Israelis Agree With Bibi

In the wake of the flotilla controversy, Israelis resoundingly back their government's stance on Gaza.

A reliable new poll of Israeli public opinion shows that attitudes on the Gaza blockade are heavily hawkish -- in diametric opposition not only to most international reactions, but also much of the Israeli media's own commentary. This finding is the first detailed measurement of Israeli views following the Israel Defense Forces' (IDF) violent boarding of the Gaza-bound Mavi Marmara, which resulted in the deaths of nine people. The poll surveyed Israeli Jewish opinion and was conducted by telephone interviews on June 7 by Pechter Middle East Polls, a young, Princeton, N.J.-based survey research and analysis firm working with pollsters throughout the region.

In the aftermath of the recent ship-boarding incident, three-quarters of Jewish Israelis say Israel should not open the Gaza Strip to international aid shipments. Narrower, yet still solid, majorities also say Israel should not accept an international investigation, nor adjust its tactics to win favorable international consideration.

Even more surprising, Israeli Prime Minister Benjamin Netanyahu's job-approval rating has now climbed into positive territory: 53 percent of respondents were satisfied with his performance, while 40 percent were dissatisfied. By contrast, 71 percent voiced dissatisfaction with U.S. President Barack Obama, and a clear majority, 63 percent, are also dissatisfied with the overall U.S. reaction to the Gaza flotilla controversy so far.

To put this reaction in context, it helps to first look at popular assessments of the deadly ship-boarding operation itself. The sole previously reported survey on this point, from a June 4 Maariv newspaper poll, concluded that a majority of Israelis thought that the operation should have been conducted "in a different way." However, in the subsequent Pechter poll, Israelis Jews were asked to consider how they think IDF soldiers should have acted once confronted with violent activists aboard the ship. A plurality, 46 percent, thought Israel used the "right amount of force" aboard the Mavi Marmara, and nearly as many, 39 percent, said Israel used "not enough force" in boarding the Turkish ship. Only 8 percent thought that the IDF used too much force.

The Israeli public appears even more inclined to hawkish solutions when it comes to future attempts to breach the Gaza blockade. The poll noted media reports about Iran's purported plan to send Red Crescent vessels to Gaza, asking respondents if Israel should "let them in quietly" or "stop them whatever it takes." The results are strikingly lopsided: 84 percent would stop them, whatever it takes, while just 7 percent would let them in quietly. Similarly, when asked what Israel should do if the Turkish navy and Turkish Prime Minister Recep Tayyip Erdogan personally attempt to break the Gaza blockade, as some reports have suggested might happen, three-quarters said Israel should stop them at any cost.

Alternative policies garner only minority support from the Israeli public. Just one-fifth (22 percent) of respondents advocate opening Gaza to international humanitarian shipments. More incremental shifts elicit a slightly more sympathetic popular response, but fall well short of gaining majority support. Two-fifths (37 percent) of those surveyed would support "an international inquiry committee that will investigate the recent ship incident." Almost as many (35 percent) agree with the general proposition that Israel should "adjust its tactics to elicit a more favorable international reaction."

This data carries a number of important political implications, both for Israeli domestic politics and the Israeli-Palestinian peace process. Of most immediate importance, Netanyahu's job is not in jeopardy as a result of this latest international imbroglio. If the Israeli public were to blame any of its elected officials for this diplomatic setback, it would be Defense Minister Ehud Barak, who represents the Labor Party. The new Pechter poll shows that Barak's approval rating, unlike Netanyahu's, is now in negative territory: Just 41 percent are satisfied with his job performance, against 52 percent dissatisfied. Even so, around 75 percent of Israelis reject the notion that Barak should resign his post, according to last week's Maariv poll.

The Israeli public's hawkish stance also constrains Netanyahu's ability to substantially alter Israel's Gaza policy in the wake of the Mavi Marmara incident. In moving toward acceptance of some kind of international presence on an investigative commission and toward some increase in Israel's allowance of humanitarian aid to Gaza, Netanyahu is reaching the outer limits of what the Israeli electorate could realistically be persuaded to accept.

