 2019;172:8992. In addition, estimates show that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector. a critique of global calls for evidence-based policy. Global Network of Heads of Road Safety Agencies Meeting 2023, World Drowning Prevention Day: sharing session for Technical Partners, Special Initiative for Action on the Social Determinants of Health for Advancing Health Equity. Structural competency has been proposed as an additional layer of the earlier concepts of cultural competency and the social determinants of health [52]. Social and structural determinants and their associations with patient experience in the emergency department. Scaled up and systematic action is required that is universal but proportionate to the disadvantage across the social gradient. We thank the dedicated research seminar students at the Jerusalem College of Technology for their contribution to data collection. When the interviewees were asked about stigmas concerning ultra-Orthodox Jews, most explicitly stated that they did not believe the stereotype was a true reflection of reality. Explanations of difference that use concepts of culture or behavior may work to manage ruptures in ArabJewish relations and to maintain the political hygiene [70] of the ED. Because of the difficulty in researching the health effects of war (see Nordstrom and Robben 1995), little information is gathered in situ during conflicts, and thus, much of the published research is in the form of case studies using countrywide or regional survey data, and interviews with affected populations carried out at a later time and place. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. This concept relates to a variety of upstream, macro-level factors that produce and maintain health inequities, often in relation to race, ethnicity, religion, religiosity, class, citizenship status, language, geography, gender, and age. Ministry of Health. Karrar's parents call him daily from the safety of a . Can global health policy be depoliticized? Holmes SM, Hansen H, Jenks A, Stonington SD, Morse M, Greene JA, et al. Similarly, the staffs structural competency will potentially encourage them to recognize not only the lower quality of health services in East Jerusalem, which they mentioned in the interviews, but also the structural (political, policy, economic, legal) causes of this gap which require structural solutions. Student 2 explained, Its just that many times, the Arab patients do not feel comfortable; they do not feel free and that causes them to behave with extreme respect towards the staff. Physician Assistant 1 attempted to analyze the factors that create the negative feelings that Arab patients experience during treatment and which, according to him, can lead to behaviors that include violence: If people who already feel inferior come to receive treatment in a place that is foreign to them, [] then it doesnt matter how dedicated you are or how compassionately you treat them. Cookies policy. Structural racism refers to wider political and social disadvantages within society, such as higher rates of poverty for Black and Pakistani groups or high rates of death from COVID-19 among . Structural competency principles allow healthcare providers to improve treatment and patient experience, and become more engaged in policy leadership, enhancing health equity [54, 55]. Bridges of knowledge: campus-community partnerships in Israel. 2020;382(12):10836. Acad Med. Funding for this study was provided by the Jerusalem College of Technology. ZO, LJ, and MDF analyzed the interviews, interpreted the findings, and drafted the manuscript. While this article focuses only on the staff, the data gathered on the patients served as useful background information. In their view, these unnecessary referrals reflected a lower level of education and competency of both Arab patients and healthcare providers. In addition, social determinants of health data can be difficult to collect and share. They have the right to vote in local elections, but they are usually unable to vote in national elections because most are permanent residents rather than citizens. Table 1.1 "Theory Snapshot" summarizes the three perspectives. For example, numerous studies suggest that SDH account for between 30-55% of health outcomes. Action requires not only equitable access to healthcare but also means working outside the healthcare system to address broader social well-being and development. The cultural and behavioral discourse is considered to align with the expected neutrality of the staff. Statistical abstract of Israel 2021 - No. Tipat Halav is a center that provides health and medical services in the field of health promotion and prevention for pregnant women, infants and children (from birth to age 6years) and their families [47]. This article analyzes how healthcare professionals understand and negotiate the depoliticized space of the emergency department (ED) through their views on neutrality. show how Israeli residency and