It would be simplistic and inaccurate to attribute the failure to contain violence within Arab society solely to neglect on the part of the Israeli authorities. Nor would it be fair to blame the Arab community or their national leaders. The reality is far more complex. Regardless of the causes of this violence, a successful intervention will be challenging, and runs the risk of backfiring. At the turn of the millennium, I was involved in a project which, over a period of several years, dramatically improved the quality of medical care within Israel’s Arab communities. A description of that process may provide some insight into how a successful and effective intervention that elicits local cooperation and avoids some of the pitfalls might be conducted.
Until recently, both the Arab leadership and public have opposed Israeli police intervention in their local affairs. To avoid arousing unnecessary antagonism, national policymakers who understood these sentiments, deliberately kept the police out of Arab communities as much as possible. The dilemma of when and how to involve police in communities where the socioeconomic level is low – especially when there are cultural differences is not limited to Israel. In the U.S. police intervention in predominantly Black neighborhoods is often looked upon with suspicion and even hostility. Just as Black communities tend to be distrustful of the U.S. police, so, too, until recently, Arabs have been wary of Israeli police intervention, and have opposed it.
But times have changed in two significant ways. Firstly, as violence within Arab communities has escalated, members of the nonviolent majority, fearful of the violence, are no longer prepared to tolerate the status quo. They have soberly come to realize that, without outside intervention, change is unlikely. They are likely correct. As has been shown recently in some American cities, under-representing police presence in violence prone communities is a contributing factor to an increase in violence. Secondly, Arabs are becoming increasingly integrated into Israeli professional life including the police force and are consequently more willing to rely on and trust national institutions including the police. Thirdly, the present government is taking the problem seriously. Mansour Abbas of the United Arab List, who chairs the Special Committee on Arab Society Affairs, now ensures that the Arab voice is heard from the highest echelons of government. The entire coalition, Jewish parties included, has prioritized the containment of violence within the Arab communities.
The historical significance of this simultaneous double paradigm shift cannot be over emphasized. Israeli Arabs and their leaders have made a 180-degree turnabout from resisting police involvement to supporting it. The government has also progressed from merely paying lip service to Arab needs to official classification of an Arab problem as a priority issue. This juxtaposition of complementary attitudes is not an opportunity to be missed because of poor implementation.
Nevertheless, I anticipate that attempts bringing about effective change, even if well-conceived and well intentioned, will be prone to implementation problems. Some opposition and confrontation with the police from those who instigate or benefit from violence will be inevitable. Desperate though they themselves may be to see an end to the current situation, one may anticipate that those who have relatives involved in the violence will feel some degree of sympathy for the lawbreakers, in which case the specter of an unsavory confrontation between local citizens and police may prove intolerable for them. Unpleasant mishaps such as police arraigning the wrong person, or a bungled arrest entailing the injury of a suspect or innocent bystander may not be totally avoidable
At the turn of the millennium, I was involved in a project to improve the overall quality of medical care in Israel, in which all our health-fund (HMO – like) clinics countrywide were involved. For purposes of this blog, While the project involved all our clinics, I shall focus on our activity in Arab communities in the north, where I worked. The project required doctors in Arab clinics to participate in a health-fund program that fundamentally changed and improved the way they worked. While not as confrontational as dealing with violence, this nonetheless required health organization representatives, most of whom were Jewish, to persuade Arab medical personnel to change their way of working. New demands were placed on them, and they were expected to adopt and maintain new standards of care. In general, physicians do not like to be told what to do and are definitely unenthusiastic about changing or adding to their already overburdened routine. Fortunately, the project was well and tactfully planned, emphasizing positive reinforcement rather than punitive measures and actively involving local clinic directors in formulating a work plan. Although we did encounter opposition to the project, we were nonetheless able to overcome it and help physicians and clinic teams to change their ways. After several years, these changes were implemented everywhere, and the quality of patient care dramatically improved.
Initially, when we encountered poorly run clinics, especially in the Arab sector, it was difficult to bring about positive change. With regards to clinics in the Arab villages, while Arab and Jewish physicians can work anywhere, many Arab community clinics were staffed predominantly by Arabs, and not all of them were well run. I was a regional medical administrator at the time. When we encountered a poorly run Arab clinic – where physicians arrived late, left early, were not service-oriented and provided substandard care – we found ourselves frustrated: though they suffered from poor health as a result, the clinic’s patients would not tolerate a Jewish administrator to call their Arab personnel to task. As a result, we found improving clinic function extraordinarily difficult.
