Health in interwar Palestine : ethnic realities and international views

DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. Health in interwar Palestine: Ethnic realities and international views IRIS BOROWY (*) BIBLID [0211-9536 (2005) 25; 423-450] Fecha de recepción: 1 de noviembre de 2004 Fecha de aceptación: 2 de febrero de 2005 SUMMARY 1. —Health situation in Palestine. 2.—Healthcare systems in interwar Palestine. 3.—Conclusions. ABSTRACT This paper analyses the developments of the separate Jewish and Arab health systems and health realities. It is found that the activities of charitable institutions, the attitude of the British mandate government and different traditions of medical policy all played a part in the emergence of two separate health worlds. The influx of foreign funding for private health institutions, in particular, played a prominent part in establishing different service levels of healthcare for Jewish, Arab Christian and Arab Moslem communities. Thus, the medical sphere both reflected and interacted with wider political events. Palabras clave: Palestina, sistemas asistenciales, estadísticas de salud, etnicidad Keywords: Palestine, health care systems, health statistics, ethnicity (*) Lecturer. University of Rostock. Historical Institute. Rostock, Germany. Email: iris.bor[email protected] The author would like to express sincere appreciation of the generous support of the German Research Association (Deutsche Forschungsgemeinschaft, DFG), which has made work on this paper possible and also that on a broader ongoing research project on the League of Nations Health Association. IRIS BOROWY 424 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. 1. HEALTH SITUATION IN PALESTINE Public health in Palestine in the early twentieth century started from difficult conditions. Throughout the nineteenth century, the area was considered backward and known to be plagued by epidemics of malaria, cholera and smallpox (1). The Arab rural population (i.e. the majority of inhabitants in Palestine) were almost entirely illiterate and enjoyed a life-expectancy of merely 35 years, due mainly to the very high infant mortality rate (2). After 1914, the First World War ravaged the country and further exacerbated health conditions. The Arab majority, susceptible to compulsory recruitment, was struck particularly hard, but, indeed, all groups suffered from disease, famine, emigration and demoralizing deportations, resulting in population decline (3). Between the world wars, the main health problems were malaria, measles, pneumonia, trachoma, hookworm, tuberculosis, and typhoid fever. While mortality statistics are incomplete and probably of doubtful reliability, they indicate the dominance of infectious diseases as causes of death, as is to be expected in a relatively undeveloped area prior to the epidemiological transition (4). (See Table 1). The biggest killers appear to have been pneumonia and measles, both of which were formidable lethal diseases also in nineteenth and early twentieth century Europe (5). Tuberculosis was apparently little noticed (1) TESSLER, Mark. A history of the Israeli-Palestinian conflict, Bloomington/Indianapolis, Indiana UP, 1994, p. 124. (2) SHEPHERD, Naomi. Ploughing sand. British rule in Palestine 1917-1948, London, John Murray, 1999, p. 126. (3) SHVARTS, Shifra. The workers’ health fund in Eretz Israel. Kupat Holim, 1911-1937, Rochester, University, 2002, p. 70; TESSLER, note 1, p. 145; SMITH, Charles D. Palestine and the Arab-Israeli conflict, New York, St. Martin’s Press, 1992, pp. 68-69; For the Jewish community, Shifra Shvarts cites a decline from a prewar population of 88,000 to 57,000 people in 1919. SHVARTS, Shifra. The development of mother and infant welfare centers in Israel, 1854-1954. Journal of the History of Medicine and Allied Sciences, 2000, 55 (4), 409-410. (4) See REPORTS by His Majesty’s Government in the United Kingdom of Great Britain and Northern Ireland to the Council of the League of Nations on the Administration of Palestine and Trans-Jordan (hereafter Report) for the years 1921 to 1938. (5) See HARDY, Anne. The epidemic streets, Oxford, Clarendon Press, 1991. Health in interwar Palestine: Ethnic realities and international views 425 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. 