Ha’aretz Dec. 31, 2021

One of the formative childhood impressions of Nihaya Daoud, professor of public health at Ben-Gurion University, was an understanding of her parents’ feelings of having missed out: Her father had to forgo hopes of pursuing an education and worked all his life in construction, and her mother, an outstanding student, ended up being a homemaker.

“I grew up with the experience of my mother wanting very much to continue her schooling and of my father wanting to get a good education, but it didn’t work out for either of them,” Daoud, 55, relates. “So everything was invested in us, the children. In my teens, they sent me to every possible after-school enrichment group: art, nature, mathematics. The message was: Be outstanding.”

Daoud took the message to heart and was determined to put it into practice. So, a little over than a decade ago, when she got an offer to do a postdoc at the University of Toronto, she didn’t think twice. She had children, of whom the youngest was in the third grade, and her family was somewhat taken aback at the thought of her leaving home for two years.

“After all, there are generation gaps when it comes to the notion of what a woman needs to be and how far she is allowed to go to fulfill herself,” Daoud explains. “It was hard for my mother that I was going alone. She’s the one who planted these ambitions in me, but even so, she thought that was a step too far.”

It wasn’t only in Daoud’s family that eyebrows were raised. “I remember one of my Jewish colleagues asking my partner: ‘How can you let her go alone like that?’” she says. But Daoud, a social epidemiologist whose research centers around inequality in health policy and women’s health, ignored the tongue-clucking. One of her most-quoted articles from her period abroad deals with the connection between low economic status and intimate-partner violence among Indigenous women in Canada. Even as she was authoring articles for prestigious publications, Daoud’s stay abroad allowed her to take a new look at the place where she grew up.

“There is solidarity within migrant society in Canada – people help each other. Here it’s no longer like that. People have become alienated from the life of their community: I’m out for myself alone and that’s it.”

Was it always like that?

“No. The Arab society I grew up in was far more egalitarian. Our neighbors would bring us flour and we would bring them grapes. There was mutual surety. People today don’t care about their neighbors, no one looks to the right or the left. Some drive a Mercedes, others have nothing to eat. Arab society has undergone individualization processes that are more acute than in the United States and Canada. The economic disparities today are appalling.”

The recent historic entry of an Arab party (the United Arab List, aka Ra’am) into the coalition in Israel was also marketed to the Arab public as a move to help maximize material achievements.

Bottom of Form

“Totally. [UAL leader] Mansour Abbas’ rhetoric is individualistic-capitalistic, and doesn’t necessarily spring from concern for the collective. It’s a discourse that serves the wealthy segments of Arab society. Israel, of course, supports this. The message is: excel and look out only for yourself; forget about nationality, identity. You can be the director of a department at a hospital and get a really good salary, build yourself a house that’s like a castle – but around you everything is horrific: The access route into town is unpaved, there are no street lights, there’s litter scattered everywhere, violence on every corner. And that is simply of no interest to you. That is incomprehensible. The politics of the UAL might produce something in the short run, but it’s tearing the Arab community apart from within. There are dangerous developments underway among us. And ironically, the person in the forefront of this is himself a doctor, a dentist. Abbas should have been the educated person who works from the heart.”

Your criticism of the alienation of the most successful members of Arab society focuses on physicians.

“Because that’s where I come from. Arab men who returned after studying medicine abroad did not translate their knowledge into improving the medical services provided to the Arab community. For the most part they choose residencies that can advance them personally – internal medicine, surgery – or go wherever the Israeli system channels them. It’s quite common to see an Arab ‘slot’ that is changed every five years. Every hospital ward has its Arab fig leaf. As a general rule, Arab physicians tend to prefer hospital residencies rather than community medicine. In my opinion, they need to try to exert more influence in their community.”