The survey also found extremely high levels of intensity among respondents, a fact that makes it particularly difficult for the Israeli government to move against the tide of public opinion. In my 30 years of professionally analyzing Israeli and Arab polls, I have rarely seen such a passionate response from those surveyed. For example, among the very large majorities who said Israel should do whatever it takes to block Iranian or Turkish vessels from reaching Gaza, extraordinarily high percentages said they feel "strongly" about the issue: 68 percent for Turkish boats, and an even higher proportion, 78 percent, regarding Iranian blockade-runners.

The one methodological caveat to this conclusion concerns Israel's Arab citizens, who constitute approximately 18 percent of its adult population and vote freely in its elections, but are usually considered separately in survey analysis. Had they been included in this latest poll, previous research suggests that the overall numbers would have shifted modestly in a more dovish direction. However, Arab Israeli opinion will almost certainly not be a major factor considered by the current Israeli government, which relies on the support of Jewish Zionist parties to maintain power.

These findings, however, do not spell doom for hopes of a negotiated settlement to the Israeli-Palestinian conflict. Crucially, the Israeli public's stance on Gaza coexists with relatively dovish views on other key Palestinian issues. For nearly a decade now, even during wars or major surges in terrorist attacks, a solid majority of Israeli Jews have consistently supported a two-state solution to the dispute. This fundamental fact was again attested as recently as March, in the latest Hebrew University/Truman Institute poll, which showed 68 percent in favor of that option. Moreover, that poll showed a narrow majority explicitly willing to accept "dismantling most of the settlements" in the West Bank as the price for peace.

Netanyahu's challenge is to translate these opinions into a policy that can bring both long-term security and peace to his people. Given the Israeli public's hawkish views toward Hamas-ruled Gaza, but their willingness to explore concessions in the West Bank under Palestinian Authority President Mahmoud Abbas, the most realistic way forward is surprisingly straightforward: Keep pushing Israel and the Palestinian Authority toward new, practical, political agreements. Find better ways to help the people of Gaza, but not their Hamas rulers -- whom Israelis rightly view as a threat, not only to their own security, but also to any prospect of Palestinian-Israeli peace. In other words, work with Abbas, against Hamas.



Countries Without Doctors?

How Obamacare could spark the brain drain of physicians from the developing world.

Forget about all the members of Congress who are supposedly about to suffer from "Obamacare" blowback in the mid-term elections. Forget about the deficit, the bureaucracy, and any other critiques you might have heard about President Barack Obama's health-care reform passed earlier this year. There's a far bigger consequence looming abroad: U.S. health-care reform will exact an excruciating cost on the developing world. Here's why: Tens of thousands of doctors are about to leave their home countries -- where they are often desperately needed -- to come to the United States to meet America's growing demand.

That's right: America is about to induce massive medical brain drain. The historic passage of health-care reform legislation in March will provide an estimated 32 million uninsured Americans with health insurance. But the United States will need to rapidly grow its supply of doctors and nurses to meet the demand that creates -- a fact that will surely attract qualified doctors and nurses to America's higher salaries, better working conditions, and promise of a booming industry. There's nowhere for those health professionals to come from but overseas; the domestic education system simply won't produce enough. Enter brain drain.

Even now, the United States relies heavily on foreign-trained health-care workers. A full quarter of practicing physicians in the United States and 28 percent of U.S. medical residents come from abroad. Of these, 25 percent were trained in India and Pakistan, countries with health-worker crises so acute that the World Health Organization includes them on its list of countries with a "Human Resources for Health crisis." Each country has a mere 1.13 doctors per 1,000 inhabitants, while the United States enjoys 13.22 -- one of the highest ratios in the world. Other developing countries have already lost more than half their physicians to the United States. There are more Ethiopian physicians practicing in Chicago today than in all of Ethiopia, a country of 80 million and Africa's second-most populous country. Put otherwise, the United States is importing health workers from countries where polio still kills and paralyzes children. It is, in a word, unconscionable, and Obama's health reforms will only make things worse.

