ישיבת ועדה של הכנסת ה-14 מתאריך 02/12/1998

ישיבה עם שרת הבריאות של ארצות הברית

פרוטוקול

 
הכנסת הארבע עשרה

מושב רביעי



נוסה לא מתוקן



פרוטוקול מס' 165

מישיבת הוועדה לקידום מעמד האישה

שהתקיימה ביום די. י"ג בפסלו התשנ"ט. 2.12.1998. בשעה 15:00
נכחו
חברי הוועדה: היו"ר מרינה סולודקין

תמר גוז'בסקי

נעמי חזן
מוזמנים
שרת הבריאות של ארצות-הברית, דונה שלאלח

אדוארד ש. וולקר, שגריר ארצרת-הברית בישראל

ויליאם גראן, שגרירות ארצרת-הברית בישראל

דוד השמן, משרד הבריאות של ארצות-הברית

ינון שנקר, פרוייקט איידס ירושלים

נאוה ברק

דייר חנה קטן, גניקולוגיה ופוריות, בית-חולים "שערי צדק"

שושנה גן-נוי, מנהלת מחלקת הסברה והדרבה, האגודה למלחמה

בסרטן

יהודית סלומון, אגף למעמד האישה, רבזת בריאות, נעמ"ת

אירית ענבר, מנכ"ל העמותה הישראלית לאוסטאופרוזיס ומחלות

עצס

נורית טולנאי
מנהלת הוועדה
דנה גורדון
נרשם על-ידי
חבר המתרגמים בע"מ

סדר היום

ישיבה עם שרת הבריאות של ארצות הברית



1998 .02THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER
DONNA E. SHALALA
Well, the question is the agenda for women's health in

the United States. The answer is complicated, because we have a comprehensive

strategy for women's health. We do not assume that because a woman has health

insurance from the government or from the private sector, that she has good health

care. So, our interest is in making sure that she actually has quality health care and

that her insurance covers her needs as a woman.

In addition to that, in the budget, in the President's budget. we will ask for resources to

close the gaps between immigrant women, minority women and health care. We

know, for example, that even if minority women have health insurance, they don't

necessarily get mammograms or cervical cancer screening, which is a problem in

Israel. In fact. I saw the survey that was done today, that was announced at the

conference that I was at, in which the numbers of women in Israel that are getting

screened for cervical cancer are very low, compared to other countries. It looks like

the health system does not think that cervical cancer screening is important.

So, we will increasingly emphasize in our health care system, prevention. Early

screenings. We now. if we screen breast cancer early and if we can get women to

screening, 92% of the women will survive. That is the highest percentage we have

ever had. But the issue is, can you get women to the screening early enough, and so

we will expand our outreach services by funding NGO's community based

organizations, to help bring women to the health services.

We are no longer assuming that just because they have insurance, they are going to

use the health care system. So we need an outreach system. In many ways it is back

to old fashioned public health street workers to go door to door and to talk to women

and to bring them into the health care system and to encourage them, using the media,

for example.



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

So, the first answer to your question about, what is new, what are we dong next, is to

make our health system work for women, by putting the safety net back together

again, and using more outreach services to close the disparities between women who

are well off and women who are not well off.

It does not have to do with insurance, it has to do with whether you can get them to

services. Minority women and immigrant women are often afraid of the health care

system. So, designing it in a way so that they really use it is very important to us.
MERINA SOLIDKIN
Not afraid. we are here hardly working very much with

immigrant women. We are working all the time and not thinking of our own health.

We have the numbers for breast cancers in the populationof the Former Soviet Union,

four times more than in the Israeli population.
DONNA E. SHALALA
The second issue for us is tobacco. Tobacco is a huge

killerof women. We are focusing on convincing young girls not to start smoking, as

part of a major campaign
MERINA SOLIDKIN
Is it national in schools?
DONNA E. SHALALA
Every place. I guard our soccer team, the women's

national soccer team, every time they play, any place in the United States, they talk to

the girls and give out a poster to tell them not to smoke. I got our rock stars, so we are

using every media source for a major campaign.
MERINA SOLIDKIN
The money comes from?
DONNA E. SHALALA
Well, some of it is voluntary. The rock groups

volunteered their time. Some of it is because the television stations volunteer their

time for public service. But I also went and talked with the writers for soap operas

and for allof our television shows, to get them to write good health practices into their

characters. More women get information about how sexually transmitted disease is



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

transmitted from soap operas than they do from any other source. So, you must go

those sources and talk to those writers.