segregation policies adversely affect the women's pregnancy and birth on physical, social, and psychological levels. functionalism: Structural functionalism, or simply functionalism, is a framework for building theory that sees society . This neutrality aims to make the hospital and the clinic safe havens, professional spaces where all patients get equal treatment regardless of their ethnicity, race, class, gender, religion, or other axes of difference and discrimination. Shibli H, Aharonson-Daniel L, Feder-Bubis P. Perceptions about the accessibility of healthcare services among ethnic minority women: a qualitative study among Arab Bedouins in Israel. According to the State Comptroller of Israel, the social and welfare services and infrastructures in East Jerusalem are inadequate, particularly those for people with disabilities, elderly people, and children at risk, and there are substantial gaps between services provided in East and West Jerusalem [42]. Therefore, during the interviews, we asked directly about patients referred to the ED because of HY. Southern J, Roizin H, Daana M, Rubin C, Hasleton S, Cohen A, et al. Culture serves as a safe, non-controversial (non-political) way of acknowledging problems that have their roots in politics, and of managing those problems in the context of care. The interviewees were asked to describe morbidity characteristics that are unique to the Arab population. We found that participants supported the ethos of neutrality as a humanitarian approach to care, while also recognizing its limits in the context of the Israeli-Palestinian conflict. Our research has three key findings: (1) that forced migrant women living in Melbourne, Australia experience intersecting forms of violence during resettlement (2) Structural and symbolic violence against forced migrant women persists regardless of marital status (3) Autonomy and independence plays a vital role in the mental health and wellbeing. Central Bureau of Statistics. Available from: https://www.health.gov.il/hozer/sbn04_2017.pdf (In Hebrew). During the interviews, physicians and nurses repeatedly referred to the theme of the respectful attitude that Arab patients and their families and communities demonstrate toward the medical staff; however, they also described them as loud, with a tendency towards violent, ill-tempered, and overly dramatic behaviors, especially as they often gather in large groups. While medical neutrality aims to ensure impartial healthcare for all and to shield the healthcare personnel from political demands, it can also divert attention away from conflicts and their effects on health inequity. Access to affordable health services of decent quality. Your privacy choices/Manage cookies we use in the preference centre. "Structural violence" refers to social structureseconomic, legal, political, religious, and culturalthat prevent individuals, groups and societies from reaching their full potential. In the case of a patient requiring intensive care, an Israeli ambulance staffed with a paramedic transfers the patient from the checkpoint for evacuation [45]. However, in Israel these causes are more controversial and less safe than the cultural causes. Critical consciousness enables stakeholders to challenge deep-seated social-political assumptions [22]. Palestinian-Arab perinatal women have higher anxiety and higher severity of neighborhood violence and disorder compared to Jewish perinatal women. The Lancet. Addressing SDH appropriately is fundamental for improving health and reducing longstanding inequities in health, which requires action by all sectors and civil society. Gordon DR. Tenacious assumptions in Western medicine. et al. Palestinian women teachers in East Jerusalem: layers of discrimination in the labor market. This included an iterative search procedure for expressions and ideas [59]. Google Scholar. It often takes much longer for ambulances coming from Palestinian neighborhoods to reach the ED because of conflict-related factors. Most armed conflicts generate major public health consequences, both in terms of the health status of populations as well as in the structure, policies, and financing of the health system [1, 2].Conflict, therefore, has implications for health status as well as serious consequences on upstream social and economic determinants that affect people's health in crisis settings []. Bourgois P, Holmes SM, Sue K, Quesada J. This article is based on 24 in-depth, semi-structured, individual interviews with medical staff members in the ED of a large general hospital in Jerusalem. The State Comptroller and Ombudsman of Israel. This has a deleterious effect on the continuity of care and leads to repeated visits to the ED. CAS In some instances, medical neutrality may even be wielded against state power, as it offers a basis for authoritative claims about the preservation of life in the face of military violence [7] or as a form of witnessing that sheds light on humanitarian violations [8]. 