Another problem was assessing quality control. Until then, there had been no easy and accurate way to assess the quality of care a physician provided. Physicians’ degrees, or even their level of popularity, do not necessarily indicate the quality of their performance. As an example, an Arab physician who came from a large extended family within the village tended to be popular whether or not he was a good physician. As charts were not yet computerized, at best, we could review the manual medical charts of a few patients to get a general idea of the quality of care provided. However, if the depictions in those charts were not representative of how that physician worked in general, we could not assess his/her overall competence. Also, as in any specific patient-physician interaction, the patient’s disease characteristics and personality can significantly influence the quality of care. In short, prior to the data-processing revolution, assessing physician competence was imprecise and challenging.
Around that time, however, data accumulation and processing were becoming more sophisticated. As our health fund had centralized all our patients’ information, we were able to exploit the revolution in data processing for their benefit. We possessed a newly developed ability to assess a physician’s performance more efficiently: by collecting data from numerous patients treated by the same physician, we could now build a physician practice profile. While one patient’s characteristics may significantly affect the quality of care he or she receives, by tracking the data of numerous patients tagged to the same physician, we could construct a profile that represented physician function independent of a particular patient’s characteristics. We could then compare one physician’s profile to that of other physicians and establish attainable standards of care. For example, we could identify what percentage of a physician’s diabetic patients had their sugar levels balanced and compare the results to those of other physicians with similar patient demographic breakdown. We could thereby identify physicians who were probably under-treating diabetes in their practice. Such a finding represented what we termed a physician function factor. This tool was a game changer in terms of assessing physician quality of care.
When we presented this information with appropriate explanations, all those involved realized that the data conclusions spoke for themselves and that we were not arbitrarily singling them out. It was a prime example of using authority, not power. The objective data we presented generally provided the impetus for change without the need to resort to administrative coercion. We could then both help the clinic to initiate a change and monitor the results over the coming months and see if they improved.
Clinics in our health fund typically have a physician director who leads a team of several physicians, nurses, and other medical personnel. In addition to group meetings, the number of clinic directors in our region was small enough to allow us to also work with them individually. Once they became convinced that our information was reliable, and that there was a problem in their clinic, perhaps with the performance of one of their physicians, these directors wanted to improve that physician’s functioning as much as we did. We also made each clinic’s data directly available to its director. Thus empowered, the directors began to analyze the data on their physicians, identify potential problems, and intervene on their own, rather than waiting for us to do so. Eventually they were able to continue more independently.
Slowly, things began to change and improve. We used an approach called institutional learning: if the team at one clinic developed a successful intervention technique, we would often try to apply its approach to other clinics that were struggling with a similar problem. I should add that, though we were dealing primarily with medical care issues, cultural and economic factors also played a role. For example, to encourage mammography breast-cancer screening, whose participation in the test was low in the Arab sector, we provided a taxi service that ferried several women simultaneously to the nearby town where the test was performed. Not only was this intervention culturally acceptable, but it obviated the expensive and inconvenient need for husbands or fathers to chaperone the women in the middle of the day.
Today, by all criteria, the standard of care in most Arab villages is as good as in adjacent Jewish and mixed clinics.
I believe that an examination of our project can offer insight into how change can be effectively implemented in Arab communities and potential pitfalls can be identified.
For a policy to be effective, several principles must be addressed. Firstly, intervention has to be carried out in a professional and authoritative manner. Secondly, it is important to ensure that it is performed with tact and sensitivity, and in a way that elicits cooperation from those whose performance has to change. Winning the trust of the Arab communities is vital and will require visible accountability on the part of the police and security services. Justice must not only be done, but also be seen to be done. Police and security services often prefer working in the dark, without being held accountable for the unpleasant choices they make, but such an approach in my view, is not suited to a situation in which public popular support for their actions is required. Thirdly, rather than an exclusively imposed top-down process, there should be active involvement of local figures wherever possible. We found that local involvement can sometimes accomplish what high-ranking officials from outside simply cannot. Fourthly, just as to change physicians’ behavior, we had to take cultural and demographic factors into account so too is it fair to presume that the violence containing project address relevant social problems. Unemployment, poverty, and lack of education are more prevalent among those who are violent and may well be indirectly contributing causes of the violence. These issues need to be addressed as part of the program to contain violence.
This supportive rather than punitive intervention will make the project both ‘carrot and stick’ like rather than just using a stick. Finally, while general principles may apply to all communities, the approach will probably need to be individualized in accordance with relevant contributing factors and personalities within each specific community. Our experience in the medical project was that both weak- and strong-willed directors benefitted from an individualized approach. The weaker directors and clinics required more intense individualized intervention; the strong-willed competent directors benefited from giving them more latitude to solve the issues their way. An unexpected benefit from this approach was that many of those same strong-willed directors who had been initially hostile to the project but had been given more latitude in the handling of it, in the years that followed, went on to advance to high positions within our health organization.
For the project to succeed, national institutions and Arab communities will have to trust and cooperate with each another. If this does indeed happen, the positive ramifications of Jewish-Arab relations could extend well beyond containing violence in their communities.