So, our prevention campaign is very sophisticated, because wherever people get their

information, I do not believe in public health brochures. I have never met an

American teenager who has ever read a public health brochure and changed their

behavior. But they want MTV and change their behavior. Or they look at magazines.

We are running a big campaign on osteoporosis. This is the Mel Campaign, this is me

with a moustache and there is a huge milk mustache campaign to get people to bring

milk, and this is the osteoporosis one that I did myself, and it is in all the magazines.

So, whatever the communications is that will reach people, forget about brochures.

The public health people will want to do more brochures and more boring programs.

You have to reach kids in the coffeehouses in all the places where they gather.

So, prevention and communications, particularly on tobacco, is a huge issue for us in

relationship to women. More women die from lung cancer and heart disease than

from breast cancer and it is all tobacco related. More women die from tobacco related

diseases. So that is the second issue that we are focused on in terms

The third issue is research, and that is, we continue to make major investments in

research. But not just in research on women's health, but in researchers on women's

health. We are using our money to expand the generation of researchers, men and

women who do work on women's health. The head of the National Institutes of

Health, Dr. Harold Varmus won the Nobel Prize for his work on breast cancer

actually. We want to increase the number of people who do research on women's

diseases.

We also have ordered the National Institutes of Health, under a presidential directive,

that any time they are doing research on a disease that affects women, they must have



1998 .02THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER

women in the clinical trials. They no longer can do research that is paid for by the

government on a disease that affects women, without having women in the trials. So

that we understand more about women's bodies in relationship to this.
MERINA SOLODKIN
We have the same approach in different areas.
DONNA E. SHALALA
But it turns out you have order the scientist. The first

research on breast cancer was done on men. It was not until 19993 that we ordered

the scientists to change their behavior, that we actually significantly increased the

numberof women in clinical trials. So, our research strategy is different. It isnot just

research on women, it is researchers on women, because we want to fmance the

trainingof the next generation of scientists. Because our scientific system, and many

of your scientists participate in it, is researcher driven. So, what you need is a lot of

researchers out there, who are interested in women's healtii.

We cannot depend on our Congress just to set aside money for women's health. It is

too small an amount. To move women's health into the mainstream, we are doing it on

a large scale. We are about to mount the largest clinical trial in the history of the

United States on a whole seriesof issues related to women's health.

I gave a speech this morning, which we will give you copies of, if we brought it with

us. on how we moved women's health into the mainstream of American politics. In

the last Senate election in New York, the two men that were running for the United

States Senate fought about which oneof them had done more for women's health. So,

it is a bipartisan issue for us. Very good politics for us. Extremely good politics for

us.

So, on a whole rangeof women's issues, the third thing that we have done that is very

significant, and I think Minister Motza actually gets it now, and that is, we have

moved away from women's reproductive health, to the whole life spanof women, and



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

no longer will our women's health financing fund. Think of women's health as just

reproductive health. From the time a girl, before she is bom, until she dies, most of

our phone calls now to our information network about menopause. Women aren't

calling us about heart disease or lung disease or breast cancer, they are calling us

about menopause.

So, we are expanding the research across the life span of women and trying to get

some balance in our investments. Trying to get the health care system to understand

that when we say women's health, we meathe full life span of women. On

reproductive health, we are still making major investments in reproductive health,

particularly some new issues related to AIDS, to help women to protect themselves.

SoI am giving you a flavor. I think the speech sort of outlines one of the more

political speeches that I have given, about how we moved the women's health issues

into the main streamof American politics and the inter decision making.

The combination of advocacy and scholarship and bipartisan politics and Jewish

humor, right.
TAMAR GOZANSKY
I just want to thank you for being with us and the major

issues you put before us. We will try to deal with them about breast cancer. Three or

four years ago they said, "You see, there are only 25% of women after the ageof fifty

who are entitle to feeof charge." They are going to do the check up and so on. All the

institutions involved said, "We can do nothing. You see women are lazy, the don't

want, they worry." Then we asked them to send invitations, personal invitations.

After three years of sending personal invitations, now we have 50% of women who

are passing. So, 50% is too low, I mean we want more. But the system of direct

contacts, it worked.

