Major issues in women's health.

The issue of equity in health care for women is complex and needs to be examined on many different and interrelated levels. At the most basic level is the question of gender disparities in scientific knowledge. Recent evidence suggests that modern medicine has amassed less information about the epidemiology of disease and its treatment in women than in men (National Institute of Health, 1991: 7). Gaps in scientific knowledge and data on women, in turn, limit our understanding of their unique health needs, leading to gender bias in public policy, in medical education and training and ultimately in clinical practice and service delivery (Laurance and Weinhouse, 1994: 60-82). The question, therefore, is not whether women in Israel receive equivalent care, compared to men, but rather whether they get the kind of care they require given their gender-specific needs.

Health and Illness

The Gender Gap

Life Expectancy 

The gender gap in life expectancy in Israel is 4 years: 79.5 for women and 75.5 for men (CBS, 1997a, Table 3.19). This difference is significantly smaller than the average of seven years difference in the life expectancies of men and women in most of the developed world. In fact, while Israel ranks among the top five countries in the world in terms of life expectancy for men, women are not even in the top ten (ICDC, 1997: 5557). These trends alone suggest an untapped potential of the health care system with respect to women. The challenge for epidemiologists, health policy analysts and planners is to attempt to explain these differences and respond appropriately.

The longer life expectancies of women relative to men means not only that women are dependent on the medical care system for longer periods in their lives, but also that they are more likely to be alone as they get older, with no one to care for them when they are ill. Women constitute 57% of the population over 65 (CBS, 1997: Table 2.10). By age 75-79, only 27% of them live with a partner, compared to 82% of the men in the same age group (Modan et al, 1996). These differences, too, need to be taken into account in health policy and planning.

Gender Differences in Mortality

The leading causes of death for both men and women in Israel, across the life span, are heart disease, cancer and stroke, in that order. In 1994, 5,560 women died of heart disease compared to 5,837 men. There were 3,773 deaths from cancer among women and some 4,200 among men (CBS, 1997b). For every Israeli woman who died of breast cancer, more than 6 died of heart disease.

Age standardized mortality rates for most of the leading causes of death are higher among men than among women throughout the developed world. In Israel, however, women are at greater risk of dying of cancer than are men for much of the life cycle. In 1994, cancer accounted for 44% of all deaths in women ages 55-64 and heart disease for 25%. By ages 7579, the situation is reversed: heart disease accounts for over 40 % of female mortality and cancer for about one-fourth. Among men, the risk of dying of heart disease or cancer is roughly equivalent throughout most of the life cycle, with the largest relative increase after age 65.

While Israeli men have one of the lowest mortality rates for cancer among men in some 20 countries where registries are kept, Israeli women have among the highest in the world higher than the mortality rates from cancer in European countries, but lower than that in America (Zadka, 1993). This is accounted for primarily by breast cancer, which in 1994 claimed over 800 lives, nearly twice as many as colon cancer--the next leading cause of death in Israeli women. In men, lung cancer heads the list of causes of mortality with some 706 deaths annually, followed by colon cancer (CBS, 1997: Table 3.22).

Gender Differences in Morbidity

Women are known to suffer more than men from many chronic conditions such as hypertension, diabetes, osteoporosis, depression, incontinence and other bladder problems, chronic fatigue and migraine headaches - the so called "cripplers" as opposed to the "killers" (Paltiel, 1988: 189-211).

Gender differences are consistently found in reported physical and emotional well-being, as well as in actual disability, particularly among the elderly and the poor in Israel. Salzberger, for example, studied 360 married Israeli couples over a ten year period. In families classified as moderately or severely deprived, she found that functional impairment due to illness increased 350% for women, compared to 58% for men. Women were more likely than men to report multiple health problems, which they attributed to pregnancy and childbirth, persistent side effects of previous illness and family stress. Among the most frequently cited ailments were emotional disorders and depression (Salzberger, 1990, 1991: 41-50).

Studies of elderly persons also reveal more illness and disability in women. The rate of disability among those over the age of 75 is 50% higher in women than in men, and since women are more likely to be living without a spouse, they are also more likely to be placed in institutional care (Stessman et al, 1996). Relative to men, elderly women report higher rates of hypertension and abdominal problems, as well as muscle or joint pain, chronic fatigue, digestive problems, respiratory problems and a host of other chronic conditions (ibid; CBS, 1994).