Daoud doesn’t flinch from probing the festering wounds of her community, but her gaze is also constantly fixed on the Israeli establishment that has neglected them. Her research, for example, has focused on the impact of social and political phenomena (home demolitions, polygamy, lack of civil status) on morbidity and on access to health services among Israeli Arabs. As such, her work differs from classical research in this field, she explains: “Other public health researchers perceive variables such as gender, level of education or employment as elements that interfere with research. As such, they have neutralized and standardized these variables. I do the opposite. I don’t put the bacteria and viruses at the center – rather the social and political systems.”

“That is not the research mainstream,” Daoud emphasizes, noting that “it’s not easy to sound this kind of critical voice in the political constellation in Israel and as a member of a minority. It hasn’t always had an attentive ear. When I was working on my doctorate there was a discussion about whether to make do in the research hypothesis with the term ‘discrimination,’ or to opt for ‘racism.’ I urged ‘racism.’ My advisers kept telling me, ‘We need to teach you a lesson about survival in Israeli academia.’”

Feminist lifestyle

Daoud was the first Arab woman in Israel to obtain a PhD in public health, and afterward became the first professor from her community in that field. Besides being a highly prolific researcher who holds an array of public positions and serves on various national bodies, she also finds time for political activism. Among her community, Daoud is considered an authority on health, social and gender issues, and Arab politicians also seek her advice from time to time. In the last election she received offers to run from two parties, she relates, but rejected them outright.

Daoud is married to Anwar, the principal of a school in East Jerusalem. The couple live in the Jewish-Arab community of Neve Shalom, located between Jerusalem and Tel Aviv, and have three grown children. She grew up in the city of Tira in the “Triangle” (a concentration of Arab locales in the center of the country, adjacent to the Green Line), which was also where her mother was born. Nihaya is the second daughter among seven children (“Six of us studied academically”). She believes that the massive push and encouragement she received from her parents is not necessarily unique to her family and also has a historical context.

“The need to prove yourself through higher education is an ethos that was adopted by many ‘internal migrants’ after the Nakba,” she says, referring to the war of 1947-49, the “catastrophe,” when more than 700,000 Palestinian Arabs fled or were expelled from their homes. “They lost their home, lands and source of income, so for them studies became part of their struggle for existence. For those who remained in their community and on their land, the aspiration to pursue an education was not so powerful, whereas the internal migrants developed resilience by pursuing that path.”

Daoud recalls that the library in her parents’ home was always rich and diverse, and included political literature. She usually joined her father at Communist Party meetings; her sister studied medicine in Bulgaria with the party’s financing. For her part, she preferred to remain in Israel and enrolled for an undergraduate degree in nursing at the Hebrew University of Jerusalem – and has been in academia almost continuously ever since.

“While I was at Hadassah [Medical Center in Jerusalem] doing my doctorate in public health, I was the only Arab in that program and practically the only one around in general – except for the cleaners,” she relates. “No one made any concessions for me. On the contrary: I had to work harder in order to get ahead.”

By way of illustration, she recalls a case “when I contacted the Helsinki Committee [which oversees medical research and trials on humans] at a well-known academic institution whose name I won’t mention, and asked to speak to the chairman. The secretary called him to the phone, saying, ‘There’s some Arab woman who wants to talk to you.’”

During her time in Toronto, beginning in 2010, where she pursued her post-doctoral fellowship, Anwar and their children visited her during vacations, while she traveled to Israel whenever she could. Throughout most of the period the household chores were carried out by her husband. “During routine times, too, if I came home at 8 P.M., and he hadn’t prepared food – there was none.”

Daoud’s feminism was not confined to her home. She volunteered with the hotline for battered women in the Israeli Arab community and was intensively involved in such civil society organizations such as Women and their Bodies, a Jewish-Arab NGO. Her latest project, which she co-founded with four other female professors, is geared to encouraging female Arab students to work toward advanced academic degrees in all fields. However, an attempt to establish a council for the advancement of Arab women ended in frustration: “Women from a whole range of fields – law, education, health and so on were involved in the initiative. It was supposed to operate according to the model of the Israel Women’s Network [lobbying organization]. It was a great disappointment. Women from Arab parties, who consider themselves true feminists, simply torpedoed it because of struggles over getting credit.”