But with regard to tobacco, we are so far away from your position, it is difficult even



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

to explain, what are the miserable money, and to do anything among youngster, we

have a very fast growing numberof youngsters who are beginning with tobacco at the

ageof thirteen. It is so difficult.
DONNA E. SHALALA
But, if you go and ask young people, which is what we

did. We went and asked the kids, "How can we stop you from smoking?" they said,

"You have to start earlier. Don't wait until we are eleven years old." You have to

start earlier and then keep it up right through the system, and we have to have role

models that say to us, "Smoke your opponent, not in soccer, no your cigarettes."

So, it requires a major education campaign. The kids also have to understand that the

tobacco companies are trying to manipulate us. One of our best advertisements has a

bunch of old men sitting around a table, talking about how they are going to get the

kids to spoke tobacco as replacement smokers. There are headsof tobacco companies

sitting there and the kids designed that ad. We let our young people design our anti

smoking ads.

In this area, like many other areas focused on young people, you have to be very

careful not to just listen to public health experts. I bring young people in and let them

talk to the public health experts, and let them review and design the advertising. The

most effective ads in the United States are in Massachusetts where the kids design the

ads.

On breast cancer, the science now suggests that you ought to get mammography after

forty, andif you are at risk
SHOSH GAN NOI
In Israel we are saying since fifty years old, and only if a

woman is in a high risk she has to take it at forty every year.
DONNA E. SHALALA
Politicians are going to have to make a decision here,

because everyone in Israel tells me what you cannot afford. The fact is that tobacco,



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS ? DECEMBER02.1998

and if you could significantly reduce the number of kids who start smoking, you

would have enough money for your health care system, because the cost of smokers is

very different than the costof AIDS. You get AIDS in most partsof the world, you

die. AIDS patients in many ways are cheap, because they die early. But smokers

have long term chronic diseases, and the economic cost of smokers are huge, and you

have enough money to finance all the things you want to do in women's health, that is

why the President wants to reduce the number of children that start, to save the long

term cost on the health care system.
SHOSH GAN NOI
I wanted to relate to you what you said earlier about

breast cancer and smoking, because those are the things that we are dealing with here

in Israel in the Israel Cancer Association. I think one of the leading projects was to

bring the women to do the mammography, to go and check themselves. Then we

started on this campaign, the initiationof this program to write on the HMO's, to write

personally to the women and as Member of Knesset Gozansky said, it is rising now,

because it started only a year ago, and it is rising, but we are not satisfied.

We are doing this campaigning in the media, and through the newspaper. Like we are

taking women as role models for the women.
MERINA SOLIDKIN
Unfortunately, we are doing the campaign only in the

Hebrew media. I want to say about Arab women, we are doing trials. We studied on

a little model then we are enlarging it now together with the Health Minister and the

HMO's,of course, to do this project and we are seeing also that the women are more
SHOSH GAN NOI
I see that you make efforts, but number four times more

than the Israeli population, it speaks about priorities. We heard here David Bar Ebash,

who is the General Director of the Ministry of Health, and he said the real number of

breast cancer cases in the immigrant community.



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998
MERINA SOLIDKIN
I did not go yet to the Russians, to the women who

came from Russia and there they are coming first to like, merkazei klita, centers

where they are learning Hebrew. So we have some doctors who are speaking Russian

and they go there and speak about self-examination, mammograms, and the

importanceof doing mammograms for the immigrants. Now we start also a campaign

in the media and the television and the radio. About pamphlets. I must say that we did

a survey with the Health Ministry and people want to get brochures. They say they

want to get pamphlets and brochures sent to their homes.
DONNA E. SHALALA
I talked about teenagers.
MERINA SOLIDKIN
Okay about teenagers and smoking too. We are doing

enormous efforts, but it is not enough.
DONNA E. SHALALA
I mean my point about brochures, was about teenagers.

Teenagers cannot be reached through brochures.
MERINA SOLIDKIN
I just want to finish about smoking because you pointed

out very important issues. We saw it also that the peer counseling, people who are

going and lecture other students, it is more successful and we are taking also the role

models, but we have to do more. In Israel, it is not freeof charge on television.
NAOMI HAZAN
Again I apologize for being late, and I apologize

because I have to leave as well. But Wednesday is part of member's days in the

plenary and things are a little crazy. You can imagine most of us, members of

Knesset, female and male with one or two exceptions, are lay people in this field of

health. We don't have medical training. Like membersof parliament everywhere, we

are somewhat dilettantes by definition because we make decisions on a variety of

issues, which we don't have time to do research.