A survey of 450 Jerusalemites over the age of 70 revealed gender differences in morbidity for every condition measured: women suffered more from heart conditions, respiratory problems, joint and muscle pain, chronic fatigue, psychological disorders, problems with the digestive system, malignancies and other manifestations of chronic illness. The most significant gender difference was related to joint and muscular conditions. These, of course, may seriously limit mobility and independence in women and reduce their ability to remain in non-institutionalized settings, if there is no spouse to provide assistance (Stessman et al, 1996).

The above findings are in line with a fairly universal phenomenon in modem societies: while women have longer life expectancies than men, they report more ill health and suffer more from long-term disability. The nature and severity of women's health problems vary according to age, economic status, and ethnic or racial background, but this overall gender difference remains remarkably constant (Apfel, 1982; Verbrugge, 1976; Doyal, 1990; Hoffman, 1996).

Hypertension and Diabetes

Diseases that reduce the quality of life for women and often lead to more serious conditions in women are hypertension and diabetes. Hypertension plays a more important role in the development of congestive heart failure and other coronary problems in women than it does in men; it also places women at significantly higher risk of stroke (Strokes et al, 1987; Hoffman, 1995).

Often women with hypertension are unaware of their condition, and thus it goes untreated. For example, in a General Health Fund survey in which 1000 women ages 20-60 were examined (Eshed, 1991), some 30% of those over the age of 45 were found to be suffering from hypertension, but only a third of these women were aware of their condition.

Diabetes is another illness that sets up secondary risks for women (Kannel, 1985). Diabetic women have higher risks than diabetic men of complications from coronary artery disease, the leading cause of death for those with diabetes; women have more severe circulation problems that can lead to limb amputation; and a greater tendency toward auto-immune and reproductive disorders (Hoffman, 1995: 133-134).

In Israel, it is estimated that approximately 3% of the female population (compared to 2.7% of males) suffers from diabetes. The disease affects North African Jews and Arabs more than Ashkenazi Jews, and mortality rates are higher for Arab and Mizrahi women than for Ashkenazi ones (ICDC, 1997: 123-129).

Women's Hidden Health Problems

Reproduction itself predisposes women to additional health problems and alters the probability of developing certain conditions and diseases (Salzberger, 1991; Hoffman, 1995). Pregnancy increases the risk of diabetes, hypertension, heart disease, gallbladder disease and, of course, post-partum depression, about which very little is known in Israel. Popular myth has it that Jewish women feel nothing but elated at childbirth. When The Association for the Advancement of Women's Health in Israel conducted a survey of services for women with post-partum depression, field workers were told more than once that there was no such problem (Horowitz, 1996).

There are many other chronic conditions that affect women exclusively, at a higher rate or simply differently than men, which are often under-or misdiagnosed by doctors and rarely discussed by women with their physicians or among themselves. Eating disorders, incontinence, lupus and other auto-immune disorders, thyroid disorders, domestic abuse, substance abuse, hot flashes and other symptoms of menopause are just a few of the hidden health problems with which women often live because physicians and emergency room attendants have been poorly trained to detect and diagnose them.

Gender Bias in Medical Practice

Heart Disease

Heart disease is perhaps the most striking example of how gender bias can permeate every phase of the medical process, from research through training, prevention, diagnosis and, finally, treatment. It is an illustration of what women's health specialist, Dr. Eileen Hoffman, refers to as androcentrism in medicine - "the assumption that men and women have similar profiles when non-gynecological problems emerge" (Hoffman, 1995).

Because heart disease has long been considered a "menonly" condition, it has been understudied in women; results from research on men are simply extrapolated to women. Doctors know very little about the diagnosis and treatment of coronary artery disease in women and the medical profession has yet to design diagnostic tests and instruments that are gender-specific. Women who do seek help for chest pain or other symptoms often report that such signs are attributed by doctors to psychosomatic conditions, problems at home or something they have eaten (Ra'anan, 1998: 27-30).

The result: Israeli women fare worse than men during and after acute myocardial infarctions and by-pass surgery (Ra'anan, 1998; Tzivoni, 1991; Greenland et al, 1991). They have greater impairment of functional status when admitted for surgery; they are slower to recover and more likely to die both during hospitalization and in the year following discharge.

