Plagued by failure: ‘The Yom Kippur War of the Israeli health system’
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Investigative report'They thought judgement day wouldn’t come. Well, it’s here'

Plagued by failure: ‘The Yom Kippur War of the Israeli health system’

Experts say Health Ministry has long suffered a lack of coordination, planning and oversight, leaving it woefully unprepared for coronavirus despite strong signs disaster loomed

  • Magen David Adom workers wearing protective clothing as a preventive measure evacuating a man suspected of having coronavirus to Shaarei Tsedek hospital in Jerusalem, March 30, 2020. (Yossi Zamir/Flash90)
    Magen David Adom workers wearing protective clothing as a preventive measure evacuating a man suspected of having coronavirus to Shaarei Tsedek hospital in Jerusalem, March 30, 2020. (Yossi Zamir/Flash90)
  • A health care worker at Hadassah Ein Kerem hospital holding a model of a coronavirus test kit, March 26, 2020. (Olivier Fitoussi/Flash90)
    A health care worker at Hadassah Ein Kerem hospital holding a model of a coronavirus test kit, March 26, 2020. (Olivier Fitoussi/Flash90)
  • Israeli Prime Minister Benjamin Netanyahu and Health Minister Yaakov Litzman hold a press conference about the coronavirus at the Health Ministry in Jerusalem, March 4, 2020. (Olivier Fitoussi/Flash90)
    Israeli Prime Minister Benjamin Netanyahu and Health Minister Yaakov Litzman hold a press conference about the coronavirus at the Health Ministry in Jerusalem, March 4, 2020. (Olivier Fitoussi/Flash90)
  • An ultra-orthodox youth is tested for coronavirus in Bnei Brak, March 31, 2020. (Ariel Schalit/ AP)
    An ultra-orthodox youth is tested for coronavirus in Bnei Brak, March 31, 2020. (Ariel Schalit/ AP)
  • Medical staff in the central laboratory of the Meuchedet health group. (Health Ministry)
    Medical staff in the central laboratory of the Meuchedet health group. (Health Ministry)
  • A coronavirus test being performed. (Health Ministry)
    A coronavirus test being performed. (Health Ministry)

The summer of 2006 was a wake-up call for the home front. Israeli civilians, it became apparent during the Second Lebanon War, were inadequately protected, both against a large-scale military conflict and, as the Health Ministry later put it, “an incident of plague.”

The following year the State Comptroller issued a report. It slammed the Health Ministry’s emergency readiness and called for sweeping change.

Nearly 13 years later, amidst the worst health crisis the state has ever faced, The Times of Israel’s Hebrew sister site Zman Yisrael — in collaboration with Shomrim, the center for media and democracy — has investigated years of neglect and austerity within the health sector at large. Exposed is a Health Ministry that — many current and former officials who spoke on condition of anonymity contend — tragically fumbled its opportunity to close the gaps in readiness during the early months of the current coronavirus pandemic, before it arrived on Israel’s shores.

Prof. Meir Oren, a former director-general of the Health Ministry and former director of Hillel Yaffe Hospital in Hadera, likened the current situation to Israel’s worst security disaster — its inability to foresee the surprise attack on two fronts in the fall of 1973. Today we are seeing, he said, “the Yom Kippur War of the Israeli health system.”

Oren is deeply familiar with the country’s emergency health plans. From the early 2000s onward he has been cautioning the leaders of Israel’s health and financial systems, in person and in writing, that the country is woefully unprepared for the outbreak of an epidemic. In the midst of the current COVID-19 crisis he declined to detail the deficiencies to Zman Yisrael, but agreed to speak more generally.

Prof. Meir Oren, former director-general of the Health Ministry and former director of Hillel Yaffe Hospital in Hadera. (YouTube)

Noting “widespread and complex” deficiencies across the board, Oren said that the heart of the matter is “budgetary neglect,” which he called a form “of starvation that all of the governments of the past 25 years have participated in.”

