TEL AVIV — A year ago, an Eritrean woman who tried to make it to Israel was taken hostage in Sinai, Egypt where she was forced into sex-slavery, abused and raped. Like other Eritreans who had paid smugglers to take them to Israel or made the trek alone, she was thrown into one of dozens of infamous torture camps in the lawless Sinai region — where individuals are raped, tortured with electric cables, beaten with chains, burned, and starved by their Bedouin captors seeking weighty ransom payments. As the woman tried to flee the camp, she was shot several times in the back. Barely alive after sustaining injuries to her spine, she was picked up near the border by Israeli soldiers, who brought her to Soroka Hospital in Beersheba. Despite numerous surgeries, the woman is now incontinent and needs 24-hour care. Who’s going to cover those costs?
At about the same time, a 30-year-old computer engineer from Sudan was kidnapped from near a refugee camp along the Egyptian border and brought to Sinai, where he was extorted for cash. He was held for $35,000 ransom, an amount his family couldn’t afford to pay, at which point his captors tortured him and cut off first his fingers, and then both his hands. No longer useful to his Bedouin captors, the Sudanese man was let go and he too was subsequently picked up by the Israeli army near the border. He received medical treatment in Israel and he now needs prosthetic limbs, which cost thousands of dollars, as well as rehabilitation. But who’s supposed to pay for it?
The issue of payment for migrants’ medical needs — from extreme cases like these two, to more routine requirements — points to a larger question Israeli society is currently debating: How much care should the government be providing for this migratory population, comprising 80,000-100,000 individuals, which lacks health insurance and steady access to healthcare, save for sporadic visits to the offices of Physicians for Human Rights or hospital emergency rooms?
In grappling with that question, the state is pitted against NGOs and individuals who claim the government routinely skirts its responsibilities under the 1951 UN Refugee Convention, of which Israel is a signatory.
In the face of the government’s initial, relative inaction on treating the migrants, one south Tel Aviv clinic began providing medical care for the asylum-seeking and undocumented migrant worker population three years ago. The Tel Aviv Refugee Clinic was set up and staffed, with minimal government assistance, thanks to donations and volunteers — an army of doctors, nurses, and administrative types from around Israel and the rest of the world — who lend their knowledge and time to the project.
Orel Ben Ari, 31, who heads the medical center, transformed a dilapidated, four-room facility into a state-of-the-art medical center. He brought in young idealists — like Jonah Mink, 27, a young doctor from Buffalo, NY who, together with Tobin Greensweig, 29, founded MigrantHealth:IL, a public health startup that raised money to implement a savvy electronic medical records system and a community outreach/medical translation program at the clinic. And at the end of 2012, the Clinic scored an investment of $868,000 (NIS 3.2 million) from the Ministry of Health.
The ministry has now rented out a new, expanded space at the Tel Aviv Central Bus Station for the operation and officially changed its name to the Public Health Clinic (though it’s still informally known as the Tel Aviv Refugee Clinic). It now has two wings: one that provides free emergency care for the migrant population via a staff of doctors who are paid by the ministry and managed by Terem; the other is Ben Ari’s original volunteer-based operation.
The ministry’s investment into the center (it had originally covered rent and utilities at the former premises, and a half-salary for Ben Ari) was partially a reward for the clinic’s independent work and partially due to the realization that the good or ill health of the migrant population has an effect on the rest of Israel.
Dr. Michael Dor, the deputy director of management at the Ministry of Health, framed the government’s decision to fund the clinic as something between a humanitarian obligation and a tactical step to combat the overcrowding of hospitals around the country – particularly the inundation of emergency rooms in Tel Aviv. Dor said that, although Israel doesn’t legally have to provide the migrant population with anything beyond emergency care and medical attention for children, the government felt it had to take a role in helping the populace, on a humanitarian level.
The more pressing part of the decision may have stemmed from what he called the “boomerang effect,” the reliance on emergency rooms and the rise in urgent-care situations from members of the migrant population — a direct result of their preventive healthcare needs not being addressed earlier. “The financial debts from the migrant population in hospitals are huge,” he said. “At Ichilov Hospital in Tel Aviv, their debt for unpaid bills amounts to more than 10 million shekels [over $3 million].”
Another issue is that many migrant women delivered babies at local hospitals without having received prenatal care, which led to complications and high costs, he said. “In the end,” Dor explained, “it’s Israel that’s footing their bill.” For example, there were approximately 1,000 instances last year in which migrant women gave birth at Ichilov Hospital, Dor said. “The migrant women also had a high percentage of preterm deliveries,” he said, “and those need a lot of treatment.” A preterm baby requires a long hospitalization period and costs hospitals upward of 230,000 NIS ($62,0000), he clarified.
