International Spotlight: Israel

Abstract

The State of Israel provides significant opportunities to study social processes that can enhance our understanding of the aging experience. It has high life expectancy and rapid growth of its older population. With an older cohort that is composed largely of former immigrants and includes a minority Arab population, Israel provides much diversity for gerontological study. Among the unique issues facing older Israelis are the aging of Holocaust survivors, modernization in the Arab sector, and privatization in the kibbutzim. New legislation related to pensions and universal health care is expected to affect aging processes. The development of “supportive communities” offers a new service model. The article notes 2 longitudinal studies of importance—the Israeli component of the Survey of Health, Ageing, and Retirement in Europe and the Jerusalem Longitudinal Cohort Study.

The State of Israel has a rich history of research and education in the field of aging. All its major universities are involved in gerontological research, and there is an active gerontological society, founded only 10 years after the Gerontological Society of America. According to the Israel Gerontological Society’s (IGS) web site, “During the last 50 years, the Israeli society has undergone an intensive aging process” (http://www.gerontology.org.il/default_en.asp).

The rapid growth of the aging population in Israel has been accompanied by an increasing diversity within the aging population of the state. Large migrations, first from Europe, then from countries in Asia and Africa, and in the 1990s, from the former Soviet Union, challenge those who care for older people. But they also provide significant opportunities to study social processes that can enhance our understanding of the experience of aging. The presence of a growing and increasingly diverse older population with several major centers for the study of aging make Israel a center for advances in gerontological knowledge and practice.

Since the year 2000, Israeli gerontologists have published some 750 scientific articles in the international academic and professional press in a wide range of areas and on a wide range of issues. To illustrate the rich variety of research ongoing in Israel, we have chosen to cite the articles by Israeli researchers that examine issues of aging in Israel and that have appeared in The Gerontologist in the past ten years. By doing so, we not only provide an overview of gerontological research in Israel but also demonstrate to researchers elsewhere the interest Israeli researchers have in sharing their findings with the international community. As all the articles cited were published in The Gerontologist, the significant contribution of Israeli researchers in fields not usually covered in this journal, such as the basic biology of Alzheimer’s disease, is not noted here.

Israel has one of the highest life expectancies in the world—81 years overall, and it continues to grow. About 10% of the current Israeli population is aged 65 years or older. Given the high life expectancy and rapid growth of the proportion of older adults in Israel, mortality risk is of significant interest. For example, Benyamini, Blumstein, Lusky, and Modan (2003) examined gender differences in the self-rated health—mortality association. They found that self-rated health was related to short-term mortality but not to long-term mortality, and this relation was strongest among older women (aged 75–84 years). The authors concluded that the self-rated health–mortality association differs among age groups and genders and that work is needed to identify where this information can be accurately applied. Litwin and Shiovitz-Ezra (2006) examined the relation between baseline network type and 7-year mortality risk in late life. They found that network types were associated with mortality in the older age groups (70–79 and 80+ years). Respondents in diverse or friend-focused network types and, to a lesser degree, those located in community-clan network types had a lower risk of mortality compared with persons belonging to restricted networks. Based upon these findings, they recommend the development of network-type assessment inventories to assist practitioners in choosing relevant social interventions for their older clients.

As noted earlier, a critical element in understanding aging in Israel is the role of diversity. This is because 84% of older Israelis immigrated to Israel sometime during their lifetimes (or to the area that became the State of Israel), and they migrated from some 78 different countries around the globe. Furthermore, many arrived as refugees and some as survivors of major traumatic events—30% of current older Israelis are Holocaust survivors. The aging cohort in Israel also includes a significant minority of Arab citizens, who currently comprise a relatively small part of the older cohort (7%) but are expected to increase by 150% from 2006 to 2025 (compared with 62% for Jews). Arab-Israeli society is transforming from an agrarian culture to an urban one. As a result, expectations of being cared for by family members, as has been done traditionally in this population, may not be realistic in the future for some Arab elders.

Discussion of aging within the Palestinian territories occupied by Israel is a complicated task that is beyond the scope of the present discussion. This is because some reports on population and health in the West Bank include both the territories administered by Israel and those administered by the Palestinian Authority, but others do not. Some reports include everyone living in the West Bank, including Jewish-Israelis, whereas others include only the Arab-Palestinian population. In addition, residents of the Gaza Strip, nominally a part of the Palestinian Authority, are currently governed by a separate authority (Hamas). It can be noted briefly, nevertheless, that only 3.7% of the population of the West Bank is aged 65 years or older, and the corresponding figure in the Gaza strip is 2.7%. Overall, life expectancy in the former is 75 years and in the latter, 72 years.