Having said that, I think it is just a fact of life, parliamentary life. Because there are so



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

few female membersof Knesset, we are nine outof one hundred twenty, that is7.4%

of representation, which is really appalling. We are asked to deal with some very very

heavy issues, in a reasonably intelligent way, with very few resources indeed.

Now we are working with three handicaps in the areaof women's health. As far as I

understand, it and my colleagues can add to that. The first handicap is conceptual,

and if I got the tail end of what you said, and I glanced through your speech, I think

there is a meetingof minds on that. It has taken us a long time to penetrate the mind

cast of decision-makers that there are specific women's health problems that have to

be dealt separatelY from overall health problems.

I think we have slowly managed to break the barrier on that, but it has not translated

itself enough into allocations of resources and research in the areas that are needed.

You pointed out the menopause as being one, which is one of the most obvious as

well. There is much more attention in Israel to child bearing than there is to other

aspects of women's health, but for totally different reasons. So that is problem

number one.

Problem number two, because we did not deal at the right moment with this problem,

and because there is a National Health Bil, many of the specific or uniquely female

aspects of health care were not included in the basic basket. Therefore, we are in

constant struggle, and the health professionals that are here will verify that in trying to

get the mammography down firom the age of fifty to the age of forty. We had an

immense struggle over amnio synthesis and even on that we cannot bring the age

down in to the areas that we think are correct. Breast cancer is another example.

But if we did a study of the allocation, breast cancer versus other forms of cancer,

then really the results are not satisfactory, because we did not get in on time on the

National Health programs.



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

Now, the third elementof this is political, and you started hearing a hintof it, and that

is every issue in this country is political in ways that you cannot imagine. On a good

day we can smile, on a bad day it is very sad. But if we have finally got a leaflet out

on breast cancer or on smoking, then big arguments as to why in Hebrew and not in

English, and why in Russian and not in Arabic. Hebrew and Arabic are official

languages. Russian is spoken by at least a million citizens etc. etc. We have got a

politicization of the entire health sphere, like ahnost every other sphere of life. It

creates serious problems, but the bottom line is that the key victims, as in other

sourcesof controversy are going to be women.

So, these are three handicaps, which I would say, are in a sense unique to Israel.
DONNA E. SHALALA
These are the same handicaps that we started with. This

is the discussion that we had with our political leaders at the beginningof the process

of turning women's health into a bipartisan issue, into an issue that had no gender

identification from a political point of view. You are not going to bend me on the

issueof whether it can or cannot be done.
NAOMI HAZAN
I am just trying to bend Arik Sharon.
DONNA E. SHALALA
But let me also point out, that the only way of making

the argument isif the women's health strategy saves money in the long run. Screening

saves money by any measure. The way in which we handled the finances during our

toughest years, is that our budgeting process works in a way in which we can produce

offsets on surgeries by doing early screening and early treatment. So that our

budgeting system worked in a way in which we could point out that everything from

immunizations to flu shots to early screenings for breast and cervical cancer saved us

money in the long run within the same health care system.

So, what we did is, we have always had to live within a balanced budget in our



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

system. So, whenever I go to the Congress, to people like you, and I propose changes,

shifting money to women's health, I have to demonstrate where I am going to get the

money from, and within my budget, I identify where the offsets will be from the

investments in the early screening.

I realize that people may perceive that in the United States we don't live in the real

world, but we do in the sense that I cannot propose an initiative on women's health

unless I am prepared to finance it, somewhere within my own budget or someone

elses budget. For instance. one of the most successful efforts that women and men

had in our Congress, was to put breast cancer research money into the defense budget.
NAOMI HAZAN
We don't have it ever. But we can try it is a good idea.
DONNA E. SHALALA
But the reason they did it, was that they found some

people within the military that argued that the health of women in the military was

just as important and therefore the research agenda and the military scientists had top

include research on women's health as well as research on men's health.