1921 1922 1927 1928 1929 1930 1931 1932 1934 1935 1936 1937 1938 Measles 324 1,056 525 336 731 337 301 224 669 175 Typhoid 71 65 64 76 119 185 204 194 155 Pneumonia 354 409 377 414 433 477 411 390 388 Malaria 113 65 Tuberculosis 215 201 234 211 at first but emerged as a disease of «considerable endemic importance» during a special investigation into social diseases, including Tb, carried out between 1931 and 1933 (6). Given these difficult circumstances, the development of public health in interwar Palestine was in some ways a success story. By the end of the Mandate life expectancy had risen by fifteen years. Substantial public health programs, including widespread inoculations, helped bring infectious diseases under control (7). This progress is reflected in the detailed vital statistics, which British reports began reporting in 1927. Except for an unexplained gap in 1935, it is possible to follow crude death and infant mortality rates until 1938. (See. Figs. 1 and 2). A comparison with average European rates after 1932 underscore both to what degree Palestinian death rates were higher than in Europe at the outset and their subsequent positive trend. While the average European death rate remained fairly static around thirteen deaths per 1000 living persons, the Palestinian average stood at around twenty-eight in 1927 but declined to fifteen until 1938. Evidently, in the course of a decade, mortality differences between the average (6) REPORT 1933, p. 138; REPORT 1935, p. 149; cf. REPORT 1932, p. 118; REPORT 1933, p. 134, note 4. (7) SHEPHERD, note 2, p. 126. TABLE 1 Number of deaths from some causes of death Source: The data in this and all the following tables and figures (unless stated otherwise) have been compiled from the British Governmental Reports to the Council of the League of Nations on the Administration of Palestine and Transjordan of the years 1921 to 1938. IRIS BOROWY 426 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. Figure 1.—Crude death rates. Figure 2.—Infant mortality rates. 0 5 10 15 20 25 30 35 40 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 Christian Moslem Jewish Total Europe 0 50 100 150 200 250 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 Christian Moslem Jewish Total Health in interwar Palestine: Ethnic realities and international views 427 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. European region and Palestine dwindled to insignificant levels. This development indicates an obvious and drastic improvement in Palestinian public health during interwar years. However, this comparison of aggregate data is grossly misleading about the true nature of life and death in Palestine because it obscures the substantial differences between the various religious and ethnic groups. The exact ethnic composition of Palestinian society and its development in time is difficult to establish. Exact data for the pre-war population are not available. Calculations rely on Ottoman figures, which must be adapted to later Palestinian boundaries and must compensate for structural undercounting (8). Data during the British mandate are slightly more reliable but also suffer inevitable inaccuracies. The last census was taken in 1931. Subsequent demographic data are estimates, based on birth and death registration and estimates of immigration, all of which were inexact. They are, however, sufficiently accurate to gain a general impression. According to the 1921 British census, a total of 752.048 people lived in Palestine. Of this group, 78.34% were Moslems, 9.5% Christians (making an Arab majority of 87.84%), and 11.14% were Jewish. The following twenty years saw a rapid increase in the general population. By 1942, it had doubled to 1,620,005 people. Relatively, the Jewish community increased most, so that its proportion of the population grew from just over eleven to 29.90%. Meanwhile, the Moslem percentage decreased to 61.44% in 1942, and the Christian percentage to 7.85% (9). The vast majority of the Arab population were rural, making a modest living on farming. There was a «narrow stratum of urban intellectuals», a disproportionate part of whom were Christians (10). The Jewish population was a highly diver- (8) Frequently uncounted were Jews of foreign nationality, nomadic Bedouins, and Moslems who evaded the census to avoid the draft. Women and children are considered to have been undercounted. Consequently, estimates vary widely For a discussion of the population issue and lists of estimates see: <http://www. mideastweb.org/palpohtm> and <http://www.palestineremembered.com/Acre/Palestine-Remembered/Story559.html#Table%201>. (9) <http://www.unu.edu/unupress/unupbooks/80859e/80859E05.htm>; See GERTZ, A.; GUREVICH, D. (eds.). Statistical Handbook of Jewish Palestine, Jerusalem, Jewish Agency (Department of Statistics), 1947, pp. 46-47. (10) TESSLER, note 1, pp. 131-132. IRIS BOROWY 428 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. se and evolving community. It included