By Maya de Vries and Laila Abed Rabho

Person typing on a hospital computer next to a stethoscope. Source: Unsplash

In the meetings that we held with women in Dar al-Hawa, we found that most of them were suffering from various health problems, the most common ones being high blood stress, diabetes, back, and leg pain. When going to one of the local public health clinics in Dar al-Hawa, clinics that are managed by local Palestinians as well as subsidised by the Israeli Ministry of Health, they are likely to get good quality treatment both in terms of their health problem as well as in terms of their own understanding of the process, as these clinics operate in Arabic.

However, the situation is much less convenient when they are required to visit one of the Israeli hospitals in Jerusalem to receive treatment – not because they will not be seen for their health problem or accepted as patients, but rather, in their own words, will not be able to understand large parts of what is being said to them by doctors, nurses and other staff. Sitting in a doctor’s office or treatment room is a stressful situation can be a stressful situation regardless of the health issue that is being investigated. When the issue of a language barrier between the patient and healthcare staff is added to the equation, the patient(s), in this case, older Palestinian women, can be made to feel even more uncomfortable as he/she is required to seek help with translation.

Hospitals are highly stressful places where many types of individuals (whether patients or staff) belonging to a variety of social groups intersect on a daily basis. These meetings can constitute points of friction or moments of acquaintance between groups of people who may ordinarily be fairly indifferent to each other. In al-Quds, Israeli hospitals, this tension between Jews and Arabs has existed for many years, as we found out from some of the women we spoke to in Dar al-Hawa. One expression of this tension is the absence of the Arabic language from the hospital space.

This situation makes the women of Dar al-Hawa more dependent, as patients, than they already are: presently, most of them have to rely on either their husband, their children, or their grandchildren to accompany them to the hospital, or on a translator provided by the hospital – usually, there is only one on the ward. There is also the possibility that an Arabic-speaking doctor or a nurse may be around to facilitate translation, but this is not certain. What does make the experience a bit easier is the fact that all signs at the hospital are usually written in Hebrew, English, and Arabic. However, our participants told us that this is not going far enough – something that even the women in our group who do speak Hebrew agree with.

Dina, 58, remembers her period of hospitalisation:

“I stayed in the hospital for some time, they used to give lectures in Hebrew, I hope they bring doctors that give lectures in Arabic, because there were Arab patients who had had an open heart surgery but did not show up to the lectures because they didn’t understand Hebrew, many Arabs don’t understand Hebrew, or they do, but not to the extent that that they are able to answer the nurses.”

Sireen, 42, adds that other than the language barrier, she does not have any complaints about the hospital:

”I usually don’t go to hospitals; I used to go the hospital just to give birth. Honestly, during the period that I was in hospital, I felt that the staff and the service in the hospital was very good, I didn’t face any problems except for the language.”

On the other hand, Nasreen, who is 76 and speaks good Hebrew, recalls seeing people her age struggling whilst in hospital:

“I understand, read and write Hebrew. Other people who come to the hospital and do not know Hebrew bring people with them to help them and translate for them, it’s hard that they don’t give information in Arabic.”

Mona, a 60-year-old research participant, described the language problem in a more nuanced way, stating:

“Since we are treated at Israeli hospitals and the language that is used is Hebrew, sometimes I can’t communicate with them [doctors] or understand what they are saying, if there is someone that can translate that can help…or if the information is written in Arabic, all the medication package inserts are written both in Arabic and Hebrew, but in the hospitals, not everything is written in Arabic.”

Taking into account the stories told to us by our participants, we think that the language gap points to a more fundamental, less spoken-about problem: that of racism. Even though the issue of racism is familiar to the Ministry of Health and there is an official protocol that aims to reduce racism against patients and healthcare staff within the hospital[i], the women we spoke to think this is still an issue. Rabab, 63, says:

“I want them to treat me like any other person, I don’t want them to underestimate me, we are exposed to racism in the Israeli hospitals. For me, Hebrew is an obstacle, when I visit the doctor, I take my sisters or my children with me so they can translate. I would prefer if everything will be in Arabic. Once, my husband felt pain in his eyes so we went to Shaare Zedek medical center, I heard the doctors speak, they said that there is no ‘use’ to his eyes , so I told him in Hebrew that I didn’t understand what he meant, he answered <<you don’t live in Iraq, you live in Israel, so you must learn Hebrew>>. I wrote a complaint and sent it to the hospital.”

