Reflections on School Nursing in Israel - and the Business of Health Care for Profit: Vaccine Consent and Paternalism

 

 

“Sign this or else you will not get your pension benefits. You agree to never discuss your work for this company.”

 

It’s been over a year since I was delivered this notice, upon my departure from my 21 year journey as school nurse in the Shomron. 

 

 

 

A gag order. About - school nursing.

 

 

 

Gag orders do not really work for me. Not a Brookline kid who volunteered for Planned Parenthood,  traveled abroad as a teenager half a dozen times, marched on the Boston Common for public funds for public schools and woman’s right to choose, groomed to be an activist and seek my truth, observant Judaism was a natural course to take for its inherent empowerment of women and culture of debate.

 

 

The Schlesinger and Goodenough families were my inspiration. They lived right across the street from each other on Clark road. They both engaged in ongoing activism in both unassuming and public ways. I learned from both of these families that being involved in local politics is only part of one’s contribution to society, another more compelling one is the ongoing building of interpersonal trust. Their homes were open and accepting.  Prof. Schlesinger, professor of mathematics at Tufts university, recommended me for a summer job, and prof. Goodenough, professor of Biology at Harvard medical school, actually hired me for three summers to work in his medical laboratory. These were their efforts at helping others in empowerment. “Think global, act local” was a slogan that the people I respected held by.

 

Israel is supposed to be a lot of things - a fulfillment of a biblical promise, a haven for beleaguered Jews, a light until the nations, a democracy and at the same time a Jewish state, whatever each of those terms meas is a matter of ongoing debate, but in addition to all this it is supposed to be a semi-socialist country, with affordable health care for all. This includes tipat chalav services, which is well baby and child care, and school nursing services, in which the school nurse is on hand to perform growth examinations, vaccinations, vision and hearing tests, health education, and being a resource for the staff and students. 

 

 

 But that is long gone.

 

When I began, I was present at each school once a week. This was already a downgrade from the former school nurse’s daily presence. Our boss was the ministry of health, no  middle-man was yet managing school nursing. I admit that the system was not all that well organized, and the nurse that checked on my work, about halfway into the year, was impressed with how much I had completed already.  I had been oriented to school nursing by Naomi, who also was working in well-baby health, thus she was acquainted with kids from birth through the ninth grade. This continuity of care gave fertile ground to trust-building and patient compliance. You may think that growth evaluations are no big deal, if a child is too short, thin, or overweight, you just refer the parents to a general practitioner, endocrinologist, and perhaps dietitian right? Parents are not always aware, caring, or available. Intervening with a growth abnormality at a young age can be crucial, it may reflect a deeper underlying health problem, even a future fertility issue,  and in some cases can actually be life-saving.  

 

The slow work of ongoing contact and relationship building can tip the balance to intervention.  A cold call from a school nurse that the parent never met is no comparison.

 

When I trained with Naomi, I saw her check a child for signs of abuse, having been alerted by a teacher of some remarks the child had made, call a parent in response to some complains her son had made, she came to school and took him straight to a specialist, Naomi knew he was being followed for a health issue. She was available for such interventions. That availability would quickly fade.

 

Then Naomi told me, "they have taken my tipat chalav from me", she was devastated, having built relationships over the years. This was 21 years ago. Public health care was being divided up, continuity of care was shutting down.

 

Israeli’s tend to be distracted with the latest security concern, Jewish fear is real, but can serve as a distraction. People here are likely to lack the energy to ask, “what happened to school nursing”? Or any other critical thinking question that involves their daily life. On heightened alert, their focus to the mundane fades. And that is a business opportunity for the rest who are a wee bit swifter.

 

When health care becomes a business, in a country that is supposed to be semi-socialist, the culture of tipat chalav and school nursing becomes more impersonal. 

 

 

Management is actually motivated to promote quick staff turnover, with burned out  and appalled nurses quitting to be replaced by the younger and cheaper. I noticed a trend that nurses who quit or were fired went on to be excellent nurses in hospitals, clinics, and rehabilitation, professions that tend to be more complex than school nursing. You wonder, why were these excellent nurses not appreciated and thus retained?

 

Here is an educated guess: turnover keeps costs down by circumventing “vetek”, or seniority. 