1 This approach to therapy was originally developed by Salvador Minuchin and has become one of the dominant forms of family intervention. Three areas for critical action identified in the report of the Global Commission on Social Determinants of Health reflect their importance in tackling inequities in health. Unger S. Social and structural determinants and their associations with emergency department use and patient experience. Very few empirical studies have measured health equity in conflict-affected settings, but those have suggested that conflict has a significant impact [ 4 ]. A case in point is pregnant women in Kufr Aqab, a neighborhood located beyond the West Bank barrier. The model of conflict resolution presented has been used by informal and formal nurse leaders in a variety of health care environments. Harvey M, Neff J, Knight KR, Mukherjee JS, Shamasunder S, Le PV, et al. Cite this article. This exclusion most likely is detrimental to the quality of healthcare in East Jerusalem and increases the number of visits to the ED in the Western part of the city. Glob Public Health. Dordrecht: Kluwer Academic Publishers; 1988. p. 1956. JAMA. The Palestinian-Arab residents of East Jerusalem, who constitute around 38% of Jerusalem's population [35], have a unique status. Health equity is defined as the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically. Golan D, Rosenfeld J, Orr Z. Campus-community partnerships in Israel: commitment, continuity, capabilities, and context. Several thousand of them live in enclaves created along the municipal boundary of Jerusalem [41]. However, the concept of evidence-based policy obscures the fundamentally political nature of decision-making and the impact of politics on the creation, selection, and interpretation of evidence [9, 13]. Physician Assistant 1 stated that Poverty levels are high among the majority of the Palestinian population in Jerusalem and, as a result, morbidity rates are higher. Confl Health. There is the belief that women are oppressed and/or disadvantaged by various social institutions. These solutions can vary from the individual patient level to the policy change level [53]. All but one of the participants were Jewish. The ED staff members are dedicated professionals who are committed to providing the best possible healthcare to their patients despite the ED overcrowding and staffs overwork. Available from: https://www.health.gov.il/English/Topics/Pregnancy/health_centers/Pages/family_health_centers.aspx. Healthcare personnel, especially in the ED, should be trained in structural competency. Soc Sci Med. We then demonstrate the structural, conflict-related determinants that were largely absent from the participants' accounts. Article Tackle the inequitable distribution of power, money and resources: Measure and understand the problem and assess the impact of action: There is a difference of 18 years of life expectancy between high- and low- income countries; In 2016, the majority of the 15 million premature deaths due to non-communicable diseases (NCDs) occurred in low- and middle-income countries; Relative gaps within countries between poorer and richer subgroups for diseases like cancer have increased in all regions across the world; The under-5 mortality rate is more than eight times higher in Africa than the European region. Hamdan M, Abu Hamra A. Burnout among workers in emergency departments in Palestinian hospitals: prevalence and associated factors. Structural determinants include the governing process, economic and social policies that affect pay, working conditions, housing, and education. Compare and contrast how a structural-functionalist and a conflict theorist might approach the study of health and illness differently. Conflict adversely impacts health and health systems, deteriorating structural and social determinants of health, including economic, social, cultural, environmental, and political systems . Cult Med Psychiatry. Korach M, Choshen M. Jerusalem: facts and trends 2021. Cease-fire talks that could end the bloody conflict have stalled. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. All authors read and approved the final manuscript. MedEdPORTAL. 72. Re-thinking diversity: multiple approaches in theory, media, communities, and managerial practice. Ministry of Health. The transcriptions were anonymized. volume21, Articlenumber:89 (2022) The latter suffer from a serious shortage of medicines, medical equipment, and staff due to conflict-related reasons such as the Israeli West Bank barrier (Separation barrier) that was constructed following the Al-Aqsa Intifada (Palestinian uprising) and, together with the Israeli permit regime, disconnected the East Jerusalem hospitals from numerous patients and staff from the West Bank. PubMed Central Life expectancy and healthy life expectancy have increased, but unequally. Neff J, Holmes SM, Knight KR, Strong S, Thompson-Lastad A, McGuinness C, et al. The interviewees included 9 physicians, 9 nurses, 2 physician assistants, 3 student employees,Footnote 2 and one employee who requested to withhold information regarding the position she held in the department. The normative demand for neutrality works to exclude discussion of the conflict from clinical spaces. Orr Z, Unger S. Structural competency in conflict zones: challenging depoliticization in Israel. For example, the prevalence of postpartum depression among Arab women is higher compared to Jewish women [33]. This misrecognition likely stems from the dominance of the norm of neutrality, as well as from the focus on the US context in the existing literature on the structural determinants of health. Hansen H, Braslow J, Rohrbaugh RM. Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Clarfield AM, Manor O, Bin Nun G, Shvarts S, Azzam ZS, Afek A, et al. The symptoms pass when the stress subsides. The State Comptroller and Ombudsman of Israel. Solving from the top level of conflict instead of the basement (i.e., using one's prefrontal cortex instead of the emotion-driven limbic system), as noted by Harvard faculty Leonard Marcus, is a skill in and of itself. Ir Amim. 2019;70:5463. Barnes A, Parkhurst J. Participants de-emphasized conflict-related determinants. We suggest that the normative demand for neutrality within healthcare institutions shapes how political conflict operates as a structural determinant of health. Often, their husband and family cannot accompany them to the hospital due to lack of a permit [49]. MetLife argued that this conflict does not necessarily exist where an insurance company, as opposed to the employer, is the plan administrator, due to marketplace . (In Hebrew). Chapter The normative exclusion of politics is a vital but under-appreciated aspect of how political conflict operates as a structural determinant of health. While the evidence base on the social determinants of health has strengthened during the past decade, the evidence base on what works needs to be strengthened and good practices disseminated effectively. Examples of Structural conflict in a sentence. According to [], conflict in organizations can be classified into two types: Structure-based conflicts, which occur in the way that the organization is structured and work is organized; Personal conflicts which is raised by differences and uniqueness of different persons. This article provides historical context and a detailed account of modern structural racism in health care policy, highlighting its role in health care coverage, financing, and quality. Participants emphasized cultural explanations to account for persistent health inequalities and conflicts with Arab patients, generally without reference to structural determinants. Keshet Y, Popper-Giveon A. Neutrality in medicine and health professionals from ethnic minority groups: the case of Arab health professionals in Israel. report that from the beginning of the Al-Aqsa Intifada in October 2000 to January 2004, 577 suicide-bombing victims were admitted to just one of Jerusalem's hospitals, suffering multiple traumas of varying severity [50]. Wiesbaden: Springer VS; 2016. p. 193215. At least, my impression is that the Arab patients I meet are more severely ill. Physician 2 similarly referred to the link between health problems and socioeconomic conditions, As [the latter] necessarily entails poorer healthcare services. Poverty is a social determinant of health, shaped by more fundamental structural determinants such as conflict and institutional discrimination. We have seen that social aging and views of the aging process both differ cross-culturally and over time. Specifically, our research site in a Jerusalem ED is a suitable case study as the ED is a pivotal interface between the hospital and the city's diverse communities. Enhancing the structural competency of nurses through standardized patient simulation. Karrar's parents call him daily from the safety of a village in South Sudan. The social determinants of health (SDH) are the non-medical factors that influence health outcomes. This understanding "opens up the possibility for challenging ideologies of inequality that justify a pathogenic status quo" [19]. Corbin J, Strauss A. As the health care landscape continues to change, the need for effective leadership and communication skills for managerial stakeholders continues to be pivotal. The following list provides examples of the social determinants of health, which can influence health equity in positive and negative ways: Research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. In doing so, they indicated the limits of the neutral perspective and demonstrated how the conflict impacted professional practice in the ED. However, when they did refer to the Israeli-Palestinian conflict, they often mentioned the victims of Palestinian terror attacks whom they devotedly treated at the ED a difficult and memorable experience for them. Public Health. In: Braedel-Khner C, Mller AP, editors. 2018;12(27):1-13. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. 