Another effect of the influx of deliveries by migrant women at Ichilov, Dor added, was that Israeli women began finding other hospitals for their deliveries. “Israeli women started running away from Ichilov,” Dor said, linking the rise in births by migrant women to the drop in deliveries by Israelis at the hospital. “Last year, there was a 7% reduction in the number of Israel women who gave birth at Ichilov — and this is a tremendous financial loss to the hospital.”
So a natural place to provide preventive care for the migrants, Dor said, was via the Tel Aviv Refugee Clinic, which had already built relationships with the community.
The boomerang effect
Set against the backdrop of inflating healthcare costs and understaffed hospitals across the country, Ben Ari said that the work at his south Tel Aviv clinic makes all the more sense. Providing proper care to pregnant women at the center, he added, has the potential to directly minimize the growing burden on Israel’s hospitals.
The clinic, he explained, serves as a one-stop healthcare shop for asylum-seeking or migrant women who are pregnant. Not only does it offer the general tests that are usually done by nurses at Tipat Halav (Israel’s well-baby clinics), but it also has the capacity for ultrasounds and blood work, as well as access to gynecologists — all in one place. Ben Ari boasted that his clinic is the only one in Israel that offers all three services to women in one place at a very low, almost free, cost.
His clinic also implemented another volunteer-based social project, Mother to Mother, that empowers Eritrean women by linking them to Israeli women who support and mentor them through the child-rearing process.
Ben Ari pointed out other steps the clinic has taken to relieve the pressure on hospitals. For example, it established an Internet system in which volunteer specialists from around the country read lab and X-ray results, virtually, from their own offices. Last month, he added, the clinic held a preventive-care class focusing on tips for how to live and cope with asthma; the students were 12 patients who had already been to the hospital more than five times due to their illness.
Jonah Mink, the lanky, blue-eyed doctor who founded MigrantHealth:IL with Greensweig in 2012, also brought two new programs to the clinic. Taking a year off between his M.D. in global health from Ben-Gurion University and his residency, Mink introduced the startup’s first component — an electronic open-source system created by Greensweig that allows medical records to be shared and virtually updated. It’s based on a platform used by leading aid groups like the World Health Organization and by African countries, including Rwanda. Greensweig, a second-year medical student in the same Ben-Gurion M.D. program, recruited engineering students at the university to help tailor the software to the needs of the clinic, enabling continuity of care for Israel’s transitory population. Best of all, it’s free.
“Before this, they [the Tel Aviv Refugee Clinic] were using Excel and Word files to keep track of people they treated, but the server was somewhere in Jerusalem, and it would always crash,” Mink noted.
Greensweig and Mink also raised money via a successful crowdsource fundraising campaign for the second component of their startup: the hiring of four part-time Tigrinya-speaking nurses. (Tigrinya is the official language of Eritrea, and Eritreans are the largest cohort of migrants in Israel.)
The nurses, “ingenious, eager, and highly overqualified men from within the community,” as Mink put it, provide much-needed medical translation for their peers. This simple yet powerful tool empowers the doctors at the clinic to clearly understand their patients — enabling accurate diagnoses — and allows Tigrinya-speaking patients to fully understand their medical conditions and take responsibility for them.
Nasser, a soft-spoken midwife from Eritrea, started as a volunteer at the clinic and became one of the nurses. One of his main functions is that of a facilitator — framing the clinic’s care to properly fit his community’s needs and attitudes toward medicine. He holds instruction seminars on prevalent illnesses in the community (asthma, diabetes, skin diseases and hygiene, and respiratory infections, for example). He also navigates his peers toward a system of preventive care — via triage and follow-ups — while steering them away from a reliance on hospital emergency rooms.
“A lot of the refugees [migrants from Eritrea] aren’t here on a work visa, and they feel trapped, or helpless… They don’t always feel good about themselves, and many have experienced traumas,” Nasser said, adding that his job — of being a resource for his community and helping its members navigate the system of care in Israel — is important for both their physical and mental health.
“The model of community health workers has been proven to be tremendously effective all across Africa, in southeast Asia, in South America, and even in America, for marginalized communities,” Mink said. “We’re not reinventing the wheel here. We’re adapting low-cost proven and effective methods from around the world to this context, in Israel.”
What was unique to Israel, Mink admitted, was the country’s entrepreneurial “do whatever you like” spirit — its chutzpah attitude — that helped him get his pilot project underway. “People here don’t ask, they just do, and if they like what you’re doing, they’ll join you,” Mink said.
Mink’s wish? That he’ll be able to turn around in a year and say to the state, “OK, we’ve built a process [the electronic medical-records system and the community nurse program] in the clinic that works. Now let’s look for new ways to improve health services for migrants, while lowering costs, so that all stakeholders profit.” All that would be necessary, he added, would be the necessary political will.
As he pointed out, it takes a small amount of money up front — to pay for gynecologists and facilities for pregnant women, to fund nurses who can perform medical translation and hold public-health seminars, and to cover triage and follow-up — in other words, to keep the migrant population largely healthy.
In the end, that small investment just might save Israel money too.