Why does the United States need so many foreign doctors? In part because the country's medical and nursing schools are turning away tens of thousands of qualified applicants for lack of places and funding to accept and train them. These young Americans are forever shut out of six-figure jobs in one of the country's fastest growing and arguably most socially rewarding sectors. Reversing this trend would take years of building new medical schools, particularly in areas where there is already a shortage of doctors. Meanwhile, demand is simply growing faster than the supply of homegrown doctors and nurses.

Look no further than Massachusetts and its experience with health-insurance reform to see why U.S. demand for foreign health workers will increase. The state's health-care bill brought an additional 340,000 people into the insurance system, and demand for health-care workers subsequently rose beyond capacity. Waiting times for new-patient appointments with an internist increased 58 percent -- from 33 days to 52 days -- and half of Massachusetts's primary-care practices closed their doors to new patients, the highest level ever recorded. Massachusetts, one of the U.S. states with the highest number of primary-care physicians per capita, experienced these shortages upon expanding its insured population by only 5 percent (by comparison, most predictions say that U.S. health-care reform will increase the number of insured nationwide by a whopping 12 percent).

Even measures in the health-care bill meant to boost the population of domestic physicians might do more harm than good. Congress has proposed providing funding to increase the number of U.S. residency positions by 15,000 to meet the anticipated increased demand for doctors. Yet these bills do not increase the number of medical-school slots. So those added residency positions will have to be filled by more than doubling the country's annual importation of foreign-trained doctors.

The apparatus to bring in these overseas professionals is well oiled, with no consideration for the potential impact of an immigrant's exit from his or her country of origin. Nurses are drawn to American soil through a well-organized, billion-dollar, private-firm-based nurse recruitment industry. Physicians tend to either apply directly to the U.S. National Residency Matching Program or be recruited by residency programs or immigration lawyers. Despite consistently being among the highest paid professionals in their homelands, foreign doctors are drawn to the United States by the pull of even higher salaries and better training and facilities.

But though the prospects for emigrating physicians might be good, the consequences for the countries they leave behind are grave. Mortality rates for infants, children, and expectant mothers are especially sensitive to health-worker shortages, with child mortality tripling as communities go from five health workers per 1,000 population to less than one per thousand, according to a 2004 Rockefeller Foundation report.

Medical brain drain affects education systems, too. Only the best and brightest can pass the U.S. certification exams, meaning that those who emigrate are often top university professors. A recently released study funded by the Gates Foundation found that migration to wealthier countries is the No. 1 cause of loss of African medical school professors -- accounting for a full 25 percent, with most going to the United States. Not surprisingly, the same study also revealed that lack of professors was one of the main barriers to training more health workers in Africa.

Even in the absence of health reform, brain drain was destined to be a growing problem for poor countries. According to studies by the U.S. Bureau of Health Professions and the Association of American Medical Colleges, conducted before the passage of health-care reform, the aging U.S. population would have needed at least 40 percent more primary-care providers by 2020, and the United States would have experienced a shortage of 124,000 physicians by 2025. With little chance of the United States meeting that demand domestically, it's likely the needed nurses and doctors will come from abroad.

Ironically, while the United States is recruiting thousands of doctors to its shores each year, it is simultaneously spending billions trying to build health systems in precisely the countries whose physicians it is stealing away. In recent years, major U.S. overseas development programs have failed to meet their goals due to a lack of health workers, and funding has started pouring into training in this sector. But what's the point, if those same doctors will later just be recruited away?

The answer is clear: Until the United States is self-sufficient in the education of its own health workers, it will continue to risk the health of the most vulnerable people in the United States and abroad. The Obama administration has made a major commitment to improving the health of the poorest people in the world through the $63 billion Global Health Initiative. But much of this effort will be wasted if the United States continues to take from developing countries the very thing health systems need most: the people needed to run them.

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