Mental Health

Another women's health issue that is under-researched and under- or misdiagnosed is mental illness. As in the case of heart disease, psychological standards for mental health have been traditionally based on an androcentric model that takes men as the operative norm and fails to consider the ways in which women's unique experiences contribute to their psychological state (Broverman, et al, 1970; Chessler, 1972; Gilligan, 1982). Consequently, in Israel, as elsewhere, little is known about the etiology or treatment of depression, posttraumatic stress disorders, addiction and substance abuse or eating disorders in women and the relationship of these problems to other health conditions (Feinson, 1997).

Increasingly, however, it appears that gender differences exist in the profiles of men and women who use and abuse substances such as tobacco, alcohol or drugs and in the health consequences of substance abuse. In women, for example, substance abuse is often secondary to depression or posttraumatic stress, such as that triggered by violence or sexual abuse; alcohol is more intoxicating in lower amounts in women compared to men; women tend to keep their drinking problem a secret while in men it is usually manifested in anti-social behavior, including violence (Hoffman, 1995: 365).

Israel ranks high in the Western world with respect to violence in general, with a rate of 2.6 murders per 100,000. Among the 157 victims of murder in 1997, 26 were women; 60 % of them were killed by husbands and about one-fourth by another family member (Israel Women's Network, Resource Center).

In 1992, there were 868 attempted suicides among women in Israel, representing 63% of the total number of attempts. The highest number was among 15-24 year olds, and the most frequently reported reasons for the attempts were related to family or social difficulties (ICDC, 1997: 175-177). In contrast, men are three times more likely than women to succeed in committing suicide; they are older on the whole and their attempts are more often associated with mental illness and depression (ibid).

Reproductive Health 

Fertility rates in Israel have been decreasing steadily over the last twenty years: for Jewish women, from 3.3 children per family in 1975 to 2.5 in 1996. Among Moslems, the decrease was from 8.5 to 4.7. Within the Jewish population, those born in Asia or Africa have the highest fertility rates (3.2) and European or Russian-born the lowest (2.2 and 1.7, respectively). Israeli-born women have an average fertility rate of 2.6, which is higher than that in European or North American countries. Maternal mortality, on the other hand, which in 1994 stood at 5.2 per 100,000 live births, is significantly lower in Israel than in many other countries including the U.s. (7.2) (CBS, 1997a; ICDC, 1997: 29-36).

The rate of legal abortions has decreased from around 18,000 in 1980s to around 16,000 in the mid 1990s. Live births to teenage mothers have shown a parallel drop; more never-married women are bearing children (4 per 1000 in 1995 compared to 3.2 in 1978), presumably by choice (CBS, 1997, Table 3.15).

It is possible that the decrease in abortion rates is due to an increase in the use of effective contraception. In the first national survey of health and risk-taking behaviors among high school students, conducted in 1994,87% of the girls (and 83% of the boys) reported using "safe" methods of birth control (Harel et al, 1997).

Nonetheless, neither medically mediated contraception nor contraceptive counseling are included in the benefits package under the National Health Insurance Law. This stands in sharp contrast to the fact that methods of increasing rather than controlling fertility are well covered - including unlimited in vitro fertilization treatments up to the live birth of two children.

In fact, Israel can boast of what is probably the highest number of IVF center/population ratio in the world (22 centers in 1997).

Utilization of Services

Women in Israel use the health care system more frequently than men. They visit doctors more often (CBS, 1994, Table 3) and undergo more laboratory tests, x-rays and other examinations (ibid). However, it is in no way apparent that more care means better care.

US studies suggest that while women undergo more laboratory tests and examinations, receive more prescription drugs and have more return appointments than men for the same type of complaint or illness, they have less access than men to major therapeutic interventions (Verbugge et al, 1981; JAMA, 1991; Hibbard and Pope, 1986). Actual differences in morbidity and mortality between the sexes do not fully account for these disparities.

Although little is known about the medical "helpseeking behaviors" of women in Israel, Ben Sira offered insights into the relationship between "overutilization" of the health care system and client satisfaction with primary care (Ben Sira, 1987). He attributed recurrent complaints and visits to the doctor, which in themselves can be "hazardous" due to exposure to unnecessary medical interventions, to client judgments regarding the poor quality and efficacy of the treatment. Such assessments, he argued, are strongly influenced by the affective behaviors of the providers.