She experienced a similar letdown at the outset of her path. At the time, she was the Health Ministry official in charge of creating educational programs for the school system.

“The programs were earmarked for the Jewish public, and when I asked that the program be implemented in the Arab community, I was told that there was no budget,” Daoud recalls. “I understood then that this wasn’t the place for me, and I decided to change direction and focus on research.”

Her first significant research study dealt with how mechanisms of discrimination and exclusion lead to poor health among Bedouin women.

“We examined access to health services by means of a comparison between women from communities recognized by the state and women from unrecognized locales. Naturally, the situation in the unrecognized communities was far more serious. We saw clearly that low social status among women has implications for their mental and physical health. One manifestation of this is the frequency of postpartum depression among Bedouin women. The discrimination is so deep and rooted that very little can be done about it. I felt lost, having nothing to offer these women.”

And then you ask yourself, “What’s the point?”

“No, I never make do only with academic publication, but meet with relevant individuals to talk about the subject. The issue of polygamy, for example, came up in a committee initiated by the Justice Ministry. Regrettably, not enough Arab women were invited to appear before the panel, and its conclusions were limited. The state legitimized polygamy in order to silence the Bedouin men in regard to other subjects. Effectively, the state told them: ‘Take control of your women, but don’t talk to us about land.’ I say this in the most direct way. And unfortunately, oppression of women in Bedouin society has destructive consequences for society at large.” (While polygamy is basically illegal in Israel, it seems, the authorities turn a blind eye to it in certain contexts.)

In what way?

“If the man barely looks at his former wife or his first wife – if she has been deprived of the possibility to study, if she has no source of income, then she actually has no status. And then her authority over the children also crumbles. What investment can a woman like that be expected to make in her children? And how can anyone be surprised at what is happening today?”

Are you hinting at the so-called “loss of governance in the Negev”?

“Definitely, that is one of the explanations. When women have almost no control over their life, their influence over their children is limited.”

A few years ago, Daoud led a study that examined the scope of domestic violence in Israel, with the participation of 1,401 women. “We saw that the rate of reports about violence involving Arab women was more than twice what it was among Jewish women,” she says. The database she created served Daoud as a platform for a follow-up study, focusing on the women’s use of health services.

“The findings showed that Arab women who are subjected to violence visited a gynecologist three times more often than battered Jewish women. The Arab women also availed themselves of emergency room services at far higher rates. Our interpretation was that Arab women will only seek the help of the health system when they suffer serious physical violence. The decision to see a gynecologist was explained as stemming from a reluctance at visiting the family doctor and the apprehension that he would not respond properly. Besides, the gynecologist they see will very likely be a woman; she will not necessarily live in the same locale, and there’s a good chance she will not be a relative of the patient.”

That comment alludes to one of the major obstacles facing Arab women who are Israeli citizens in their quest for optimal health services. The obstacle, the professor notes, stems from the family structure within communal medicine in Arab society, particularly in rural areas. That is, many women are channeled to a family doctor who is also a relative.

“That’s a critical problem in regard to women who are victims of violence,” Daoud explains. “Those women will not dare see a doctor who is a relative; alternatively, if that doctor detects signs of violence, he will probably not pay much attention to them.”

I suppose that this gives rise to difficulties with less serious health issues, too.

“Correct. After all, not every visit to the family doctor is because of a cold. Sometimes you need a referral for a breast examination, or you need to reveal intimate details. It’s not pleasant for a woman if the doctor who examines her is her cousin or her husband’s cousin. She also can’t choose a doctor without coordinating it with her partner. To visit a doctor from another hamula [clan] requires an explanation: What happened? Why him, of all people? Why don’t you support our relative? That obstacle is an Arab intra-communal matter, but it is related to a system-wide fault: The more successful a physician is in attracting more patients, the more he earns, and the most available reservoir for recruiting patients is the family.”