Most of Israel’s older population resides in the community—only 4.5% live in an institutional setting of any kind and less than 3% in a nursing facility. Not all older Israelis have mastered Hebrew, even among those living in the country for decades. Consequently, one hears a multitude of languages wherever older Israelis congregate. About a fifth of older people in Israel are poor even after receipt of transfer payments. In 2008, 22.7% of households headed by an older adult were below the poverty line. This is partly related to age at immigration as many did not work enough years to earn sufficient occupational pension benefits (and some did not work at all). However, recent legislation has strengthened the occupational pension system.

Issues facing older Israelis are familiar to gerontologists—such as low income, the decision to enter facility based care, and lack of coordination between the social and health systems. Nevertheless, these issues frequently play out in a context very different from that of the United States. For example, the significant number of Holocaust survivors in Israel can raise special challenges to entering facility-based care. For some survivors, entering a nursing home means entering institutional life for the first time since the concentration camps, which can be a traumatic experience. Another example is the rapidly changing nature of kibbutz life (many kibbutzim are privatizing, which changes the relation of the individual to the collective). This brings special challenges, especially as many older kibbutz members are those who established these collectives. Older kibbutz members may take some of the changes being made as a questioning of their own world views and the way they have lived their lives.

Many topics of concern to researchers in other countries are also prominently featured in Israeli research. For example, Nuttman-Shwartz (2004) looked at adjustment to retirement as the population continues to age. By means of a phenomenological description of the pre- and postretirement experience, she found more stress and uncertainty during the preretirement phase than in the postretirement. Her work suggests the desirability of supportive preretirement interventions that would assist individuals as they anticipate leaving their jobs. Another example is the relation between the interpersonal environment and morale in old age, which was examined by Litwin (2001). A network typology derived in that study has been subsequently employed in replication studies in other settings, including the United States. This line of work underscores the importance of the classification of network types among older adults and their consideration in relation to outcomes of interest to gerontologists. Koren (2011) employed a phenomenological approach to the study of older Israelis living in second couplehood in old age. She found that such relationships were rarely characterized by continuity, raising interesting questions about continuity theory, and its interpretations.

As in other countries, health and social services play a critical role in the lives of many older adults and are also topics for research. Clinical medical care in Israel is organized and provided through one of four publicly financed and administered nonprofit health plans similar to Health Maintenance Organizations in the United States. Legislation in the past two decades has guaranteed health care to all Israelis through the health plan of one's choice. Several service initiatives geared to aging in the community are also apparent. They include the expansion of home-based services, the development of “supportive communities,” and other related services. ESHEL—the Association for the Planning and Development of Services for the Elderly—initiates services in the community and institutions as well as health promotion programs and special enrichment programs, such as computer classes.

Israeli researchers have conducted studies of both the health behaviors of older adults and the professionals who care for them. For example, Isralowitz, Reznik, and Borkin (2006) examined the reasons for benzodiazepine use among Russian-speaking elders in Israel. They discovered that contrary to that found in other studies, there were no differences by gender in benzodiazepine use for this study population. Shinan-Altman and Cohen (2009) examined nursing aides’ attitudes to elder abuse in nursing homes and considered the impact of work stress and burnout on this phenomenon. They discovered that condoning abusive behavior was closely associated with higher levels of work stressors, burnout, and low income. The authors recommend training and supervision programs to reduce work stressors and burnout among nursing aides. Iecovich (2011) examined the correlates of satisfaction among migrant live-in home care workers, a major source of home-delivered care in Israel. Among the findings, she showed that those with more job decision authority and variety reported increased job satisfaction. As such, she calls for increasing the autonomy of these essential personnel.

There are many researchers in Israel looking at biomedical and/or psychosocial issues. Funding comes from Israeli sources as well as from foreign funding sources, including the American National Institutes of Health. Many of the topics are familiar to American researchers, such as caregiver stress, facility-based care, and national studies designed to better understand the experience of aging in Israel. A portion of this research is being conducted in collaboration with similar efforts in other countries, so that comparisons can be made. In addition, there are studies of various aspects of the health care system, again some in comparative perspective with other countries such as the United States and some European nations, to better understand key issues such as challenges to the coordination of care. Two prominent longitudinal aging studies that are currently running in Israel are noted next.