 

There are two kinds of questions that a worker may ask her management, the challenging question, and the clarifying question.

Evidence-based nursing is touted in the academic literature but is decidedly not being practiced in the field.  School nurses have been saying for nearly a decade that some policies are just not working, these nurses are either brushed off or told that they are not listening. I came to understand that this was not happenstance, but a mechanism to keep the nurses in a culture of semi-fear. Should you bring up an idea that conflicts with their orders, should you question the system, that proves you were not listening! 

 

 

The culture that your feedback is turned against you, as proof that you were not listening, turned into a culture of fear. “Read the policies and leave us alone” was the order. I sent several emails to management pointing out contradictions in the policies, strongly implying that we are going to have to ask clarifying questions given that a thorough study does not mean one clear answer. That is the clarifying question.

The signature on the health declaration includes a clause of agreement to vaccines, That, with ONE notice sent to the parents, is a green light to vaccinate.

 

School nurses know that this policy, in place since approx. 2015, DOES NOT WORK.

 

This is especially crucial in 2^nd and 8^th grades. In the second grade, tetnus-diptheria-pertussis-polio is given on the same day as the influenza vaccine. In the 8^th grade, the tetanus-diptheria-pertussis vaccine is given on the same day as the papiloma virus. Clarification is crucial.

 

We do not want to anger parents. Some of us actually want to build trust, or at least, if not hailing from the privilege from which I come, they wish to do not harm.

 

We are fully aware that parents do not understand what they are signing. We have said this for years. The response? “Vaccinate and parents will learn the importance of this signature and over time the population will understand this policy.” How on earth was word supposed to spread among the Israeli population?  And, even more appalling, “they can’t sue you”. 

 

(here is a photo of the first page of the health declaration used in Israel's schools)

 

This is paternalism, it is condescending, and totally callous to basic decency.

 

Vaccinating according to the health declaration, and not checking in with the parents, "saves" time and therefore money. 

Where does the profit from all that saved money go?

 

The nurse, whether a Brookline kid, or just not wanting to anger, goes behind the back of the management and spends extra time sending emails, what’s apps to parents to assess their real wishes. One nurse said to me, “between us (meaning, don’t tell management) I do call every parent to ask what they want.” 

 

Imagine the stress this nurse is under to actually hide from management that she contacts parents to assess their true wishes!

 

Because we are told to vaccinate according to the health declaration, we are not given extra time to make phone calls. Under a previous management, 36 phone calls a day was considered a day’s work.  Since this allowance faded, nurses find other ways to communicate with parents via the teacher’s what’s app or emails.

 

The Haredi sub-community however lacks digital communication. That means that nurses there must phone parents to ascertain what they want. Which means many extra hours of work.

 

And the following really happened: Out of 50 schoolchildren in the second grade, I got definite answers for which vaccine to administer to all but four children.

 

The digital health declaration was signed for these four, with no restrictions on vaccinations - which meant, vaccinate both tetanus and influenza. In each record, I wrote that I vaccinated the tetanus, and, “in discussion with the mother, refuses influenza”.

 

What happened next? My boss confronted me, “we saw in these records an allowance for ALL vaccines. Then you wrote “refuse” influenza?" then she asked, who called who? Who called who?”

 I did this on my own time, I did not take away from metrics or productivity. But it is the very concept they wish to snuff out.

A school nurse can be rebuked with a note on her permanent record that she was not complaint with policy - for simply asking a parent what s/he wishes.

 

Did I not respect bodily autonomy? Right to choose? Respecting the patients' wishes and building trust?

 

 

And if school nurses should anger parents and go ahead and vaccinate all, knowing that this policy does not work, what conspiracy theories and anti-vaccination rumors might spread in its wake? 

I built trust where I live, in Imanuel, a largely Haredi town in the Shomron, as did the nurse who preceded me. There was never an outbreak of a vaccinate-able contagious disease here. That may be due to the communication I fostered and the trust I built. There are several with families, who  each have several children, who had been opposed to vaccines, agreeing to partial vaccine coverage.  That is the trust I built, but instead, I received a confrontational, "who called who?"

 

And Israelis are distracted.

 

I have not signed that gag order, nor do I plan to.