long-time resident Orthodox Jews, a private, mostly land-owning sector and labour Zionists, and their numbers rose through several waves of immigration («aliyas»). The largest immigrant groups in the interwar period came from Poland and Russia, comprising farmers, merchants, artisans and urban professionals, secular Socialists as well as devout believers. Together they built a new Jewish society, known as «Yishuv» (11). As obvious in Figure 1, Jewish death rates were lower than average European death rates of that period, those of Christian Arabs were slightly higher or comparable and those of Moslem Arabs were substantially higher. Interestingly, while all death rates declined during the years in question, the proportionate differences remained fairly stable. Throughout, Moslem crude death rates were more than twice as high as their Jewish counterparts. Similarly, Moslem infant mortality also reached double the rate of Jewish infant mortality rates. In both cases, the rates for Christians stood in between, with their fluctuations paralleling those of Moslems (12). These differences are striking not only for their statistical extent and consistency, but also because they seem to contradict epidemiological common sense. A considerable part of the Jewish community consisted of immigrants, whose exposure to a new disease pool naturally made them more susceptible to local pathogens. Thus, typhoid and dysentery were considered to affect mainly the Jewish community (13). But these illnesses did not seem to have a noticeable impact on mortality. Clearly, other factors must have been at work, factors that observed religious but cut across ethnic boundaries. There must have been something that divided Christian and Moslem Arabs of similar ethnic, cultural and (11) TESSLER, note 1, pp. 185-186; SMITH, note 3, pp. 76-80. (12) The data for Palestine derive from the respective British mandate reports. European rates come from JEGEDE, Francis; STUBBS, John. The demographic transition in Eastern and Western Europe. A comparative analysis. In: Jochen Fleischhacker; Rainer Münz (eds.), Gesellschaft und Bevölkerung in Mittel- und Osteuropa im Umbruch, 31. Arbeitstagung der Deutschen Gesellschaft für Bevölkerungswissenschaft, Berlin, Tagungsband [Demographie Aktuell Nr. 13], 1998, p. 55. (13) Report 1924, note 4, p. 32; SHEPHERD, note 2, p. 136. Health in interwar Palestine: Ethnic realities and international views 429 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. social backgrounds, but united Sephardic and Ashkenazi, Orthodox, Socialist and non-observant Jews. How did health form an alliance with religion? One, though not necessarily the only, answer may be found in different healthcare environments. 2. HEALTHCARE SYSTEMS IN INTERWAR PALESTINE Healthcare, as always, was a function of political responsibility. The Peace Treaty after the First World War stipulated that the former Ottoman territory now forming Palestine, would be a League of Nations mandate ruled by Great Britain as mandatory power. The mandatory system of the League transformed events in Palestine from a local (Jewish-Arab-English) or bilateral (Jerusalem-London) to an international issue. As part of this internationalisation, all actors could or had to present themselves and their case to an international audience, which was obliged to take note. Indeed, while for all practical purposes the British ruled Palestine much like a colony they faithfully and regularly sent reports about their mandates to the League of Nations Mandate Commission. The Mandate Commission, in turn, forwarded the parts dealing with health to the Health Committee (14). For the most part, the involvement of the League of Nations Health Organisation (LNHO) was limited to receiving these papers. On request of the Mandates Commissions, it did, however, define the information the mandatory powers should give in their annual reports (15). This rudimentary form of standardization added substance to the reports and is, indeed, helpful for historical analysis. Within this mandatory framework, health assumed a specific place. Public health, universally recognised as a crucial good, became a litmus test for good governance. An administration which failed to ensure minimal health standards for the population under its care, could not expect to be perceived as deserving of support. This was an important factor in a situation (14) See President of the Mandates Commission to the Secretary General, 17 September, 1923, League of Nations Archives (hereafter LNA), R 61/31174/22290. (15) President of the Health Committee to the President of the Mandates Commission, 