Reem, a 50-year-old participant, talks about her experience in a maternity department in an Israeli hospital:

“We saw there were volunteers who came to help Jewish women and teach them how to breastfeed. We did not see anyone who spoke Arabic. There is a shortage of volunteers who do such work for Arabs, and even the Arabic language was not spoken. Only Hebrew.”

To conclude, our interviewees point to the importance of the language as an important parameter that should be taken into consideration in healthcare settings and when considering the quality of care, especially in al-Quds, where the public health system is fairly well-developed due to being part of the national Israeli health system. Treatment can and should be better when it comes to not just the medical treatment itself, but also the details of patients’ symptoms and the diagnosis. In order to get a comprehensive and accurate picture of a patient’s medical problem and decide on the best course of action in terms of care, it is very important to understand ‘the little details’, and for that to happen, understanding the spoken language of health at the point of care is a must.

Below, we show two examples of the home pages of two relevant, major hospitals in al-Quds, Hadassah Hospital and Sharee Zedek Hospital. Although both are available in Arabic, Hadassah’s home page only allows the user to select a different language if the user already speaks English – the different options for languages are written in English letters: ‘EN’, ‘AR’, ‘RU’. Sharee Zedek displays the different language options in the ‘mother tongue’ itself.

Pic 1: home page of Hadassah hospital. On the right side, visitors can choose between English, Hebrew, Arabic, or Russian – but the language menu itself is in English (written in English characters).

The home page of Sharee Zedek hospital: on the right-hand side, website visitors can choose their choose language, with the choices being English, Russian or Arabic. Although written in a small font size, the choices are given in the mother tongue itself (I.e. using the Arabic alphabet), which makes it more accessible to non-Hebrew readers.

[i] see for example this page published in the website of the MOH: https://www.health.gov.il/English/Topics/Equality_in_Health/racism/Pages/default.aspx) See also an important article about separation in maternity departments: https://www.haaretz.com/israel-news/.premium-though-illegal-jewish-arab-segregation-plagues-israel-s-hospitals-1.6725140

Blog post written by Maya de Vries and Laila Abed Rabho

Please note that the participant names used in this blog post, as well as the neighbourhood name ‘Dar al-Hawa’, have been pseudonymised for reasons of anonymity and confidentiality. Dar al-Hawa is the pseudonym for a neighbourhood of 10,000 people in al-Quds (East Jerusalem).

One of the very first observations we had in the field site of Dar al-Hawa was that most people, young and old, own a smartphone. However, when delving deeper into the ways in which they used their phones, we discovered that their digital skills were very limited, and the use of different apps other than WhatsApp, is almost non-existent. Following the goals of the ASSA project, it was clear to us that part of our fieldwork should be to enable individuals to learn and improve their digital skills – an aim also aligned with what Kurt Lewin (1964) called research action in the fieldsite.

It took us more than a year to bring everything together, including finding the right organisation, the right space, getting the timing right, and finding future participants willing to join the course. When it finally happened, we were able to create a pilot course consisting of 12 meetings running for 3.5 hours each. Each of these sessions focused on one thing only, and that is teaching students how to use a smartphone. We partnered with a local organisation called “Good Thought”, a non-profit organisation established in 2003 which aims to reduce social gaps in Israel by providing teaching technical and digital skills to underprivileged groups. Good Thought already teaches similar courses, but they are usually aimed at helping students learn how to use a computer. When we approached them, it was after having spent a long time in the fieldsite, visiting people’s homes and seeing and hearing from different individuals who told us that they don’t have computers or laptops, just smartphones. Hence, we insisted that the course should be focused only on the smartphone. Because of this, the project was effectively a pilot one for the staff of Good Thought as well.

The first meeting took place on the 25th of November at the community centre in Dar al-Hawa, where 17 people arrived to receive information about the course. Eventually, only 15 people registered to attend the course – 4 women and one man. Since the state of Israel has previously declared that it aims to encourage its population and institutes to become more ‘digital’ and thus increase ‘digital equality’[1], we were lucky to receive significant subsidies for the course, meaning each participant only paid 20 NIS for the 12 meetings (NIS = Israeli New Shekel, this is the equivalent of about £4.41).