Comparing different health funds, Ben Sira found lower satisfaction with the affective behaviors of doctors and lower satisfaction with treatment - which he attributed to the high recurrence of doctors' visits - in the General Health Fund. He emphasized the importance of a holistic and a bio-psychosocial model of care in promoting effective service utilization and client well-being.

A 1996 survey conducted by the Association for the Advancement of Women's Health in Israel among readers of the popular women's magazine At, support those reported above: doctors in the General Health Fund were reportedly less likely than others to provide unsolicited information on health promoting behaviors, and their clients were less satisfied and paid more return visits than members of other health funds (Avgar and Gordon, 1996).

The At survey points to a number of trends in the health perceptions and behaviors of women in Israel that are worthy of further investigation. For example, while women rated themselves as relatively healthy, the majority reported multiple symptoms of distress, such as headaches, backaches, chronic fatigue, depression and anxiety; they were satisfied overall with their doctors, but held low expectations from the health care system; some made very frequent use of the health care system, but contrary to popular stereotypes, most were more likely to ignore symptoms than seek medical treatment. The lowest reported "well-being" was observed among women aged 3645 - those carrying the heaviest burden of home and work responsibilities. In contrast, women over 45 reported fewer symptoms of distress and a higher level of self-care (ibid).

While women as a whole perceive themselves in poorer health than men do, there are also important differences between Ashkenazi and Mizrahi women and between Arab and Jewish women. Among women over 60, Ashkenazi women are the most likely to report being in good health, and Arab women the least likely. Utilization of health services, including doctors' visits, lab tests, x-rays, physiotherapy and various screening tests, is lowest among those sectors reporting the poorest health - Arab citizens and Mizrahi Jews  (CBS, 1994).

Life Styles and Preventive Care 

Approximately 25% of women over 20 (compared to 30% of men) report that they smoke (Israel Ministry of Health, 1996). A survey of Israeli youth revealed an almost equal number of boys and girls who reported smoking at least once a week (Harel, 1997).

Women who smoke increase their already higher risk of osteoporosis; they may experience early menopause; if they are over the age of thirty-five and taking oral contraceptives, they significantly increase their risks of heart attack and stroke (Horton, 1995). Research also shows that women are more sensitive than men to the chemical effects of nicotine and their withdrawal symptoms are more severe (Hoffman, 1995: 365).

On the whole, women reportedly engage in less physical activity than men, except between the ages of 35 and 54 (ICDC, 1997: 253). This is consistent with a trend observed in the At survey, which found that women over 45 were taking better care of themselves than younger women.

The effectiveness of mammography screening in reducing breast cancer mortality is widely accepted: the results of randomized and controlled studies in different parts of the world demonstrate a uniform reduction in mortality of between 30 and 40% in women aged 50-69 who underwent screening every two or three years. Studies show more modest results in women under 50 (Rennert 1996; Fletcher et al, 1993). Yet, health funds have been slow to comply with the Israel Ministry of Health's requirement that all women over 50 be personally invited for screening, and family doctors do not always follow accepted guidelines for referring clients for mammography. Nonetheless, as a result of the National Mammography program, screening rates are on the rise - from approximately 30% of those eligible (women aged 50-70) in 1997 to 50% in the first quarter of 1998 (Miri Ziv, Israel Cancer Society).

Hormone Therapy 

Israeli doctors tend to be enthusiastic advocates of hormone therapy for women during menopause. At one of the first conferences on Women's Health in Israel, in 1991, a leading gynecologist defined this treatment as the most burning women's health issue for the medical professions: "Many women suffer from hot flashes and depression during menopause," he stated. "But it is difficult to convince them to take hormones over an extended period of time... Part of our job is related to educating women and changing behavior patterns and we must convince doctors as well of the need for such treatment" (Palgi, 1991: 104).

At the first Israeli conference on the subject of Women and Heart Disease, held in May 1998, Wenger, a leading US expert, stated, "The final word is not yet in on hormone replacement therapy. In addition to concerns about the increased risk of breast and endometrial cancer, it should be noted that clinical trials [for hormone treatment] have been conducted among healthy women. Thus, anticipated benefits may be overrated."