That is a problematic phenomenon in itself: the abuse of the family structure in Arab society to recruit physicians for marketing purposes: The health maintenance organizations approach Arab GPs and pay them huge amounts of money for bringing all their family relations into the HMO. Or, alternately, they offer them a residency slot on condition their family joins the HMO. What consequences does that have?

“Serious ones. It’s a type of corruption. As such, the health system tramples the rights of insured clients. When a physician is brought on board not because of the quality of their treatment or their excellence, but solely because of the economic benefits they can provide – you abandon your basic commitment to providing the community with optimal service by such professionals. Some of those doctors are engaged in contract work, not medicine. I see family doctors who have gotten quite wealthy this way – they make money at the patients’ expense. The same things happen in Haredi society, too, by the way. The fact that the system allows the phenomenon to exist and even promotes it among the weakest population groups is very grave. It mustn’t happen. The Health Ministry has to intervene.”

Daoud’s latest research deals with the separation of Jewish and Arab mothers in hospital maternity wards. The phenomenon itself isn’t new: It hit the headlines five years ago in the wake of a comment by Bezalel Smotrich (at that time, a lawmaker from Habayit Hayehudi) on the subject: “It’s only natural that my wife would not want to lie next to someone who just gave birth to a baby that might murder her baby in another 20 years.” Daoud does not try to quantify the phenomenon, rather to expose its roots. Her study involved in-depth interviews with hospital directors, midwives, nurses and new mothers, enabling Daoud to track three mechanisms of what she calls racial separation and inequitable maternal care in the maternity wards.

“The first level is the separation that exists in Israel in every walk of life – and there are women who want to drag the separation into hospitals. The second mechanism is the commercialization of maternity services in Israel. The hospitals receive a great deal of money from the state for each delivery they perform, and therefore the staff capitulates to the women’s requests: ‘We’ll give you what you want, just come to us.’ The third mechanism is ‘cultural adaptation.’ The hospital staffs have found justification for segregation, claiming it’s beneficial to the women.

“One of the directors told us explicitly: ‘If Svetlana is leaving the delivery room, why should I put her in a ward with Fatma? It will be more pleasant for her in a room with someone who’s like her. A Russian woman will have one visitor at most, an Arab woman will be flooded with visitors from the whole hamula.’ Just like that – in those words.”

It’s untenable for there to be no Arabs in the decision-making centers of the health system, other than physicians who served in the IDF. It’s illogical for discussions about inequality in health not to be led by an Arab.

Daoud

After being shocked, it’s worth asking: What is so terrible about that? If a woman meets only people like her all her life, why does she need to try coexistence in a situation as intimate as childbirth?

“A legitimate question. We know that separation is the origin of discrimination and racism in all realms of life: housing, education, welfare, transportation. And we see how separation of Arab and Jewish communities causes systemic racism. So there is no need to take that model and clone it in the health system. Hospitals are supposed to constitute a universal venue.”

Isn’t the conclusion that segregation leads to less optimal medical treatment a bit exaggerated?

“I don’t believe that physicians and nurses act out of conscious racism or want to give Arab women below-par treatment. But we know that the health system is overburdened and hungry, and so the staff needs to prioritize. The concern is that by the very fact that you [as a medical professional] are placing a group of women from the majority population in one room and a group of women from a minority population in a different room – you will visit the former room first. When the system suffers from understaffing, basic instincts come into play, and that’s where the danger lies.”

‘Cultural blindness’

Earlier this month Daoud received the Sami Michael Prize for Equality and Social Justice, awarded by the Heksherim Institute for Israeli and Jewish Literature (and named for the acclaimed Israeli author). A good part of her speech at the ceremony dealt with the coronavirus pandemic and its severe consequences for weaker population groups. Daoud is a member of the COVID Crisis Experts panel, a voluntary Jewish-Arab initiative supported by the New Israel Fund that is addressing, among other issues, the inequity in health care that has intensified as a result of the outbreak. Within this framework, Daoud conducted a study – which preceded similar Health Ministry research by half a year – on the connection between “red” locales (i.e., those with high COVID rates) and socioeconomic status.