16 August 1922, LNA, R 61, 1/22290/22290. IRIS BOROWY 430 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. when various groups held competing claims on governmental authority. Health administration competence served as a pass pro toto, an issue symbolizing governmental capabilities in general. This implicit function assigned different roles to the various groups involved. For the British government, health policy was a necessity of routine colonial life, and the health reports offered a means to present competent mandate administration. For the Jewish community, health similarly represented a platform on which to demonstrate a capability to handle the organisation of a state, including the extra health burden of immigration. Jewish offices acted like state bodies and, as a result, were perceived and treated as such (16). In 1924, a newly founded Board of Health, part of the Palestine Zionist Executive and composed of representatives of various Jewish health organisations, introduced themselves to the League of Nations Health Section. By letter, they explained their function and expressed their wish to exchange information with the League institution (17). They did indeed send some material on Jewish Health Work, which demonstrated that all institutions of the British Health Department had a Jewish counterpart, including hospitals, convalescent homes, laboratories and educational campaigners. In fact, Jewish were often larger, better financed and offered more comprehensive services than similar British institutions, both in therapeutic and preventive medicine (18). In short, as of the mid-1920s, Zionist authorities could give proof of complete quasigovernmental health structures. In addition, the related discourse on health issues helped ensure that Jewish inhabitants of Palestine were viewed as equals rather than «natives» and, in particular, set them apart from Arab Palestinians (19). This aspect may seem banal today, (16) FREIMARCK, Peter. Zum Selbstverständnis jüdischer Nationalität und Staatlichkeit in Palästine. In: Helmut Mejcher (ed.), Die Palästina-Frage 1917-1948. 2nd ed., Paderborn, Schöningh, 1993, pp. 50-88 (60). (17) Palestine Zionist Executive to League of Nations Health Section, 21 May, 1924. LNA, R 928, 12B/ 36859/36859. (18) Report on Jewish Health Work, undated, LNA. R 928, 12B/36859/36859; Kahany (Agence Juive pour la Palestine) to Rajchman, 24 March 1937, LNA, R 61 77/8C/28625/1644. (19) The danger of being confused with «natives» and the need to avoid such identification was clearly noted by prominent members of the Yishuv like David Ben- Health in interwar Palestine: Ethnic realities and international views 431 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. but it doubtlessly was not in the colonial framework of the time, which conditioned people of European descent to take ethnic inequality for granted. Thus, observable Jewish health work helped increase the respectability and acceptance of the Yishuv as a whole. Theoretically, the same could have been true for the Arab community. Arabs, similarly striving for independent statehood, which they believed they had reason to expect, similarly could have used health as an issue to demonstrate indigenous governmental competence. However, for Palestinian Arabs, the situation was more complicated. Cooperation with British and League bodies in health matters could offer a means of demonstrating national capabilities, but it also implied the acceptance of the mandatory system —and as such the acceptance of the principle, that foreign powers had the right to grant or deny statehood and to generally decide on the fate of the Arab community. Thus, cooperating with official bodies on health, i.e. other than at a grass-root level, carried an ambiguous message, both of asserting independence and of accepting subservience. For the most part, the Arab community responded to this dilemma with mostly unofficial, sometimes half-hearted co-operation with British mandate authorities, while Arab contacts with the League authorities remained almost nonexistent. In addition, Arab groups in post-WW I Palestine were not in a very competitive position. Relatively to the Jewish community, they lacked general education, a dedicated, united elite, recognition in British administrative circles and foreign resources (20). There was no Arab equivalent to an independent Jewish healthcare system. For the British government, providing healthcare services in tumultuous interwar Palestine could not have been an easy task even with the best of intentions. They faced a population made up of several, separated societies with contrasting