The placement of the healthcare system, its relatively low ranking on the list of national priorities, he asserted, “is a conceptual and systemic failure. What’s happening now with the corona outbreak merely exposes the nakedness of the system.”

The empty drawer

At the start of the battle against the COVID-19 virus in Israel, according to multiple sources, the Health Ministry was supposed to have what Israelis call a “drawer plan” — a predetermined plan of action for a foreseeable scenario.

The dossier ought to have included policy plans and objectives, plans of action, and inventory lists and acquisition plans. This was investigated in multiple State Comptroller reports — in 2007, 2014, and 2020 — and the gap between the recommendations made and the reality on the ground was then, and remains today, bleak and disturbing.

The 2020 report, for instance, examined the ministry’s response to the March 2018 to October 2019 measles outbreak in Israel. Some 4,300 people were infected with the disease; three of them died. It was a sort of dress rehearsal for the current day situation.

Magen David Adom workers wearing protective clothing as a preventive measure evacuating a man suspected of having coronavirus to Shaarei Tsedek hospital in Jerusalem, March 30, 2020. (Yossi Zamir/Flash90)

The measles, as opposed to COVID-19, is a known entity with a proven vaccine — though there are swaths of the population that oppose vaccinating or, due to an older vaccine, were only partially immune to the disease. These two facts made it quite clear that an outbreak in the foreseeable future was possible.

Did the Health Ministry prepare? Did it implement the recommendations of previous comptroller reports? In 2020 the comptroller ruled that “there was no known and organized ‘drawer plan’ in place. [No] drawer plan for dealing with the outbreak of an infectious disease.”

In August 2008, the comptroller noted, the Health Ministry assembled a generic battle plan for combating rare biological outbreaks. This included pandemic flu, Ebola, and anthrax. It did not include a replenishing of the stock of measles vaccines sorely needed during the outbreak, and it did not include a set plan of action for an unknown virus such as COVID-19. This absence of a drawer plan — as opposed to the preparedness today in Germany, for instance — is what many medical experts say has led to the chaos in the field today.

As an example, experts point to the manner in which COVID-19’s spread was documented, which led to confusion and uncertainty among health care professionals.

“This starts with the potential patient being the one asked to report any suspicious symptoms,” said an official at one of the national healthcare providers. “Which leads to the Health Ministry not realizing what we already saw at the healthcare clinics: that this is a very fluid sort of reporting, and all too frequently it does not reflect the person’s condition and the places visited.”

The Health Ministry apparently was aware of this problem. Eventually officials changed tack and tried different measures — sending potential carriers into pre-diagnosis quarantine and using the Shin Bet cellphone surveillance methods to track potential and confirmed carriers. The efficacy of these measures is still not clear. It is clear, though, that had there been a plan in place it could have been employed immediately and not improvised on the fly.

Israeli Prime Minister Benjamin Netanyahu and Health Minister Yaakov Litzman hold a press conference about the coronavirus at the Health Ministry in Jerusalem, March 4, 2020. (Olivier Fitoussi/Flash90)

Another significant problem — one that is quickly shaping up to be the most pronounced of this crisis — is the quantity of tests available.

Before the outbreak in Israel, and despite warnings from the World Health Organization, the Health Ministry did not bother to establish a sufficient number of labs, nor did it rush to do so after the outbreak. Moreover, several officials from within the ministry voiced the opinion that there was no need to conduct massive testing.

Two weeks ago, the ministry made an abrupt about-face and set for itself a goal of testing 30,000 people per day.

Senior officials within the healthcare establishment have been sharply critical. Only a wide survey from across large swaths of the population, including those without symptoms, they say, will give a solid indication of the spread of the disease. “This is the most basic intelligence needed in the war against the virus,” one said, “and this is something they’re just not doing.”