You know. we have an extensive military research system, and they did not add more

money necessarily to the system, they simply earmarked money that was there, and in

some cases, as the increases came in, they identified it as part of their strategy. But

this is sortof guerrilla warfare.
NAOMI HAZAN
I really only have three points, but by the way of the

IDF have just opened a medical center for women, soldiers, and it is actually one of

the most interesting medical centers. It is new and for some reason, unlike most of

what happens in this country, it is not well known. We see it partly as a result of the

workof this committee. We see it is a step forward.

But, by the way, exactly in the same context I use that argument, the oneyou just used

about the financial aspects or gains, to try to convince the IDF to supply pills to



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

female soldiers, because the army pays for abortions. I proved to them that abortions

are more expensive than pills, and still did not get, what I thought was necessary.

Two questions, one related to choice. Now this in Israel is a totally political issue,.

What would you do in a situation where the number of illegal abortions equals and

maybe out distances the number of legal abortions in a country, and how would you

deal with it. Eveiybody knows that, everybody winks, I am looking at you. I have a

tobacco question as well.
DONNA E. SHALALA
We don't actually have something, I would not know

how to measure an illegal abortion as such. I am sure there are still some backroom

abortions in the United States. But our strategy is totally different on that in this

administration. Our strategy is to reduce the number of abortions,. We believe the

number of abortions should be rare, and therefore, we believe also, because we have

pro choices in administration, that abortions should be legal, safe and rare.

Almost all of our focus has been on doing everything we could to prevent an abortion

situation. That means extensive family planning, extensive research and we both, as

you know, the FDA has just approved the morning after pill, argue 486 will probably

be submittedif the family planning ever decide to submit it. But our research in this

area and our work, particularly among American teenagers, has been to reduce the

number of abortions.

We have reduced the number of abortions significantly. We also have increased the

amount of abstinence among our population. When people say to me, "You cannot

change teenage behavior, " I said, "You can change teenage behavior." You can

reduce the number of abortions; you can increase the amount of safe sex, but most

importantly, from our point of view, you can increase the amount of abstinence in

your system. But it takes tremendous work at the community level.



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

I mean, we have been working for a decade with our NGO's and its parents, and you

cannot leave parents or schools or religious leaders off. Religious leaders cannot get

off the hook on this issue, they have to be part of the solution, in terms of working

with families. The ethnic communities have to take their own responsibilities in this

area.

So, I cannot answer your question directly about illegal versus legal, but I can say that

it is possible to put together, and we did not significantly increase our resources. But

it is possible to get the system to work together and get communities to take

responsibility. This was all community-based work to reduce the numberof abortions,

and in particular, to make sure that the government's official position is that

abstinence is a good thing for young people.
NAOMI HAZAN
One more question. I did not hear you address the

questionof smoking in female terms, except for the risks. That means. how would you

go about addressing young women?
DONNA E. SHALALA
Well, to tell you the truth, young women, I said two

things just about, how you pitch them on smoking. Number one. is on the issue of

looks and that is that most young women smoke because they think it is the glamorous

thing to do, so you have to take the glamour out of smoking. It will make them thin,

so it is very important that you deal with the issueof weight for us, as partof that.

Let me give you an example. For the African American community, there are less

African American girls that smoke in the United States than white girls, because they

have a different body image. Therefore, the issue of weight does not affect that

community.

Finally, the bigargument we have been able to use and the most effective, is what does

it do to your skin as a young person? For boys you deal with the issue of whether



1998 .02THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER

they are going to have any breast to be able to run down the field. For girls, if it

affects their looks, if it destroys their skin and their nails and they smell awful, and

they have asked us to basically pitch girls based on those kinds of arguments, against

these come out of focus groups, out of extensive testing, of teaching materials and of

how you make the pitch.

Young people were part of the solution. I cannot emphasize enough, that when you

want to reach young people, you have to go and ask them. What kind of arguments

work with you? I will try to give shorter answers.
ARNOLD SHANKTOR
lama graduateof the Hadassah School ofPubhc Health

in Jerusalem. I guess as a man at this part of the table,I am to represent the fact that

men too care for women's health. I am also the chairof the Jerusalem AIDS project,

which is Israel's largest NGO dealing with AIDS prevention, and I apologize that

some of the media attention from your press conference yesterday had shifted a bit

Ms. Shalala from your press conference to the activity that was held at Ben Gurion

Airport, just parallel to that, that was Israeli Arab joint AIDS prevention campaign,

marking the world AIDS day.

