All men are created equal, stated America's founding fathers in the Declaration of Independence 230 years ago. But after these free men and women are born, inequalities make their appearance - especially when it comes to medical care. This is too often true in the US, where some 50 million people have no health insurance and, in crisis, go to public hospital emergency rooms where they usually have to queue up for minimal care. But it is true - increasingly so - even in Israel, where since 1995 every resident has been entitled to a basic basket of health services from doctors, clinics, pharmacies and hospitals. They are not illegally refused admittance to public hospitals or community clinics, but some socioeconomically weak groups can't afford "copayments" for medications or visits to specialists, have difficulty reaching medical facilities, haven't been educated in disease prevention, eat cheap and unhealthy junk food, get no exercise and may not even know they have a right to demand equal treatment. Among those who suffer from inequalities in health care are elderly people, Arabs, Ethiopian immigrants, women, the poorly educated and poorly paid, the unemployed, residents of outlying development towns and the poor in urban centers and haredim. Health inequalities should - and probably will (given the social demands of some coalition partners) - become a major issue on the new government's agenda. But it will take time, as the issue been raised here only recently. A major player in raising awareness of health inequalities is Jerusalem's Myers-JDC-Brookdale Institute's Center for Health Policy Research, which recently published a 36-page report in Hebrew on a study. Called "Reducing Health Inequality and Health Inequity in Israel: Towards a National Policy and Action Program," it was headed by Prof. Leon Epstein, Dr. Baruch Rosen and three colleagues, and funded by foreign donors and the Israel National Institute for Health Policy and Health Policy Research. The Jerusalem institute followed up publication of the study with an all-day symposium on May 4 that was attended by leading experts and decision-makers in the health system. Institute director Prof. Jack Habib noted that enjoying a decent level of health is a prerequisite for enjoying life and being a productive individual. "As the health system is in the process of setting national goals, we hope this report will contribute to it." The main principle of the National Health Insurance Law - passed in 1994 and coming into effect on January 1, 1995 - was the provision of egalitarian health services to the whole population. But the researchers, who conducted face-to-face interviews with 103 health system and governmental decision-makers and academics found that the vast majority conceded that the system displays significant inequity. The researchers' main aims were to examine the place of inequality in health services, the views and actions of health system and government leaders, and suggest ways to reduce the lack of egalitarianism, partly based on professional literature published in other countries, including the US, Britain, Sweden and Holland, which have launched state programs to alleviate the problem. Epstein, a leading public health researcher and former dean of The Hebrew University-Hadassah Braun School of Public Health and Community Medicine, explained that such inequity is a lack of justice, a difference that is not required by reality and one that can be prevented. Inequity in health cannot be wiped out altogether because of differences in education and income, but it can be minimized. Epstein noted that Israel can be proud of an increasingly growing life expectancy and reduction in infant mortality, "but these are averages. There are differences between Jewish and Arab communities, and within the Jewish and minority sector." Over the past few decades, the death rate of newborns has been reduced drastically throughout the country among Arabs and among Jews. However, the ratio of infant deaths between the best-off Jews and the worst-off minorities has still not changed, he said, and is about one-to-seven. BUT THERE are ways of improving the situation, as the higher the educational level of Arab women, the lower the mortality rates among their babies. Another indicator of health inequalities is the rate of diabetes in different populations and sugar-insulin balance in diabetics. The prevalence of Type II diabetes (resulting largely from obesity and lack of exercise) is higher among people with a lower education, Epstein reported. And once someone is diagnosed and treated, there are major differences in control of sugar-insulin levels (as determined by the level of HbA1C in blood samples) between higher socio-economic groups and lower ones, even though all of them are entitled to the same visits to doctors and medications. Whether women aged 50 to 74 undergo mammograms to detect breast cancer at an early stage or not is also an indication of inequality, he continued. For reasons of lower education, bashfulness, modesty, avoidance or being "too busy" caring for large families, haredi and Arab women are much less likely than other Israeli women to get biennial mammograms, even though they are free for this age group. Thus the disease is diagnosed among them at a later stage and is more likely to be fatal. Most of the decisionmakers interviewed for the study conceded that despite the lofty ideals of the National Health Insurance Law, the system was pervaded by inequality. They were surprised by the degree of inequality in health services and regarded it as an important subject that deserved high priority in allocation of resources. This was so not only because of its harmful effects on individual patients who could not afford the better health care enjoyed by the economically and socially advantaged, but also because of the risks it posed to the social fabric, the researchers wrote. Rosen, who heads the Myers-JDC-Brookdale Institute's Center for Health Policy Research, said that even though there are differences in lifestyles and how people take care of themselves or abuse their health, the health system nevertheless has a role in minimizing inequality and educating weaker elements. It doesn't mean, Rosen added, that doctors are bad or don't want to help, but they need more training in promoting healthful lifestyles and encouraging poorer, less-educated patients to take care of their diabetes or high blood pressure, for example. "The Israel Medical Association heads told us they agreed with our conclusions and wanted to know what they needed to do. That is very encouraging. Prof. Epstein has already been invited to speak about the report to the heads of over 15 organizations involved in health care. They are open to it and realize that what is needed is not just more of the same," Rosen said. Most of those interviewed said doctors and health funds should receive specific incentives for reducing inequity in the provision of health services and promotion of good health. The decisionmakers stressed that poor health has major economic implications on Israeli society in general - loss of work days, for example - and on the health system due to the costs of treatment. But most admitted that increasing egalitarianism in the health system did not appear to be a national priority, although the study was completed before the latest elections, in which the social agenda received many votes. Most of those interviewed called for intentional decision making at all levels of government and society to reduce inequality in general and specifically in health care. NOT ONLY the Health Ministry is responsible for promoting egalitarianism in health services. The Education and Environmental Quality Ministries, for example, are also involved, and decisions must be made by the prime minister, cabinet, Finance Ministry and Knesset, they said. Local authorities, which are generally aware of health problems of their residents, and the Israel Defense Forces should also be involved, they said. Academics (especially medical school administrations) should come down from their ivory towers, and religious leaders in the haredi and Muslim sectors should use their pulpits to educate and minimize inequality. Epstein recommended that a national committee be appointed to lead the struggle against health inequality by overseeing the development of infrastructures, training of health system staffers about cultural differences and promotion of disease prevention in specific groups and the population at large. Such goals can be reached, he concluded, as other countries have proved it is possible. In Britain, for example, the heavy influx of migrant populations has resulted in the launching of "immigrant-friendly hospitals" whose medical staffs speak their language and understand their culture and aim to reduce health gaps by 10%. "Whenever British ministers present their budget proposals, they always have to present concrete plans for reducing health inequities," Epstein said. It is time for the new health minister, Ya'acov Ben-Yizri, to read the report and bring its conclusions and recommendations to the cabinet for a serious discussion.