Women in Medicine

Over the last two decades, there has been a dramatic increase in the number of women accepted to Israeli medical schools. While in 1975, less than 30% of those studying medicine were women, by 1995 the number had risen to 48%. This level is higher than the level of female medical students in the US (Notzer and Brown, 1995).

The wave of immigrant doctors from the former Soviet Union resulted in an increase in the number licenses granted to women in Israel - from only 30% in 1989 to 49% in 1993 (ibid).

Nonetheless, gender differences persist in the choice of medical specialties, with women still concentrated in the lower paying and less prestigious fields of family medicine and pediatrics while men dominate in surgery, gynecology and internal medicine (Notzer and Brown, 1995). One result of this traditional division of labor is that many more male doctors are found in in-patient settings, while female doctors are concentrated in out-patient clinics. In 1991, only 12% of hospital-based doctors were women (Shuval, 1992). In addition, women still face obstacles to promotion within academic medicine where, despite increasing numbers, the majority of women remain concentrated in lower level, clinical instruction positions rather than in senior research and teaching positions (Notzer and Brown, 1995).

Medical Training and Research

Given the fact that women represent the majority of the users of health care services, about 70% of the health care workers, and about half of the medical students, it is surprising that Israel's medical schools still do not offer a single course on Women's Health.

Equally surprising is the absence of research on women's health issues. A Medline search, using the terms "women," "health" and "Israel," for the years 1990-97 revealed only 55 articles. The majority of entries related to traditional female caregiving or support roles, such as nursing, teaching, and caring for ill spouses, along with pregnancy, childbirth, feeding, etc. Many of the articles had to do with the emotional reactions of women to stressful situations, such as marriage to military men, armed conflict, abortion and other medical procedures.

Few studies focused on factors contributing to illness and the response to it in women, on the delivery and outcomes of primary care or on conditions common or specific to women.

The persistent gender gap in medical research has been well documented (Laurence and Weinhouse, 1994). Insufficient research on women is not only discriminatory but dangerous, since medical care, drug treatments and even diagnostic tools that prove effective in men may not be generalizable to women. Therefore, using men as the medical standard in a paradigm in which women are at best a deviation may influence clinical decision-making and put women at serious risk.

Women are an invisible majority in a system that functions as if they were a minority. If public health policies are to truly promote women's health, women need to become part of the picture in medical research and practice, within a model that takes women as the operative norm. The nature and underlying causes of gender differences in illness need to be investigated more fully. Additionally, investigations of women's biological functions need to be replaced with an examination of their social statuses as wives, mothers, daughters, and workers, and studies on the impact of gender inequalities on physical and psycho-social well-being.

Righting inequities and redefining women's health in women's terms will take time, since women, as well as doctors, have been socialized into a male-centered, bio-medical system. But defining women in women's terms is not a problem unique to medicine. It is an essentially feminist issue and as such deserves to be addressed in the context of general efforts to improve the status of women and remove barriers to women's full participation in society.

Licenses Granted to Medical Practitioners in lsrael, 1948 - 1993

Years             Men           Women         Total

1948-1989         12,409 (70%)   5,421 (30%)  17,830
1990-1991 (*)      2,701 (62%)   1,622 (38%)   4,323
1992-1993          3,308 (51%)   3,162 (49%)   6,470

Total: 1948-1993  18,418 (64%)  10,205 (36%)  28,623 (100%)

Source: Notzer, Neta. and Brown, Suzanne, 1995, "The Feminization of the
Medical Profession in Israel," in Medical Education, 29 (5).

(*)January 1990 marked the beginning of the issue of licenses to
immigrants from the former USSR.
Medical Education in Israel, 1995

Specialty               % of women  % of men   % of all   significance
                        residents   residents  residents

Boards of Medicine (*)  35          37         36         NS
Surgery (**)            7           19         16         P<0.0l
Psychiatry              17          9          11         P<0.01
Gynecology              7           13         11         P<0.01
Pediatrics              19          14         16         P<0.05
Family Medicine         15          8          10         P<0.01
Total n                 738         1728       2466
Total %                 (100%)      (100%)     (100%)

Source: Notzer and Brown, op. cit.

(*)Includes: internal medicine, cardiology, nephrology, neurology,
gastroenerology, diagnostic radiology, and oncology

(**)Includes: general, thoracic and cardiac, plastic, orthopaedic and
pediatric surgery, ophthalmology, neurosurgery and anesthesiology