Actually, I have three short comments, if I may. One is that unlike other places in the

world, including your own country, we have been able to see here in the Middle East

that HIV can be a uniting factor and not so much a diverting factor. Only yesterday it

was marked in this very committee the fact that Israelis and Palestinians and other

Arabs are joining forces together to fight HIV AIDS in an area in the world where the

virus is not that prevalent, like in others.

Here is the questions which has to do also maybe with some of the politics of your

own country, but should there be a way, we would have very much liked to join our

other international partners and NGO's in asking the American administration to not



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

reduce, but to increase, if possible, the aid to fight HIV AIDS around the world,

through your projects and programs, which have been approved by Congress. That is

due to the fact that sometimes you run after the fire, and we are in the part of the

world where the first has not yet been that spreading.

I ama pu8blic health expert, so it is always the questionof where do you put first the

resources, where there is the crisis already, or where they are just to be in years to

come. We would have liked very much to see ourselves some efforts made by the US

government and yourselves, also in areas where still there is a low prevalence and a

low incidenceof HIV infection and this is partof the world that we live in.

A very specific question to you, if I may, has there been a true shift in the behavior of

American adolescence, which you have just described with safer sex and abortion,

when you look at the sub groupsof America, and looking at America as a whole, and

we are reading also research to demonstrate actually the use of the condom, not to be

that high, as reported by the CDC and others. Is a changeof behavior is only towards

abstinence or towards the increaseof the useof the condom?
DONNA E. SHALALA
All the evidence that we have is there is an increased

use of condoms by teenagers and by young adults in the United States. In large part

because of the AIDS scare, but also because of these campaigns related to teenage

pregnancy. Now, it is hard to sort out the AIDS crisis from the teenage pregnancy

issue from a welfare reform increasingly. We are no longer financing people for the

restof their lives, but as a transition to get into the work force in the first place, so that

no young person could anticipate thatif they had a child, we are going to set them up

in a separate household and they would not have to go into the work force.

So, there are so many things going on at the same time that sorting out the

explanations are more complicated. But I would stick, the national data is based on



1998 .02THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER

the CDC surveys. They are. of course, individual cities and places. The most

impressive data is where communities come together and work on the issue. So, that

is the only answer I can really give you.

On the issueof funding, it is outof control in Africa. Tuberculosis is outof control in

Russia and the decisions about our international activities, as in part made by me,

because of my leadership in the World Health Organization, the International

Organizations, but in part made by the US Aid people. in terms of their trying to get

the kind of infrastructure and leadership that they can work with in parts of Africa,

wher AIDS is just going to destroy the economyof this, which it already has in many

partsof the world.

In Egypt, people said exactly the same thing to me. "We have a low incidence, you

don't pay attention to us." That has always been true in public health that we go

where the big crises are and in large part, because we have some confidence that you

can put together the infrastructure in your own countries.

Since so many Israelis are working with us on the international issues that relate to

AIDS, that is as straightforward an answer that I can give you.
HANA KATON
I am a senior gynecologist for fertility expert at Shaare

Tzedek Medical Center and a mother of ten children. I wanted to talk about the

different aspect of critical problems in our country and interaction of pregnancy. I

understand that in America fetal side is outlawed and also interaction pregnancy

above 24 weeks, is that true? Well, is there a week into fetal side actually to birth and

also interaction to pregnancy we have what is called a higher consultant service, and

this is done. I just wanted to know how the legal procedure is, but how did you get to

illegate these procedures. How we happened to succeed to illegate these procedures,

that is one thing.



1998 .02THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER

The second thing, in terms of the obstetric practice in our country, I just want to tell

you we have a very special population in Jerusalem where around 25% of the

population in Jerusalem are grand multi parents, which means more than six children,

and we have a high prevalence of great grand multi carriers of over ten children and

we have written much of the multi literature and the good prognosis with good

obstetric pre natal care of these women, who are from different socio economic

standards actually, and we think we attribute tot he literature many new things. For

instance, induction of labor grand multi parents, which was not done before, or

feedback in grand multi parents which was not done before. We found very good

results in termsof the peri natal outcome.

