Medical Treatment of Refugees and Asylum Seekers in Israel
“Do not inquire the name of him who asks a shelter of you. The very man who is embarrassed by his name is the one who needs shelter.” (1)
As medical students in Israel, we were privileged to volunteer in an open clinic for refugees and asylum seekers in Tel-Aviv during the past year. The clinic is operated by Physicians for Human Rights (PHR), a non-governmental organization (NGO). This article will review the clinic’s activities, and within this framework we have conducted an interview with Iman Aghbariyya, the manager of the open clinic. Let us first understand the background of the current situation.
Refugees in Israel
The UNHCR’s (UN High Commissioner for Refugees) annual 2008 Global Trends report shows the number of people forcibly uprooted by conflict and persecution worldwide stood at 42 million at the end of last year. The total includes 16 million refugees and asylum seekers and 26 million people uprooted within their own countries (2).
Since 2007 there has been a dramatic increase in the number of refugees and asylum seekers arriving to Israel, mainly from Africa, following regional conflicts and humanitarian crises. Nowadays, about 17,000 reside in Israel (2), coming mostly from Erithrea (7000) and Sudan (5500), and the rest from other countries like the Ivory Coast and Congo. Nearly all asylum-seekers come to Israel through Egypt. Israel’s southern border is over 230km long and porous, only a low fence separating the two states. Asylum-seekers pay Bedouin guides hundreds of US dollars to get them to the frontier where they risk getting shot at by Egyptian border guards. According to UNHCR and NGOs in Cairo, in recent years hundreds have been wounded and detained while attempting to cross the border, several have been deported to their countries of birth, while others have been shot dead (3).
In Israel, under certain circumstances, regulations can allow asylum-seekers to work, and grant temporary protection and non-refoulement (a commitment not to force people back to where they came from). However, getting non-private medical treatment is a more complicated problem. Until their legal status is regulated, asylum-seekers are entitled to get emergency medical treatment but not to use the public healthcare system. Therefore, once in Israel, they are forced to receive their medical assistance from UNHCR and local NGOs, including Moked, Assaf, the African Refugee Development Centre (ARDC) and Physicians for Human Rights (PHR). Last year, the Israel medical association opened its own clinic, providing free primary treatment for refugees.
The Clinic
PHR-Israel was founded in 1988 with the goal of struggling for human rights, in particular the right to health, in Israel and the Palestinian territories. Today PHR runs five projects: the Palestinian territories project, the prisoners and detainees project, the migrant workers and refugees project, the project for the unrecognized villages of the Negev, and the residents of Israel project. In addition, PHR runs a mobile clinic in the Palestinian territories, and an open clinic in Tel Aviv that provides services for all within Israel who have no legal status and therefore no health insurance.
The entrance of the open clinic in Tel-Aviv
Since its foundation in 1998 about 20,000 patients have been treated by the open clinic. The clinic is run mostly by volunteers and operates on two levels. On the humanitarian level, the clinic aims to provide the best possible health services to all in need, including migrant workers, refugees, asylum seekers and other status-less persons lacking medical insurance; On the ideological level, the clinic leads the struggle to change policies and to apply the national health insurance law to the populations treated by the clinic.
For the thousands of refugees and asylum seekers arriving in Israel in 2006-2007 from Africa, the only address for medical treatment was PHR-Israel’s Open Clinic. The large number of refugees and asylum seekers made a significant impact, as the Open Clinic received over one hundred patients each evening, some with severe physical and emotional trauma.
Iman Aghbariyya has been running the open clinic for the past year. She first started to work at PHR 10 years ago, as application coordinator. She is very excited and proud of her work at PHR, managing a full time job alongside raising her 4 children. Over the years she served in different positions and before running the open clinic she ran the mobile women clinic, which promotes women health issues and provides medical care for women in villages with limited access to medical services.
Iman Aghbariyya during her work in the open clinic
Iman tells us that the clinic was founded after a migrant worker who suffered from an infected wound, died because he was afraid to seek medical care:
“About a year before the Clinic opened, a migrant worker from Ghana came to the ER suffering from a morass in the anal region. Due to his fear of seeking medical attention he had waited for almost two weeks, and only sought help when his situation became very serious. On intake in the ER he was suffering from severe infection and underwent surgery on him the same night, as well as ostomy surgery due to the severe compromising of the anal area. He was subsequently treated in the intensive care unit, and over the following two weeks underwent several operations due to worsening of his situation.
