By Barbara Sofer
On August 26, 1920, when American women were first given the right to vote, Hadassah, the Women’s Zionist Organization of America had already established in 1918 the first post-high school academy for women in pre-State Israel, a western professional school for nursing. Additionally, Hadassah had already begun its mother and child clinics, cutting death rates in childbirth and vastly improving the chances for children in poverty-stricken pre-State Israel. Nevertheless, in 2023, women are still facing gender-related challenges as both patients and medical professionals.
Advancing Women’s Care and Medical Careers
Women have made major gains in getting equal health care over the last 15 years, but they haven’t come far enough, according to Dr. Donna Zwas, the founding head of the Hadassah Medical Organization’s Linda Joy Pollin Cardiovascular Wellness Center for Women in Jerusalem. Underdiagnosis and under-treatment of women’s heart disease — despite cardiac disease remaining the number one cause of death in women worldwide — is emblematic of gender bias that persists in medicine.
“In 2023, there are still glaring disparities between the health care women receive and the health care men receive,” says Dr. Zwas. “For example, in our field of cardiology, women’s arrival time from ‘door to balloon,’ from reaching the door of the emergency room to reaching the cardiac catheterization center, used to be an hour longer than men’s, but it’s still a measurable 12 minutes longer in 2023. When you add this to delays in help-seeking by women, and differential treatment by emergency response services, women with heart attacks have a three times higher probability of dying compared to men with heart attacks.”
At the same time, women health professionals face continual challenges in the workplace, in their daily lives and in salary scale.
That has to change, argues Dr. Tamar Elram, a gynecologist/obstetrician and director of Hadassah Hospital Mount Scopus in Jerusalem.
“The significant growth in women entering the medical field is already changing the face of the career,” says Dr. Elram. “Women have a different attitude toward work-life balance. The more equitable role of men in childrearing and family responsibility has also created a greater desire for men, too, to have a more satisfactory work-life balance. The field of medicine needs to adapt and reflect these new realities.”
In the past, women residents were more likely to choose “feminine disciplines,” like being pediatricians and general practitioners, which are more convenient for bringing up children, according to Dr. Elram. “Today, woman want to be obstetricians and general surgeons, and balance that with family life,” she says.
Studies in the United States show that women medical residents often postpone having children to the point of risking infertility, but not in Israel.
“When I was a resident in obstetrics and gynecology it was rare for a woman to go into this field, but today the overwhelming majority are women,” says Dr. Elram.
Although the number of children women give birth to and raise often decreases as women become better-educated, that isn’t the pattern in Israel where women are becoming better educated and still leading the developed world in family size. For example, Dr. Elram has five children; cardiologist Dr. Zwas has four.
“Medical residents and nurse graduates are at the prime ages for having children and are likely to be pregnant at least once during their training years,” says Dr. Elram. “The training programs need to be adjusted for this reality. For example, according to law in Israel, pregnant women do not have to do night shifts and shouldn’t do them. This, of course, requires adjustment of the training and human resource planning within hospital departments.”
Currently, six of the 20 residents in obstetrics/gynecology at Hadassah’s two hospitals are pregnant.
Taking Charge
Dr. Zwas and her cardiology team are marking a decade of the women’s heart clinic and the Pollin Center’s community outreach programs, which were created to address the needs of women in all sectors of Israeli society, making a particular effort to reach minority populations who are at high risk for heart disease.
For example, says Dr. Zwas, in extreme religious Jewish households, women are often the breadwinners despite giving birth to an average of six children. Childrearing and work push out time for exercise, proper diet and self-care. Many Arab women have fewer children than the very religious Jewish women, but suffer from obesity, poor diet and secondhand smoke in a traditional society in which it’s impolite to ask family and guests to refrain from smoking.
Dr. Zwas and her team stress the need for all women to take charge of their own health needs, “because no one else will.” Israel has universal health care, but women typically neglect available preventive health care because they are busy caring for others and fail to be assertive about their own legitimate health requirements.
Arab women in Jerusalem have a 50 percent rate of diabetes. Nevertheless, to Dr. Zwas’s disappointment, the Center for Disease Control and Prevention’s efficacious programs to prevent diabetes were not as successful as she had hoped, even when they were culturally adapted by the Pollin Center. “Only when we added an empowerment unit to the curriculum, did the success rate boom,” says Dr. Zwas. The Pollin Center’s health-promotion course is now offered in Arabic at Jerusalem community centers.
Women are also far less likely than men to take advantage of cardiac rehabilitation, says Dr. Zwas.
“The reasons for this range from family responsibilities to lack of social support to differences in how the referral is presented to the woman. Typically, when a man is in rehab his wife comes along, encourages him and sits through the session," says Dr. Zwas. "When it’s her turn, transportation issues and caregiver issues get in the way. And once the woman arrives, she may feel out of place. In Jerusalem, where many women cover their hair and dress in modest skirts and long-sleeved shirts, they feel uncomfortable wearing gym clothes in a mixed environment. All these factors contribute to reduced follow-up and health behavior change after a heart attack, with deleterious results.”
At Hadassah’s cardiac rehabilitation center separate hours have now been instituted for men and women to address this problem.
Until recently, many women who had a stress test, which requires the placement of electrodes on the chest, were exposed, despite the presence of male technicians and physicians. Through Dr. Zwas’s team’s activism, the national protocols have changed. Today, women throughout Israel must be offered covering when they take a stress or echo test.
“This isn’t only a concern for religious women, but for all women who don’t want to be uncovered,” says Dr. Zwas.
Dr. Elram also aims at empowering her patients. “When I do a gynecological exam, I meticulously and gently explain what I’m doing and that this is the full scope of what is included in a pelvic exam. Anything more is abuse.”
Research, once conducted mostly on men or on male animals because of the fear of the impact of menstrual cycles on the data, has become more gender-minded. “No one would even think of testing a new medication on men only,” says Dr. Elram.
“Medications affect women differently than men, not only because they may weigh less, but because of differences in fat and muscle distribution and because of genetic differences in metabolism and the effect of the medications,” says Dr. Zwas. “A patient’s sex has to be taken into consideration when choosing medications and for dosage. There is often a built-in bias toward male metabolism when creating drugs and in administering them.”
Women also need different interventions and motivation to adapt healthier habits, says Dr. Zwas. “Equity also means applying different tools for making healthy change. While men may prefer one-on-one direction, health-promoting groups are powerful tools for women.”
Women doctors and nurses take on decision-making life roles, but they, too, may be reticent about standing up for their own rights, says Dr. Elram. “We have a long way to go to be assertive about what we deserve. We should not feel we’re getting a favor for better work conditions or salaries. If it doesn’t suit us, we have to be able to say ‘thank you but no thank you.’”
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