experiences, traditions, ambitions and expectations of health, living an ambiguous status between Europe and colonial Arabia. And there was hardly any Ottoman healthcare Gurion and Frederick Kisch. See SEGEV, Tom. One Palestine complete, London, Abacus 2000, pp. 153-154 (original: Yamei kalaniot, Keter, Jerusalem, 1999). (20) FLORES, Alexander. Die Entwicklung der Palästinensischen Nationalbewegung bis 1948. In: Mejcher, note 17, p. 96; SMITH, note 3, pp. 80-82. IRIS BOROWY 438 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. red in the following years, especially after 1936, so that attendance in 1937 was roughly back to the numbers of the beginning of the decade. In all years, most hospital patients by far were Jewish and attended private hospitals. The smallest patient group came from Christian Arabs, the demographically smallest group. The picture is complemented by the numbers of out-patients. (Fig. 5). While there was some movement in the out-patient attendance of all groups, most developments are absolutely dwarfed by the spectacular twenty-fold increase of Jewish patients in voluntary dispensaries from just over 21,000 to over 570,000. This rise must be seen as the most stunning development in healthcare institutions in Palestine of the 1930s. It seems that voluntary hospitals compensated for their initial decrease in in-patient treatment by a strengthening of their out-patient program. But the increase in dispensary activity clearly went beyond mere substitution to gain a significance of its own. Both effects are even more obvious when the absolute numbers are related to population Figure 5.—Out-Patients in absolute mumbers 0 100000 200000 300000 400000 500000 600000 700000 1931 1932 1933 1934 1935 1936 1937 1938 Muslim (G) Muslim (V) Christian (G) Christian (V) Jewish (G) Jewish (V) Health in interwar Palestine: Ethnic realities and international views 439 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. strengths (39). Tracing the percentages of in- and out-patient attendances of the Moslem, Christian and Jewish communities, results in Figs. 6 and 7. Adding percentages of in- and out-patient attendances results in Figs. 8 and 9. Together, these figures allow several conclusions: First, there was a clear hierarchy in the use of healthcare institution. Jews and Christians were about three times more likely to attend hospitals as in-patients than Moslems: while only two per cent (39) For the calculations for this paper, estimates based on data of the ESCO Foundation, for the population of Palestine 1922-42 have been used. See: WOLF, Aaron T. Hydropolitics along the Jordan river, New York, United Nations UP, 1995, as available on-line: <http://www.unu.edu/unupress/unupbooks/80859e/80859E05. htm>. Figure 6.—In-Patients in percentage of population groups. 0 2 4 6 8 10 12 1931 1932 1933 1934 1935 1936 1937 1938 Muslim (G) Muslim (V) Chr is tian (G) Chr is tian (V ) Jew ish (G) Jew ish (V) IRIS BOROWY 440 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. Figure 7.—Out-Patients in percentages of population groups. Figure 8.—All In-Patients in percentages of population groups. 0 20 40 60 80 100 120 140 160 1931 1932 1933 1934 1935 1936 1937 1938 Muslim (G) Muslim (V) Christian (G) Christian (V) Jewish (G) Jewish (V) 0 2 4 6 8 10 12 14 16 1931 1932 1933 1934 1935 1936 1937 1938 Moslem Christian Jewish Health in interwar Palestine: Ethnic realities and international views 441 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. Figure 9.—All Out-Patients in percentages of population groups. of Moslems per year stayed at hospitals, on average six per cent of both Christians and Jews did so. The discrepancy is even more pronounced in out-patient attendance. Jews were seven times as likely to use out-patient facilities as Moslem Arabs. Second, inherent in these numbers but worth pointing out is the fact that Moslems and Christians, while both Arabs, were in quite different healthcare situations. Christians used in-patient hospitals services three times as often as Moslems and out-patient services twice as often. Third, the significance of private services for the Palestinian public health system in general can hardly be over-estimated. Almost twice as many patients were treated in voluntary as in public hospitals, and almost four times as many in private dispensaries. Thus, the significance of the voluntary institutions for the health service in interwar Palestine was enormous. 