“He eventually died as the result of multisystem failure and the uncontrolled infection. The doctor treating him was horrified by his death. He met a friend who was active in the Association for Civil Rights in Israel and told her about this case, saying it was intolerable that in an advanced society someone should die from a minor illness just because they were too scared to seek medical attention in case they were deported. After calling several organizations, they were referred to PHR-Israel, which agreed to take up the challenge”.
The clinic is operating five days a week, three afternoons as a general clinic, once a week as a specialists’ clinic (gynecology, orthopedics and more) and one morning as a pediatric clinic. The clinic relies on volunteers who include about 160 family doctors, pediatricians, gynecologists and other specialists, 27 nurses, 54 medical students assisting with the triage, 50 translators, and 50 non-medical volunteers who assist with reception. In addition to the doctors coming to the clinic, about 30 doctors with a broad range of specializations receive patients in their own clinics, free of charge or with only a symbolic fee. Physiotherapy, acupuncture and dietician services are also provided.
In principle, each visit in the clinic costs the patient 10NIS (~2 Euros) but in fact, no charge is collected since even this sometimes can’t be afforded by the patients. Practically, no other choice is available to them because a similar visit in private clinic would cost around 500NIS (~100 Euros).
Funding is provided by many organizations, as well as private donors. The medicines are supplied by pharmaceutical companies (mainly drugs near expiry date), and from patients who no longer need the medications they have purchased.
The clinic cooperates with hospitals and other voluntary organizations in Israel. It is connected through agreements with various medical institutions that allow the patients to receive a variety of examinations, and other services, sometimes including surgery, free of charge or with significant discount. Tel-Aviv Sourasky Medical Center (Ichilov) donates a large amount of laboratory work, Assuta hospital provides discounted surgery and Sheba hospital at Tel Hashomer provides discounts for both examinations and treatments.
The Profile of the Patient Population
Until 2007 the most prominent group among those seeking help from the clinic were migrant workers, coming to Israel from developing nations to secure a future for their families. Since 2007, due to both local and global reasons, the profile of the patient population has changed. Along with activation of a deportation campaign against unauthorized migrant workers in Israel, the number of patients began to rise. The reason was mainly an increase in the number of asylum seekers and minors, arriving in Israel as a consequence of the political situation in their countries. Refugees and asylum seekers had accounted for a small proportion of patients in 2006, but during 2007 their relative weight rose steadily (3).
A detailed examination of the statistics for 2007 showed the increase in the number of refugees and asylum seekers, along the decline in number of migrants (taken with permission (3))
The patient population is comprised mainly of young and basically healthy people (ages 20-40). Many patients suffer from seasonal illnesses such as upper respiratory infections. Others suffer from other “simple” conditions such as urinary tract infections, but also from trauma following street fights. It is not all that surprising that many patients also suffer from psychological co-morbidities when you consider traumatic experiences they may have undergone on their way to Israel, and their life circumstances that entail much uncertainty and insecurity.
As an example of the cases the clinic deals with nowadays, Iman tells us about the following case:
“A 28 year old refugee from Erithrea, who arrived in Israel a few months prior to his visit, came to the clinic due to rectal bleeding, and abdominal pain. He was referred to the ER (which is obliged, by law, to attend to emergency cases). In the hospital, after a comprehensive workup, a malignant rectal tumor was diagnosed. He needed chemotherapy to reduce the size of the tumor before surgery. He would need further chemotherapy and radiation after surgery. The oncology ward refused to admit him for this expensive and long lasting treatment without a sponsor. Application for financial help to the UNHCR got a negative answer due to the high cost. Consequently he did not get the chemo treatment. The emergency treatment he finally received in the hospital included surgical resection of the tumor, and a stoma surgery. The patient is in need of stoma bags, costing over 1000 NIS (200 Euros) a month, and the clinic is trying to raise the money for his treatment.”
Similar stories of refugee patients can be found worldwide. According to Dr, Hadas Yaron, coordinator of the refugee project in AMNESTY Israel, UN agencies and human rights organizations share the opinion that the solution for the problem should be a joint action by the international community. The issue needed to be solved is not a war ending after several years, but a chronic situation of unending wars.
When we asked Iman what she wishes for the clinic, she answered that she wishes there will be no more need for it, and it will close. We join her in that wish.
Eyal Lotan and Eleana Meyers-Earon are medical students in their final year at Sackler School of Medicine, Tel-Aviv University, Israel.
elotan(at)post.tau.ac.il
eleana_m(at)hotmail.com
References
1. Victor Hugo, Les Miserables.
2. Data taken from United Nation High commissioner for Refugees (UNHCR). http://www.unhcr.org
3. Under your wing, refugees and asylum seekers at physicians for human rights-Israel’s open clinic. January 2008.