«Medicine and the State. The Medicalization of Reproduction in Israel In: Daphna Birenbaum-Carmeli and Yoram S. Carmeli,(ed.) Kin, Gene, Community: ...»
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Yali Hashash, "Medicine and the State. The Medicalization of Reproduction in
Israel" In: Daphna Birenbaum-Carmeli and Yoram S. Carmeli,(ed.) Kin, Gene,
Community: Reproductive Technologies among Jewish Israelis,
Berghahn Press, 2010 (in print).
Medicine and the State
The Medicalization of Reproduction in Israel*
Department of Jewish History, University of Haifa
Feminist and sociological researchers in Israel over the last two decades have consistently claimed that Israeli reproductive policy has always been, and remains, an expression of the State‘s nation-building efforts. Within this framework, two main contentions are made: (a) Israel‘s ―reproductive policy‖ primarily aims at winning a ―demographic race‖ against the Palestinian Arabs and is, therefore, pronatalist1 and (b) Israel, although pronatalist, is equally concerned with the reproduction of the ―New Jew‖, who exhibits physical and/or cultural attributes that fit Westernized/modernistic qualitative demands.2 These two contentions take for granted that as a profession, medicine has assumed the role of an obedient servant of the State, lending its expert skills to the Jewish nation-building project. Further, Israeli scholarship in the field has sometimes understood gynecologists to be agents of progressive processes that allow women to gain wider control over their reproduction.3 Thus, medicine as a profession has not only been portrayed as the loyal servant of the State in its nation-building project, but also as the servant of women in need of rescue, and reproductive possibilities. Critical sociological research, on the most part, has therefore neglected gynecology as a subject of independent analysis. 4 In this chapter, I wish to trace the medicalization of reproduction in Israel by pointing at and tracking gynecologists' interests. I shall argue that beyond national, political, cultural and ideological agendas, the medical establishment in Israel has also acted in its own interests in increasing its professional power and influence by ever deepening the medicalization of reproduction. From this perspective, ideological justification structures were instrumental, nurturing the medical establishment’s ever growing power position. I will suggest that Israeli medicine cannot be understood as a mere tool used by a presumably homogenous State to promote a coherent political agenda or reflect a clear value system. As this chapter aims to expose, Israeli physicians have their own interests, which they try to promote within or vis-a-vis the State. Since it is my understanding that cultural explanations, such as pronatalism, have often worked to cloud rather than clarify the understanding of such processes, this chapter will focus on more ―structural‖ dimensions, i.e., the negotiation between Israeli medicine and the State over resource allocation and legislation regarding reproduction.
Working within the generally accepted frameworks of Foucauldian analyses of state power and doctors‘ professional power, my emphasis is on the continuous negotiation over state resources taking place between state agencies, and non-state actors who can potentially use bio-power and population control discourses as vehicles for obtaining professional resources (Fligstein 2001). According to this view, professionals employed as administrators within state apparati facilitate the production of a common language which eventually directs state agencies to embrace professional interests in their decisions and policies. This understanding applies to medical professionals as well, who in their negotiation with state agencies, and while acting from within state agencies, frequently manage to rely on scientific language to achieve almost full autonomy over the practice and funding of their professional domain (Abbott 1991).
In the domain of gynecology, professionalization and the very inclusion in the field of medicine largely pivoted on the medicalization of pregnancy during the second half of the 20th century. Barker (2003) describes how in the United States, a network of state officials and medical professionals directed state action toward establishing medical knowledge as the exclusive source of authority and jurisdiction in matters of reproduction, gradually rendering other professionals and sources of knowledge irrelevant. In other countries, medicalization has taken the aura of a national enterprise, depending on and aiming for public legitimacy, constituting itself as a vehicle in the service of national objectives. At the same time, physicians and particularly gynecologists came to occupy state administrative positions with an active role in decision-making processes (Abbott 1991).
In this chapter, my aim is to point to the professional interests that doctors and gynecologists have had in specific directions of evolution and change in Israel's reproductive policy over the years. In other words, I hope to underscore the role of doctors and medical researchers in the shaping of legislation and resource allocation.
My focus is on three historical moments in the medicalization of reproduction in Israel.
Section one will examine population regulation between the 1950s and the 1970s, focusing on the issue of contraception use. Whereas traditional sociological literature has emphasized the state's ideological motivation to minimize the use of contraception as a means of population regulation, this section will suggest the medical interest in expanding the use of medical contraception, thereby creating a clientele for experimentation, while taking part in a larger debate over the appropriate size of families in Israel.
Section two will examine the medicalization of pregnancy termination, as it developed during the 1970s. This section reveals the abortion debate as an arena for legitimizing an existing medical practice, as well as furthering the medicalization of pregnancy and reproduction in general.
Section three examines the converging debates over human cloning, stem cell research and oocyte donation that are currently underway in Israel. It reveals the major influence that the medical community has had on legislative processes in this area, particularly the effort to ensure scientific access to human oocytes and to remove legal hindrances to scientific cloning research.
Interestingly, these processes, and medical pressure aimed to influence legislations in general, are not necessarily covert. Indeed, the Israeli Medical Association (IMA) openly lists this sphere of activity as part of its role and mission.5 I: Reproductive medicine and population regulation in Israel In the 1960s and 1970s, population regulation was discussed by various stateappointed professional bodies in Israel. Although it is traditionally thought that the Arab-Jewish "demographic race" was the major focal point of these discussions, my study shows that the diversity within the Jewish population and the state population policy with regards to the various Jewish groups was at least equally important in most professional deliberations, in which doctors played an active integral part (Hashash 2004).