The challenges surrounding the testing of the population do not end there. Today in Israel if one feels sick, they are either tested in their home by a Magen David Adom ambulance crew or sent to a drive-in testing site. Those tests are then sent to a lab. If the person tested happens to belong to the healthcare clinic affiliated with the lab, then the tests are sent to the clinic and relayed to the patient. In all other cases, the results are sent back to the Health Ministry, which either contacts the person’s healthcare service or relays the results itself. This takes valuable time.

Medical staff in the central laboratory of the Meuchedet health group. (Health Ministry)

“Why the merry-go-round?” asks an official at one of Israel’s healthcare providers. “There are only four [public] healthcare options in Israel, not 40… There are people who have had to wait 10 days for results. That has crucial epidemiological significance.”

Arie Paz, a former Health Ministry comptroller, said categorically that Israel generally and the Health Ministry specifically are not prepared for an epidemic, though it is not on account of lack of time.

“The outbreak of measles two years ago caught us utterly unprepared and exposed and proved that the healthcare system in Israel has never prepared itself for an epidemic,” Paz said. “We are the champions of unpreparedness, certainly in time of emergency, and that is a chronic and hereditary disease that’s been prevalent in the healthcare system for years. There’s a saying in Spanish: ‘No blindness is worse than the blindness of those who don’t want to see.’ That is our syndrome.”

The (ostensibly) humble swab

If you ask senior physicians in hospitals across the country why, in their opinion, widespread testing was not done, the answer is primarily a lack of swabs.

“Israel is capable of attacking in Iranian territory and it nearly managed to land a spaceship on the moon, but it can’t manufacture a swab, a little cotton-topped shaft. It’s illogical and unbelievable,” said an official within the healthcare system.

An ultra-orthodox youth is tested for coronavirus in Bnei Brak, March 31, 2020. (Ariel Schalit/ AP)

The official added that he’s certain that had someone come to the prime minister — to any prime minister — and told him or her that within the span of a month the state could produce one million such swabs at a cost of roughly one million shekels with a shelf life of 10 years, the prime minister would have ordered the ministry to proceed. “But on account of a lack of synchronicity, there’s no one who stepped forward.”

As another official put it, “the problem isn’t budgetary, it’s organizational.” One million shekels for swabs, the official said, is a minuscule sum and a no-brainer of a decision. “The issue here is a lack of organizational consideration, of taking a moment to stop and say, ‘hold on, let’s think about what we need in a time of emergency.’”

This apparent lack of forethought has manifested itself in other ways. For instance, the state of the medical apparel and the stock of medicines in the emergency inventory.

“If a disposable robe has an expiration date of 20 years from the time of purchase, then you buy it for the emergency storage units and, after 15 years of sitting there, you rotate into use in the hospitals and buy new ones for the emergency storage unit. That’s how you resupply. But that didn’t happen, and the result is that the lack of material is far worse than anticipated,” said a senior official in an Israeli hospital, who was a signatory to a March 23 petition addressed to the prime minister asking him to fire Health Ministry Dir.-Gen. Moshe Bar Siman-Tov.

The petition argued that Bar Siman-Tov was “making decisions that are divorced from the clinical reality in the field.”

From left: Prof. Sigal Sadetsky, head of the Public Health Services in the Ministry of Health, Ministry CEO Moshe Bar Siman-Tov, and Health Minister Yaakov Litzman outside the Central Laboratory of the Health Ministry at the Sheba Medical Center in Ramat Gan, February 4, 2020. (Flash90)

The official’s comment relates to the acquisition, in 2010, of disease outbreak protection kits for the healthcare clinics. The inventory of that gear, including disposable robes and N95 surgical masks, was never updated and is now, in part, out of date.

As a result, healthcare clinics have been chasing after ministry officials to try and receive permission to use expired gear, some of which is no longer salvageable. As one of the healthcare providers put it, “If the filter on the mask still works but the mask itself is falling apart, it’s useless.”