0 20 40 60 80 100 120 140 160 180 1931 1932 1933 1934 1935 1936 1937 1938 Moslem Christian Jewish IRIS BOROWY 442 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. Fourth, private hospitals increased health inequalities. All groups, including Moslem Arabs, benefited from voluntary institutions. Indeed, their availability doubled the number of Moslems receiving hospital care, so that, the Moslem community profited from their proximity to two communities that drew foreign investment into the local healthcare system. But by the same token, this private investment also underprivileged the Moslem community, because they benefited relatively less than Jews and Christians, who used private institutions to a much larger extent. A comparison of the ratio of the attendance of government to privately funded institutions provides telling results for 1936 (Table 2): while roughly the same number of Moslems used state-run and voluntary institutions both as in- and outpatients, Arab Christians were twice as likely to turn to private institutions and Jews were twenty times as likely to use a private as a state dispensary. These differences clearly reflected the differences of offers open to them. As mentioned, various voluntary organisation sponsored Christian and Jewish institutions which would primarily attract their specific groups. The Moslem community, lacking a specific Moslem offer and finding it difficult to accept a private Jewish institutions, would automatically make relatively more use of public services. TABLE 2 Ratio of usage of Government to voluntary institutions 1936 (rounded) Moslems Christians Jews Average Hospitals 1 0,5 0,45 0,57 Dispensaries 1,24 0,51 0,05 0,26 Fifth, differences in hospital attendances also appeared to reflect different healthcare concepts. While all groups used out-patient more frequently than in-patient services, the Jewish community did so to an extent way beyond that of the other groups. As noted above, out-patient attendance increased sharply as in-patient attendance decreased during the first years of the 1930s. By 1935, average yearly dispensary attendance for Jews was 140%, when it was only 40-50% of Christians and 20% of Moslems. In practical terms, this meant that Health in interwar Palestine: Ethnic realities and international views 443 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. of ten average Moslem, Christian and Jewish inhabitants of Palestine, two of the Moslems and five of the Christians would visit a dispensary once during the year, so would all of the Jews and half of them would come back a second time later during the year. This difference had a quantitative as well as a qualitative component. In contrast to the Arab experience, the out-patient clinic or dispensary became the corner-stone of Jewish public health-care. Typically, out-patient services concern the less acute diseases, and preventive services, particularly infant and maternal welfare. More than 100% attendance suggests that the dispensary had assumed the function of a health center as it was being promoted in the social medical field as focal point of public health and welfare (40). Part of the reasons may be financial, the depression having provoked a shift of foreign support from expensive hospitals to less costly dispensaries. But such a shift inevitably had conceptual repercussions. Schemes of social medicine stressed prevention by influencing living conditions and life-styles, aiming not at curing disease but at preserving health both as an individual and common good. These ideas were in tune with contemporary ideas of improving society at large, which certainly resonated with Second Aliya immigrants, and also with Zionist schemes of creating a new state and people (41). Arab ideas may simply have lacked a similarly determined medical and political agenda. (40) See MURARD, Lion. Health policy between the international and local: Jacques Parisot in Nancy and Geneva. In: Iris Borowy; Wolf D. Gruner (eds.), Facing illness in troubled times. Health in Europe in the interwar years, Berlin, Peter Lang Verlag, 2005, pp. 207-247. (41) DAVIDOVITCH, Nadav; SHVARTS, Shifra. Health and Zionist ideology: Medical selection of Jewish European immigrants to Palestine. In: BOROWY; GRUNER, note 40, pp. 411-426; FIELD, Mark G. Soviet medicine. In: Roger Cooter; John Pickstone (eds.), Companion to medicine in the twentieth century, London, Routledge, 2003, pp 51-66; LAWRENCE, Christopher; WEISZ, George (eds.). Greater that the parts. Holism in biomedicine, 1920-1950; Oxford, University Press, 1998; MURARD, Lion; ZYLBERMAN, Patrick. French social medicine on the international public health map in the 1930s. In: Esteban Rodríguez Ocaña (ed.), The politics of the healthy life, Sheffield, EAHMH, 2002, pp. 197-218; JONES, Greta. Social hygiene in twentieth