One more thing, in terms of IVS, in our country, actually women are entitled to

economic support for fertility treatment until two children. Once they have more than

two children, I want to know in America, is there any system, which actually cuts off

the amountof health care?
DONNA E. SHALALA
No, and the decisions on abortion have basically been

made by our courts. Some of us would prefer that they were left to physicians and the

patients and their religious advisors and standard care, but basically the decision of

when life begins, have been made by our courts, in terms of when abortions are

terminated.
YUNITIMBAR
Iam the Executive Manager of the Stop Roses Foundation in

Israel. We are a new foundation. I have many questions. I want to ask about the bone

measurement diagnosis. I believe that early diagnosis will prevent fractures in the

future. The doctors in Israel are not dealing with it, it is still private. Women should

go privately and make this bone measure diagnosis. I would like to know how it is in

your country.



1998 .02THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER
DONNA E. SHALALA
We basically, the program that the government funds

for the elderly, the Medicare program. basically covers something called all medically

necessary services. So, rather than the government listing specific services, we try to

cover, use a doctor's judgment to cover the services. Now, in some cases, where you

might have to add nresources, like mammography, where we want a standard of care,

we got the National Cancer Institute and the American Cancer Society to reach an

agreement, so women were not confused about when they should get mammograms.

So, the standardof care was published, and the Medicare program will follow it.

But we try not to let the government fight out what the standardof care is, as opposed

to providing the information of weathering the American Medical Association and

other medical organizations to determine the standard of care.; We guarantee a

benefit package of all that is medically necessary. Then hopefully the physicians will

follow standardof care.
YUNITIMBAR
Our medical insurance does not pay for scans.
DONNA E. SHALALA
Our system will pay for scans. Now if it is considered

experimental, they will not necessarily pay. So the private system, remember we have

a private and a public system. The public system operates under all medically

necessary services. The private system can pick and choose and we carmot mandate

that they use an experimental service. When people buy the private health insurance,

they are supposed to read and find out what is covered.
GILA SIDON
I am one of the managers of the Center for Women. You

mentioned before about menopause in the States and I would like to know if you

could elaborate about it. What is done about women in mid life?
DONNA E. SHALALA
Well again. our health care system covers services and

on issues whether women take Estrogen, it really is up to the doctor and the woman.



THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER02.1998

We do not, I could not prescribe a traditional standardof care, because there is Still a

debate about the use of Estrogen. Our view is that women ought to have choices and

that the scientific evidence ought to be laid out in a way, which they understand.

There are different stages in their lives that evidence ought to be repeated by their own

physicians. So, when I talked about our interest in training people, it was also training

the physicians that work with women. The Commonwealth study that was reported

on today also revealed during an early interrogation of it that women change doctors

in the United States more than men do, because they are not satisfied that their doctor

is trained to deal with their diseases.

So, as our health care system has gotten more competitive, people need to be trained

more if they are going to keep their women patients. So, there is some economic

incentive to get more training. You almost cannot find a health care system in the

United States that does not have some special set aside for women. What we have not

done, we have not just covered the service, we are trying to think about training

people, putting the research money in.

But it took us years to get to this point, and oneof the piecesof advice I have in this is

to pick your fights and to say you have a message. We used breast cancer as the

wedge to get women's health funded, with tremendous coalition support. We turned it

into a bipartisan issue. We did not cover everything all at once. We took a step at a

time. and we never lost our enthusiasm or our willingness to get our help from every

place. We have the most right wing, conservative men in our United States Congress

that are wildly supportive. They are not pro-choice, but they are wildly supportive of

anything else that supports women's health. We are particularly skilled at doing that.

We happen to have a President now that thinks it is the most important issue on earth.

I cannot guarantee for any country on earth about that, but we came a long way before



1998 .02THE KNESSET COMMITTEE ON WOMEN'S RIGHTS - DECEMBER

we got there, and we took it step by step, but we never lost our enthusiasm and it was

hard at every place,

I mean, people made fun on the floors of Congress. As we got more women into

Congress, it became helpful, but it has really been those coalitions between men and

women, between Conservatives, between the most religious partof our society and the

least religious. So, as I said today, these were important coalitions for us.
MERINA SOLTDKIN
So, Secretary of Health and Human Services, Ms.

Donna Shalala, thank you for your wonderful presentation, and we were very glad to

meet you here. Some things were new to us, and possibly, we can use your approach,

your very useful approach to women. Thank you very much.

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