The leading instructor was N’, a Palestinian woman from al-Quds (East Jerusalem) who is a teacher by profession. Maya de Vries was her assistant throughout the course. In terms of participation and attendance rates, the course was a big success, as more than half of the participants attended 100% of the meetings, and the second half attended around 80-90% of the meetings. This indicates that participants were pleased with the content of the meetings and found it meaningful and helpful. Throughout the course, participants shared these feelings with us and told us how happy they are to be part of it. They also shared with us the fact that this course gives them a reason to get out of the house, and reduces some of the loneliness and boredom they experience on other days of the week when they don’t have other activities planned. One of the participants,  Malak (aged 78) said the course “was something to wake up in the morning and feel happy for”. Here, the act of learning and developing digital skills as part of a group with a mutual goal provided sociality as well, which is something that can be lost in older age.

N’ and de Vries also came to learn difficult it is for individuals who do not speak Hebrew or English to control their smartphones, even if the language of the device itself was set to Arabic. During a lesson about how to use the MyVisit app (a government app assisting users in booking appointments with various formal institutes like electricity companies or the National Insurance Institute etc.), we did not manage to find an Arabic version of it. Hence, those who did not learn Hebrew or English at school were excluded from this particular lesson and completely depended on their group mates as well as N’ and De Vries, to help them.

Figure 1: The MyVisit App (in Hebrew). The smartphone is held by one of the participants. Photo by Maya de Vries (CC BY)

We also came across several government-provided apps and websites which either did not have any Arabic content or had little Arabic content. Furthermore, only 3 out of 15 participants had an email account, and many government-provided apps require email registration to use. Although now each participant has an email account, which they created as part of the course’s assignments, they still found it more difficult to use these. Thus, if the government wants to increase digital participation among different groups, they should think about Whatsapp as an easier-to-use, more functional tool.[2]

In addition to the matter of digital inequality, we also considered the sociopolitical gaps related to the geopolitical conditions of Dar al-Hawa and al-Quds in general[3]. For example, we discovered how difficult it is for this age group to both click on the touch screen as well as wait for their ‘request’ to be uploaded. Many times, we had to explain to our students that they need to be more patient and wait for the app to upload their request, or for the website to appear. We repeated this instruction until our very last meeting – we do not think there is a clear solution to it other than continuing to practice using these tools.

Figure 2: Learning how to turn on the flashlight/torch on their smartphone (Photo by Maya de Vries CC BY)

WhatsApp is the most used app on participants’ phones – they all have it and they all know how to use its basic features such as sending messages and forwarding messages and photos. Nevertheless, we dedicated two lessons to WhatsApp use, including taking photos and selfies, which were not practicalities most of the participants were familiar with. We also taught them how to create a new group and how to record messages. Following WhatsApp, the second most popular apps were Facebook Messenger and Youtube. No one had any health apps on their phone, not even apps related to their health clinic, which has an Arabic language app.

One of the ASSA project’s findings across various field sites, including Japan and Ireland, was that ‘step counter’ apps are in widespread use among the populations studied. These step counters were not used by our participants, not even the versions that are free and built into their phone, although some had heard of step counting and the fact that there was an app on their phone that did just that. No one had actually opened the app, however.

Unfortunately, 12 meetings are simply not enough to teach participants all that smartphones can offer their users. This was something our participants felt during the course as well, and during the final session, they asked to have a second round of the course so they can learn more and develop their skills by learning how to use things like digital banking as well as other features we did not have the time to teach.

Going beyond the skills taught to the participants, as we quoted Malak before, we also heard, in the final session, how happy the students were when coming to the course and learning new things that can assist them in becoming less dependent on their children and grandchildren. Such feelings around the practicalities of independence should be more present among the older population in Dar al-Hawa. Thus, by creating more similar future courses, we are also hoping to make local older people’s lives easier and happier by increasing their knowledge in the digital arena.

Figure 3: The last session’s feast: participants brought home-cooked food to celebrate their achievements during the course. Photo by Maya de Vries (CC BY)

[1] See more here (in Hebrew): https://www.gov.il/he/departments/digital_israel

[2] We hope to create a greater change and solve this problem.  At the end of March, we are meeting with a representative from the E-Government office (Mimshal Zamin in Hebrew), thus hoping to work with them on both the language gaps, specific the Arabic one, but also on other accessibility issues for older people.

[3] The asymmetry in the education system has a long history, mainly starting after the 1967 annexation of East Jerusalem. For more, see the following Ir Amim report at http://www.ir-amim.org.il/sites/default/files/Education_Report_2017-Fifty_Years_of_Neglect.pdf