Long term policy? Not here

Many of the professionals interviewed for this article asserted that years of incoherent policy were brought into sharp relief by the current crisis, and yet, at the start of the year, there was still time to change course, had the emergency alarm been sounded in time.

“Just as Waze lets us know that there’s a hazard 500 meters ahead, so too did the world indicate to us that an epidemic was coming our way,” said one senior source.

That light flashed on in early January, when the WHO declared that coronavirus was likely a pandemic and that countries ought to prepare themselves for its arrival.

A coronavirus test being performed. (Health Ministry)

“At that point meetings ought to have been convened and scenarios and responses ought to have been presented and decisions made. For instance, can we get by without swabs? No. Can we live without 100,000 hospital beds? Yes. Based on that [information], you organize. One million swabs cost one million shekels? You don’t wait, you equip yourself. Same for masks and robes. But that apparently did not happen,” said the source.

Emergency supplies were not acquired, labs and hospitals were not readied, doctors and medical personnel were not briefed and trained, the source said.

A month passed. The virus began its global spread. A handful of Israelis abroad had fallen ill, including 15 Israeli nationals aboard a cruise ship docked in Yokohama Japan. On February 13, Health Minister Yaakov Litzman announced that Dr. Itamar Groto, deputy to the director-general of the ministry and the highest-ranking physician in the ministry, would travel to Japan to oversee the treatment of the Israelis there. To some that was a grave error in judgement.

Screen capture from video of Deputy Director-General of the Health Ministry Itamar Grotto. (Twitter)

“It’s akin to the IDF Chief of Staff sending his deputy off to another country during a time of war, and this at a time when the director-general himself is not a doctor,” said one source.

Moreover, Groto mostly handled administrative matters while abroad and was forced to quarantine himself upon return. “That’s simply not the way things are done,” the source said.

Nor was there the necessary long-term planning for emergency. A senior official at one of the four healthcare providers gave the example of portable x-ray machines. Those devices are more expensive than the stationary models, but had someone thought that there might be the need to conduct chest x-rays of patients’ lungs across wide swaths of the public, the hospitals would have been instructed to buy the more expensive ones.

“No one from the emergency division came to the director-general and said, listen, this is what needs to happen,” the source said. “The cogs don’t know how to run together.”

For years, a senior hospital official said, the battered public health sector in Israel has been forced to cut expenses relentlessly. “And you ask yourself, don’t they see that people are going to pay with their lives? They always thought judgement day wouldn’t come,” the official added. “Well, it’s here.”

Magen David Adom paramedics in protective gear. (Olivier Fitoussi/Flash90)

The Health Ministry responds

In response to the allegations put forth in this article, the Health Ministry issued a written statement, saying that it is “learning” from the State Comptroller report, and that some of the report’s recommendations are being implemented as the epidemic continues.

“We hope and believe that a report issued in the midst of the coronavirus crisis will be used as a learning tool and for constructive criticism, rather than a goring tool,” the statement said.

According to the Health Ministry, preparations for the novel coronavirus outbreak began in mid-January, including the acquisition of protective gear, ventilators, and corona-testing kits, and the prepping of special isolation wards in hospitals and clinics.

A lab test for coronavirus. (Tomer Neuberg/ Flash90)

The statement claimed that Israel was “one of the first countries to realize the gravity of the disease,” and that the Health Ministry along with the National Security Council took drastic measures, including sealing off borders, which were later adopted by other nations.

“As for the measles outbreak mentioned in the article: Israel is apparently one of the countries that dealt most successfully with the global measles outbreak,” the statement said.

“Israel has managed to lower new infections to single-digit numbers per month. Since the start of the new year there have been a total of five new cases: four in January, one in February, and none in March. This result is related to the quality of service provided by the public health system within the ministry and the efforts of the nurses in the national well-baby clinics,” said the ministry.

This article was adapted from the original on The Times of Israel’s Hebrew sister site, Zman Yisrael. The investigative report was made possible with the help of Shomrim, the center for media and democracy.

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