“The handling of the coronavirus crisis in Arab society has failed,” she asserts. “A person who is not from the [public health] field was appointed project director for the Arab community. That absolutely infuriated me. There are so many experts, and he of all people is appointed? We all saw the consequences. The Arab locales were red most of the time. In general, the ministries tend to appoint Arabs who are convenient to work with because of their connections to the government. That is the mentality of a military regime.”

Did the appointment of Prof. Salman Zarka as the general coronavirus commissioner bring about a change for the better in dealing with Arab society?

“I haven’t see a change of that kind. The commissioner looks at society in general.”

Is it of no importance that a Druze physician is the supreme professional authority for handling the crisis?

“He comes from the army [Zarka is a colonel in the reserves], from the Medical Corps. As such, he has groomed himself to be an Arab in that realm.”

Daoud has tried to wield influence internally. While Prof. Hezi Levi was serving as director general of the Health Ministry, she worked to establish a dedicated committee under its auspices to deal with the coronavirus crisis in Arab society. A committee was in fact established, but Daoud resigned from it after one meeting.

“They appointed political figures in a way that was inappropriate and unsuitable,” she explains. “When I saw that the [ministry’s] director general didn’t show up for the first meeting, I understood that it was a panel with no teeth, nose, mouth or eyes – because not even transparent data were presented to us. They appointed a committee so they could say they appointed a committee. I said thank you and left.”

It sounds as if you are a little disappointed at not having been called on to serve in a more senior capacity.

“Actually, no. As I said, I had the opportunity of entering, I was invited to meetings. I don’t have an ego in this connection. I am trying to point to a far more systemic problem. It’s untenable for there to be no Arabs in the decision-making centers of the health system, other than physicians who served in the Medical Corps. It’s not reasonable that the person who now oversees a ministerial budget of hundreds of millions of shekels that was earmarked to advance health in Arab society is Jewish. It’s illogical for discussions about inequality in health not to be led by an Arab. Where are we?”

She goes on to note that “an absurd and inexplicable situation has been created. There are a great many Arab workers in the health system, including physicians in senior positions, but Arabs constitute less than 1 percent of the staff in the Health Ministry’s main headquarters. The apparatus that makes the decisions, sets policy and channels budgets is almost completely devoid of Arabs.”

Still, Daoud says, “I am not saying that everything is bad. The health system in Israel is one of the best in the West. The Health Ministry also acknowledges the disparities that exist within it, which is a far better situation than in the past. It is simply not doing enough to reduce them.”

In this context the professor has drawn up an orderly plan that calls for establishment of a ministerial unit for dealing with minorities and the return of the “nationality” rubric to medical documents.

“The civil society organizations fought to have that rubric canceled in the 1980s, which was a mistake on their part,” she explains. “Classification by nationality and other social categories can serve as a tool for setting policy. If you know that a certain phenomenon exists among the Arabs, and there are other clear data regarding the Haredim – specific responses can be adapted for those communities. That would be better than the situation today, where the system suffers from cultural blindness.”

Recognition of this problem is half the way to its solution, Daoud maintains: “The health system needs to be courageous and to acknowledge the inequality that exists within it. When that is dealt with, we will see calm within the system. Much of the violence against medical teams stems from patients’ racist attitudes toward the health-care professionals treating them, from the professionals’ attitudes toward their patients or from patients’ attitudes toward other patients. The system must recognize this. The shooting at the entrance to Soroka [Medical Center, Be’er Sheva, recently] was not a chance event. The health system is a microcosm of all of society’s ills. The disparities in education, employment, housing and transportation are expressed palpably in our bodies, and then we come to the health system sick.”