SHARE-Israel is the Israeli component of the Survey of Health, Ageing, and Retirement in Europe. Based upon the American Health and Retirement Survey, SHARE is a major empirical enterprise that seeks to better understand the status of persons aged 50 years and older (Litwin, 2009). It combines an international and interdisciplinary approach that allows comparison of the health, social life, and economic situations of older people in some 20 different countries, including Israel. Funded primarily by the U.S. National Institute on Aging (NIA/NIH grants R21AG025169, R03AG029258, and R01AG031729) and by Israeli sources, SHARE-Israel is administered by the Israel Gerontological Data Center (IGDC). Data from SHARE-Israel are freely available to researchers. They may be obtained from the SHARE project (http://www.share-project.org/) or from NACDA—the National Archive of Computerized Data on Aging of the Inter-University Consortium for Political and Social Research at the University of Michigan. An article in The Gerontologist demonstrates the use of SHARE data. It compares Israeli respondents with those in 11 European countries in order to validate a research measure of subjective income (Litwin & Sapir, 2009). The authors found that self-rated economic status is a robust indicator of financial capacity, with the caveat that the oldest old may underestimate financial difficulties.

The Jerusalem Longitudinal Cohort Study follows West Jerusalem residents born in 1920–1921. Established in 1991 by the Department of Geriatrics and Rehabilitation at Hadassah-University Hospital, the study includes description of the patterns of aging; isolation of elements of lifestyle, health factors, and biological and disease states, which are harbingers of morbidity and mortality; and identification of potential strategies and predictors of successful aging. For example, Stessman, Hammerman-Rozenberg, Maaravi, and Cohen (2002) showed that the benefits of exercise in this cohort were independent of the influence of chronic illness or general self-assessed health.

It is also important to note that the IGS issues Israel’s premier journal in the field of aging, Gerontologia. Articles in this Hebrew publication represent the state of the art of Israeli gerontology. Special issues of the journal are periodically organized around selected themes. Recent special issues have focused on intergenerational justice and economics, geriatric physical therapy, and cognition and aging.

The study of gerontology has grown significantly in Israel in the recent past. More than 50 PhD dissertations and more than 200 master’s theses in the field of aging have been produced since the year 2000. The growth in the study of aging in this country has been advanced, to no small degree, by two MA programs in gerontology, one at the University of Haifa and one at Ben Gurion University in the Negev. Lowenstein’s (2005) article in The Gerontologist describes the goals, development, and outcomes of the program at the University of Haifa. In addition to these two regular degree programs, there are a range of courses on gerontologically related factors and their social and health concomitants at several other institutions of higher learning in Israel. Some such settings maintain concentrations or specialty tracks in gerontology within regular degree programs for other disciplines, such as social work, nursing, and occupational therapy.

Another wing of gerontology education in Israel is earmarked to enrich those who serve the older population in a variety of capacities. The Glickman Center for Education and Training at the Sheba Medical Center in Tel Hashomer was established in 1989 by the Joint Distribution Committee—ESHEL to improve the quality of elder care. Continuing professional education tracks operate at other sites as well, such as the program at the University of Haifa. Yet another wing of gerontology education focuses upon the educational needs of older people. For example, the Bar-Ilan Brookdale Program in Applied Gerontology at Bar-Ilan University in Ramat Gan promotes the contribution of older adults to society through continuing education. Similar learning opportunities for older adults exist at other Israeli universities as well.

Given the wide range of interests among Israeli gerontologists, it is impossible to identify just a few who would be considered the “top” researchers. However, an excellent place to start searching for Israelis investigators by area of interest is the web site of the IGDC (http://igdc.huji.ac.il/). Operating in English and in Hebrew and located at the Hebrew University in Jerusalem, the IGDC works to pool data and to link researchers across Israel’s universities and research institutes.

In conclusion, we note that research, policy, education, and practice in the field of aging are all responding to an ever changing and increasingly heterogeneous aging population. There is much to learn from the Israeli experience in all these areas. We encourage anyone with an interest in the impact of a rapidly changing aging population to consider the Israeli experience as they respond to similar challenges in their own countries.