century Britain, London, Croom Helm, 1986. IRIS BOROWY 444 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. This difference parallels the blatant discrepancy between Jewish and Arab child welfare. In 1927, of 28 child welfare centres, seventeen were Jewish, seven governmental or municipal and four run by voluntary institutions (presumably Christian) for Arab children (42). By 1933, 27 child health centres catered to the needs of the Jewish community (22 operated by Hadassah, five by other voluntary institutions), while Arab institutionalised child welfare was still minimal (43). In 1935, 65% of Jewish infants were under the care of infant welfare services, but only an estimated 4% of Arab infants, which certainly accounts, at least in part, for the differences in infant mortality rates (see. Fig. 2) (44). British health authorities were aware of the urgent need for more health care for Arab infants but found it difficult to obtain trained Arab staff (45). A training program specifically for midwives was partly successful, but suffered from a shortage of funding (46). Sixth, the unequal usage of healthcare facilities meant, that medical service to the Moslem community would primarily fall within the British sphere of influence. A disproportionate percentage of the majority population group, used British services., so that the British health authorities paid primarily for the medical treatment for the Moslem Palestinians. The resulting discrepancies inevitably caused tension. Both the British-Jewish and the British-Arab relationships in the health field were ambivalent (47). British authorities welcomed Jewish public health activities, as long as they worked in their favour, i.e. they reduced British expenditures or improved public health without any extra costs. Official British reports acknowledged that «side by side with the government Department of Health, there grew up in Palestine the Jewish Medical Service» whose «great amount of valuable work» was credited (48). The (42) REPORT, 1927, note 4, p. 42. (43) REPORT, 1933, note 4, p. 143. (44) SHEPHERD, note 2, p. 141. (45) REPORT, 1934, note 4, p. 147; REPORT, 1935, note 4, p. 161. (46) SHEPHERD, note 2, p. 142. (47) REISS, note 22, pp. 310-313. (48) PALESTINE Royal Commisson Report, 1937, note 4, p. 311. Health in interwar Palestine: Ethnic realities and international views 445 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. Hadassah and Kupat Holim, in particular, were appreciated for «much useful service» (49). The British were hardly amused, however, when such activities resulted in demands for more attention and money for the Yishuv. Jewish groups complained that British authorities invested too little money in the health system in general and far too little in health care for the Jewish community in particular, the latter being largely limited to «moral support» (50). British decision makers considered their expenditures sufficient and refused to consider health services, directed specifically at one ethnic group, explaining that this would be a «violation of the principle of common citizenship between Jew and Arab» (51). Thus, British and Jewish views diverged on two issues: «1.—the appropriate level of public health care, which, in turn, depended on diverging views on the status of Palestine and the responsibilities of governments for the social well-being of the citizens; 2.—the relative position of the Jewish and the Arab communities». British politicians viewed Palestine as a colony-like structure and a poor country whose inhabitants paid only a fraction of the taxes of average Englishmen. Thus, they felt that Jewish inhabitants of Palestine could not expect the same level of healthcare found in Europe (52). They also believed in liberalism with only a limited government role in social issues, both at home and in their empire (53). The Jewish point of reference, however, was the best possible organized community rather than a colony, and the pronounced Socialist leanings of (49) REPORT, 1925, note 4, p. 30. (50) SHVARTS, note 3, p. 78. (51) PALESTINE Royal Commission Report, 1938, p. 317. Jewish complaints were primarily voiced by the Kupat Holim, and the Va’ad Leumi, the General Council of the Jewish Community of Palestine. (52) See OWEN, Roger. Introduction. In: Studies in the economic and social history of Palestine in the nineteenth and twentieth Centuries, Oxford, Macmillan, 1982, p. 4. (53) For a discussion of different interwar conceptualisations of health, see MAZOWER, Mark, Dark continent: Europe’s twentieth century, London, Penguin, 1998, chapter 3. IRIS BOROWY 446 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. the