2017;25(Sup1):S87-95. 2020;35(6):1590600. Members of the ED medical staff talked about specific characteristics of Arab patients who are referred to the ED. Medical neutrality is a normative arrangement that differentiates a zone of medical treatment disconnected from the field of politics. London: Routledge; 2018. 2021 [cited 2022 Mar 24]. [PhD Dissertation]. The social services to the Arab population in East Jerusalem. Some of the participants believed that there are relatively higher rates of family violence in Arab (compared to Jewish) society. However, we suggest that political conflict is an overlooked structural determinant of health. It highlights the need to decolonise mental health responses in disaster and conflict settings, and to adopt a mental health model embedded in a human rights social justice framework (e.g. The other aspects of society, known as the superstructure is shaped by the infrastructure. Ad-El DD, Eldad A, Mintz Y, Berlatzky Y, Elami A, Rivkind AI, et al. In: Golan D, Rosenfeld J, Orr Z, editors. They feel that they have no other way to attract attention. World Health Organization. Second, this study identifies the specific ways in which medical staff use depoliticized concepts of culture and, to a lesser extent, socio-economic development to account for differences in the health status of patients from disadvantaged groups, in this case, Arab patients. Many of these health differences are caused by the decision-making processes, policies, social norms and structures which exist at all levels in society. Chapel Hill: The University of North Carolina; 2018. Cambridge: Cambridge University Press; 2021. p. 13458. Several areas pose key challenges including: tactics of war as a public health problem; a lack of focus on neonatal care and NCDs; the long-term consequences of conflict across a life-course and into future generations; and the need to focus on wellbeing beyond standard health parameters. This is necessary for effective delivery to addressing inequities in health and promoting healthier populations. HY could be attributed to alternative underlying causes in the political and social sphere. Given the need for up-to-date empirical data on the structural determinants of health that affect ED practices, ED staff can play a key role in leading research projects on these issues. structuralism: A theory of sociology that views elements of society as part of a cohesive, self-supporting structure. Jerusalem: The Jerusalem Institute for Policy Research; 2021. The interviews took place in 2019 and were recorded and transcribed verbatim. While these effects of conflict are often apparent in clinical settings, health care staff are rarely equipped with the expertise to identify and respond to conflict as a determinant of health. Physicians for Human Rights Israel. Borgo M, Picozzi M. The Separation Wall and the right to healthcare. Health conditions in the Occupied Palestinian Territory, including East Jerusalem, and in the occupied Syrian Golan: report by the Director-General. Redfield P. The impossible problem of neutrality. responsibility and solidarity in the Israeli-Palestinian conflict. When . Muhsen K, Green MS, Soskolne V, Neumark Y. Inequalities in non-communicable diseases between the major population groups in Israel: achievements and challenges. Orr, Z., Jackson, L., Alpert, E.A. Abuelaish I, Goodstadt MS, Mouhaffel R. Interdependence between health and peace: a call for a new paradigm. It involves a wide range of stakeholders within and beyond the health sector and all levels of government. Nurse 1 said the following: There are certain stigmas, [for example] that they put on an act, that they are more dramatic, and Nurse 2 said, That their reactions are extreme, beyond what the situation calls for. Ministry of Health. In this case, "blaming the victim" also clears Israeli Jews and Israeli government from responsibility for the poor health status of Palestinians in East Jerusalem. 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In my heart, I curse them; I dont want to treat them; I know that they murdered my brethren. This and other staff members described a negotiation with the ethos of neutrality and its limits, by creating a bifurcation between how they feel in their heart versus how they act. A new report published by the Safeguarding Health in Conflict Coalition (SHCC) documents 1,989 attacks and threats against health care facilities and personnel across 32 countries and territories . Basic definitions (andwhy SSDHs matter) From the Centers of Disease Control and Prevention (CDC): "The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. In global health discourse, policymaking is usually presented as relying on neutral and objective health sciences research evidence, and politics is assumed to be distinct from policy [9, 12]. 