The national family planning program was among the major issues that were discussed. Research has usually commented on the scarcity of family planning in Israel, interpreted by researchers as an expression of the State‘s pronatalist policy (Portugese 1998). In contrast to that approach, I shall analyze not the absence, but rather the presence of family planning in Israel, in order to explore its medicalized characteristics, and the medical influences on its shaping.
During the 1950s, the first decade of the Israeli State, population regulation was a major concern for many countries in the West, as well as for other population policy-makers globally. Different population policies that were endorsed were motivated by either strong eugenic objectives, or aspirations for social reform.
Medical establishments responded to population regulation policies by offering medical means to implement state policies, as well as medical opinions as to the healthy size of a family and the medically-recommended time interval between pregnancies.
The interest in population regulation programs was crucial for the development of the medicalization of reproduction, primarily because it constructed a legitimate working field for practitioners. But its importance was also conceptual.
Population regulation encapsulated the very idea of planning, which is the basic tool of any professional intervention. As such, the idea of planning future fertility trends or family size constitutes a favorable a priori for anyone who wishes to legitimize a professional intervention in that field.
Israeli doctors were quick to join the developing field of medical contraception. The Hebrew-language professional magazine Harefu’ah [Medicine] reported that an Israeli gynecological study had become one of two pioneering publications in the area of contraception as early as 1959 (Vego & Shapira 1968).
However, Israeli doctors' interest in the subject was not necessarily national; indeed, it was at least partly related to the activity of international bodies, such as the Population Council established by Rockefeller in the United States in 1952. In order to address global population growth, the Council worked to encourage research on contraception in various places around the world. In 1963, it included Israel in its statistical assessment of IUD clinical data worldwide (Schindler 2007; Vego & Shapira 1968). The U.S. Department of Health was also interested in funding family planning programs and research in Israel. With the help of American funding, Israeli gynecologists were able to take part in the newest research on medical contraception that was being conducted in several clinics and hospitals throughout the country during the 1960s.6 Although there was already medical interest, a legitimate clientele under medically supervised contraception was still lacking. Hence, doctors negotiated with the State, which, in the mid-1960s, was still ignorant of these developments.7 This was soon to change, but not before global interests would be translated into the rhetoric of national concerns.
Israel is an immigrant society. Between 1948--the year of its establishment-and 1960, about one million Jews immigrated to Israel from different countries in Eastern Europe, South West Asia and North Africa. The non-European immigrants were referred to as belonging to Mizrahi (Oriental) communities. These communities where culturally and economically marginalized by the hegemonic Ashkenazi (mostly East European) society and government. In the early 1960s, it became clear that Mizrahi Jews were beginning to form a demographic majority within the Jewish population of Israel.8 In 1962, demographer Professor Roberto Bachi was appointed as director of the Natality Committee (NC), which was to advise the government on aiding large families, most of whom were Mizrahi, as well as on addressing the issue of the allegedly low Jewish fertility rate.9 The fertility discussions, as I have argued elsewhere, were not necessarily designed to solve any demographic issue. The NC defined its goal as a one of regulation intended to equate fertility rates between the different Jewish ethnic groups and to create a homogenous fertility pattern. Yet, as was well known to the experts in the committee, a homogenous fertility pattern was already rapidly forming with no governmental intervention, with Mizrahi fertility declining from nearly 6 to roughly 3 children per woman over the decade after immigration, and Ashkenazi fertility registering a slight, yet consistent increase. It is therefore my contention that fertility discussions were used to address issues of the State's economic and cultural makeup, and were a site where professionals and representatives of the middle class Ashkenazi public fought over the allocation of State's resources (Hashash 2004).
The NC, whose seven members included the director-general of the Health Ministry and a senior doctor from Israel's largest HMO (Kupat Holim), suggested that public funds allocated to enhance Jewish fertility rates should be directed only to smaller, better-off families that were economically and ―culturally‖ able to afford a third or a fourth child, but whose own financial calculations made them reluctant to have this birth. This reluctance, it was claimed, might change with proper public support.10 The committee explained that larger families do not plan the size of their
families and, therefore, should not be eligible for birth incentives (NC Report 1966:
39). The NC also advised the government to distribute information on family planning as a social justice agenda (ibid: 50).
Thus, it was the NC that was in charge of officially introducing family planning as a recommended means of fighting poverty, eventually recommending how to supplement small families' income.11 In that way, it contributed to the creation of a legitimate clientele for new medical contraceptives. The cautious yet clear dictum of applying family planning as a major weapon to fight poverty and to prevent deterioration in the quality of the population resonated with the American Population Council agenda, enabling doctors to openly engage in medical contraceptive research and practice with a legitimate target population: women of Middle Eastern descent with several children.
The head of the Gynecology and Obstetrics ward of Rehovot Hospital, for example, published an article in which he explained that the IUD was primarily suited to "women who have given birth, and in particular women who finished giving birth and were of low educational level." The pill, he tried to point out, was suitable to all "but primitive women who are not able to take it responsibly every day" (Lancet 1970: 69).
The establishment of the Demographic Center in 1968 worked to expand this process. The Demographic Center's propaganda campaign was designed to mobilize "families with two children to increase their families to 3-4 children, and advise large families on family planning." The Center's active committee members frequently referred to the national threat of burdening the public with population growth in the lower strata.12 The NC and the Demographic Center helped in creating a legitimate clientele for medical contraception. But, concrete state apparatus was still amiss if family planning would be established as a nation-wide practice that was medically managed.