The origins of the women’s health movement The Women’s Health Movement in the United States emerged in the late 1960’s. It was, in large part, a response to the increasing “medicalization” of women’s lives that had transformed natural female processes, such as menstruation, pregnancy, childbirth and menopause into causes for medical intervention. The movement represented an attempt on the part of women to regain control over their bodies, as reflected in the landmark publication of the Boston Women’s Health Collective, Our Bodies, Ourselves (1973) [1]. It was above all aimed at generating women’s health information, which was virtually non-existent at the time. The establishment of clinics by and for women and the generation of a large volume of papers, reports and books on women’s health, challenged the traditional bio-medical model which was seen as medicine by, for and based on men. Women’s health, it was argued, had been sorely neglected in research and practice as a result of the relegation of women’s health needs to the narrowly defined specialization of gynecology [2]. A new bio-social model was proposed based on a comprehensive and integrated approach to female health and well-being [3]. The bio-social model takes into account the multitude of factors- biological, social and psychological – that influence health and illness in women, including poverty, domestic violence and abuse and role overload. This model calls for a restructuring of medical education and the medical system as a whole in order to guarantee women’s health its rightful place in research, training and practice and to improve the ability of the health care system to respond to the unique health requirements of women.

The women’s health movement in Israel In Israel, the women’s health movement emerged some two decades after its American counterpart and its supporters were largely from English-speaking countries. It was only in 1991 that the first conference on women’s health was organized by the Israel Women’s Network (Shdulat Hanashim). A number of leading Israeli medical figures declined the invitation to attend, arguing that there was absolutely no difference between women’s health and men’s. Nonetheless, the conference pointed for the first time to significant differences in the health status of Israeli men and women (IWN, 1991) [4]. Women in Israel had relatively shorter life expectancies and higher rates of heart disease and cancer than women in other western countries. For men, the reverse was true: they lived longer and were in relatively good health compared to western counterparts. Women in Israel, like women throughout the world, were shown to be sicker than men, to visit doctors more often, to take more drugs, particularly psychotropic drugs. In 1994, the organizers of the IWN conference established the Association for the Advancement of Women’s Health (IAAWH) as an independent organization dedicated to improving the state of medical research, consumer education and service delivery for women. IAAWH has been at the forefront of the women’s health movement, educating consumers, raising awareness among practitioners and lobbying for changes in public health policy for women.

The state of women’s health in Israel In the decade since the conference and the establishment of the IAAWH, additional, disturbing findings have come to light concerning the state of women’s health in Israel. As reported by the Israel Center for Disease Control (1998), women are twice as likely as men to suffer from migraines; they are at almost three times greater risk for acquiring an auto-immune disease; disability in acts of daily living (ADL) is twice as high in women; one in four women suffers from osteoporosis and/or urinary incontinence; one in three suffers from hypertension; and one in ten from diabetes. Men are more likely than women to be admitted to psychiatric wards, while women who suffer more than men from depression are treated in ambulatory clinics [5]. These are all conditions which dramatically reduce quality of life for women and create a dependency on the medical care system and family members. Yet research shows that men get more support and care from spouses and more information from their doctors [6]. It has also been shown in a JDC-Brookdale Institute study of Israeli women (1999), that access to services and information is lowest for those who often need care the most: lower income, immigrant and Arab women [7].

Israeli women and heart disease Perhaps the most disturbing trend observed in recent years concerns women and heart disease. Although still considered a male condition, coronary heart disease affects one out of every two women in the course of their lives—a rate equivalent to that for males. Moreover, women are 50% more likely than men to die in the year following a heart attack [8].

This may be attributed to a number of factors: First, women have been found to wait longer than men upon the onset of symptoms of a heart attack before turning for help. At the hospital there is again a longer delay for women than for men in transfer from the emergency room to the hospital ward [9].

Particularly disturbing is the finding that men are more likely than women to be referred to Intensive Care Units. Women end up in Internal Medicine [10]. As demonstrated in the table below, the differences get smaller as age increases—meaning that not only is there gender bias, but age bias as well, with younger males getting more medical attention than females or older males.

In the area of heart disease we have a prime example of how the male-oriented biomedical model can lead to ignorance and neglect of women. In research conducted at Hadassah Hospital [11] on men and women who presented with symptoms of a heart attack, women’s symptoms were more likely than’ men’s to be recorded as “atypical” or “other.” Today it is increasingly recognized that the symptoms of heart disease differ between the sexes. Women’s symptoms are “atypical” when men are used as the norm, while they might be quite typical for women. Gender differences do not end with diagnosis and treatment of heart conditions. They continue well into the hospital release and rehabillitation processes. Dr. Yaakov Klein or Shaarei Tzedek Hospital reports [12] that relative to men, women get less counseling on heart rehabilitation upon release from the hospital (72% vs. 26%) and less referral for rehabilitation programs (68% vs 18%). Here, too, there appears to be an age bias in addition to gender with 60% of the participants in rehabilitation programs between the ages of 45-65.

Medical Education and specialization Despite the impressive body of data on gender differences in health that has been amassed over the past two decades, Israeli medical school curricula and text books continue to be based on a male-oriented model. At a special meeting of the Knesset Committee on the Status of Women, convened by MK Yael Dayan in May 2002, heads of family medicine departments at the major medical schools presented a picture of training for doctors that included as little as 30 minutes devoted to domestic violence out of a six year program. There is not a single course offered on women’s health and gender differences in bodily systems appear to be relatively neglected. Today, women represent 50% of some 1000 doctors who are licensed each year. But they continue to be underrepresented in the higher status medical professions of surgery, gynecology, cardiology, etc., in academia and in positions where decisions are made, health policy determined and resources allocated [13]. Women’s health in Israel has come a long way in the decade since the first conference on the subject. It is now widely accepted that women are in poorer health than men and that their health needs are different. The time has come to give serious attention to how those needs can best be met within the health care delivery system. This remains the major challenge for the Women’s Health Movement and public health policymakers in the coming years.

References 1. Boston Women’s Healthbook Collective, Our Bodies Ourselves. NY: Simon and Shusler, 1973 2. Johnson K and Hoffman E, “Women’s Health” and Curriculum Transformation: The Role of Medical Specialization in Alice Dan (ed) Reframing Women’s Health Calif: Sage Publications 1994. 3. Hamlton J Feminist Theory and Health Psychology: Tools for an Egalitarian, Woman-centered Approach to Women’s Health. J Wom Health Vol 2(1) 1993. 4. Israel Women’s Network. Women’s Health in Israel: Conference Proceedings. Jerusalem 1991. 5. יפרח א (עורכת) בריאות נשים בישראל 2000-1999: ספר נתונים, המרכז הלאומי לבקרת מחלות, פרסום מס' 2000,219. 6. Fisher S. Groce SB Doctor-patient negotiation of cultural assumptions. Soc of Health & Illness, 7(3) 342-374, 1985. 7. גרוס א וברמלי-גרינברג ש בריאות ורווחה של נשים בישראל: ממצאי סקר ארצי, ג'וינט - מכון ברוקדייל 20008. 8. יפרח א, שם. 9. נתונים באדיבות פרופ' טובה חצ'ק-שאול, מנהל המחלקה הפנימית, בית חולים הדסה הר הצופים 10. יפרח א, שם. 11. יפרח א, שם. 12. ד"ר יעקב קליין, הרצאה לחברי תת ועדה על קרדיולוגיה של המועצה הלאומית לבריאות האישה. 13. ד"ר נטע נוצר, הרצאה, אוניברסיטת תל אביב, מאי 2000