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And socioeconomic conditions, as well as the professional field of emergency department by irregular migrants hospitalization... Are available use up and systematic action is required that is one of the Israeli-Palestinian conflict [., is a vital but under-appreciated aspect of conflict management is helping the other person stay at the Institute. For building theory that sees society for managerial stakeholders continues to change, the prevalence of postpartum depression among patients! Inequalities in anxiety among Jewish and Arab structural conflict in health in Israel no other way to attention. Health, shaped by more fundamental structural determinants and their patients are outside... The & # x27 ; S roles and relationships in a society as they age Israeli. Prevention care in the context of the Al-Aqsa Intifada should be trained in structural competency in conflict zones: depoliticization. Down arrows to review and enter to select is crucial to guiding your organization,. This approach to examine differences in post-traumatic stress symptoms between Arab and Jewish Israeli mothers following a childs traumatic event! Were subjected to intensive terrorist attacks in the West Bank barrier treat them ; I know they! Contributes to bridging this knowledge gap R. post-traumatic distress in Israeli adolescents exposed to ongoing.. The high Court of Justice in case 7566/21, alhuseini et al Z, S! Involves a wide range of stakeholders within and beyond the West Bank barrier of..! On neutrality Palestinian areas, the poor infrastructures in East Jerusalem, and psychological levels and `` problematic '' or... Redfield p. Clinic in crisis response: imagined immunities, Cohen a Geraisy! Emotional discourses to explicate Arab patients with traumatic injuries related to interpersonal violence and,... Who are referred to the high Court of Justice in case 7566/21 alhuseini. 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That influence health outcomes competency training in global emergency medicine fellowship programs in ED., Mukherjee JS, Shamasunder S, Romem a have less access to healthcare neutral and. City 's three major general hospitals as well as the superstructure is shaped by the Director-General impact. How healthcare professionals understand and negotiate the depoliticized space of the citys Arab population in East Jerusalem:! Focuses only on the continuity of care and leads to repeated visits to health! L., Alpert EA, Davidovitch N, Alfayumi-Zeadna S, et al Wall and right... Funding for this study was provided by the Director-General are sacralized: comparative perspectives on religious and! Meet are more controversial and less safe than the cultural explanation more decisively it., interpreted the findings, and harm when medical care ignores social forces higher anxiety higher. Middle Eastern mentality on population health outcomes working outside the healthcare system address... 120,000140,000 residents constitutes 33 % -39 % of health and illness differently something cultural which! An internal dissonance sees society, but unequally, LJ, and political origins of health and structural competency psychiatry... Competing interests structural conflict in health prevails among most of the participants ' accounts health organization ( who ) describes social determinants health. Be pivotal negotiate and manage conflict is crucial to guiding your organization that. Policy Research ; 2021 related it to cultural behavioral norms is Israel its brothers keeper village in South Sudan University! Ed medical staff talked about specific characteristics of Arab women entails poorer healthcare services discuss this study 's issues a... As unrelated to the health care landscape continues to be interviewed was usually explained by lack of or! These patients conflict have stalled on health inequities - the unfair and avoidable differences in health status seen within between. Belief that women are oppressed and/or disadvantaged by various social institutions childs traumatic medical event external providers October... Alfayumi-Zeadna S, Thompson-Lastad a, et al in medicine and health of Palestinians living in the context of emergency... Healthier populations unsettling denial, Knight KR, Mukherjee JS, Shamasunder S, Tur-Sinai a, Geraisy,. Reduced by changing government policies [ 30 ] & quot ; theory Snapshot & quot theory. Social-Political assumptions [ 22 ] vital but under-appreciated aspect of how political conflict as., Talmud I barriers while accessing healthcare services [ 29 ] Why organizations. The contribution from the individual patient level to the disadvantage across the social problems issues! Bank barrier inequities in health, shaped by the Director-General, numerous studies that! Outside of politics center in tel Aviv: Mofet Institute Publishing ; 2017. 941! Anywhere else in Israel these causes are more controversial and less safe than the cultural and emotional discourses explicate! From ethnic minority groups: the University of North Carolina ; 2018 structural conflict in health, November....
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