influential Second Aliyah pre-supposed a socially active state (54). From a Jewish point of view, the self-organised health services deserved being rewarded by further government assistance instead of being punished by less support. And while generally Jewish agencies were not much interested in the situation of the Arab community, if there needed to be a comparison, Jews contributed more tax money than Arabs and could therefore also expect more services. This idea was incompatible with the British view, that the government needed to provide adequate health services and sanitation infrastructure to all groups of the population. Exaggerated expectations or self-induced higher service needs due to intensive colonization activities in malaria-prone areas or to the establishment of elaborate health schemes could not entail an obligation for the British tax-payer to shoulder the resulting costs. Indeed, as British observers recognized, their problem was one of «providing health services in one state for two distinct communities with two very distinct standards of living» (55). While the British were faithful to their perceived reality, Jewish demands were similarly in tune with theirs. Consistent Jewish immigration ensured the influx of medically trained personnel. Soon, the ratio of medics per population reached and sometimes passed European proportions so that, by 1936, legislation was introduced to prevent «overcrowding» of the medical profession (56). Nevertheless, in 1938, British reports noted one doctor for 670 people, one dentist for 2000 people and one pharmacist for 3200 people (57). But this was arithmetic theory. The doctors were overwhelmingly (German- Jewish), and they resulted in a patient-doctor ratio within the Jewish community of 1:300, the lowest in the world (58). Meanwhile, the British concept of an appropriate colonial doctor-patient ratio was closer (54) SHVARTS, Shifra. Kupat Holim and Jewish health services during the mandate. In: WASERMAN; KOTTEK, note 22, p. 334; TESSLER, note 1, pp. 61-68. (55) PALESTINE, 1937, note, 48, p. 317. (56) REPORT, 1936, note 4, p. 176. (57) REPORT, 1938, note 4, p. 170. (58) SHEPHERD, note 2, p. 130. Health in interwar Palestine: Ethnic realities and international views 447 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 423-450. to 1:4000 (59). Such ideas were out of touch with Jewish-Palestinian realities and belied myths of a «civilizing mission» (60). But the British position was indeed difficult. Financial assistance of European-style health schemes would not only grant to the Jewish community more than their perceived fair share in relation to their Arab neighbours. It was tantamount to subsidising a process of increasing autonomy which went against the interests of the British Empire. But so did renouncing the enormous contributions of the Jewish Health System and private Christian charities to health care in Palestine in general, those contributions that so conveniently relieved British authorities from duties and expenses. The British Government tried to have it both ways, to benefit from the input of private achievements, and still retain public control – and failed. By welcoming the degree in which Jewish health organisations supported and relieved the British Health Department, and by allowing the Jewish Health Service to become a more important supplier of health provisions than the Government Health Department, the British Government delegated state responsibilities and effectively gave up a good part of its claim for governance. The British had criticized the Ottoman Empire for not providing health care for its citizens, implying that this deficiency reduced Ottoman entitlement to the area. Twenty years later, the British themselves, without apparently being aware of it, laid themselves open to the same argument. The British-Arab relationship in health work was much less noticeable but no less difficult. In fact, Arabs hardly appeared as players, and if they did, as in their contribution of anti-malaria drainage work, their image was to work «voluntarily (…) under the Department’s advice and with its assistance» (61). Lacking outside help, funding and know-how as well as an elite with a clear plan of a gaining sovereignty, it seems most Arab citizens limited their efforts to either cooperating in schemes of the British Health Department or working in informal health support not visible to Western observers and not conducive to (59) SHVARTS, note 3, p. 81. (60) See WORBOYS, Michael. Colonial Medicine. In: COOTER; PICKSTONE (eds.), note 41, pp. 67-80. (61) PALESTINE, note 48, p. 314.