Israel’s incursion into south Lebanon (2006) – view from Haifa/Safed

As Lisa Rubin, physician and public health officer in Haifa, northern Israel, who has been blogging for since 7 August, leaves Haifa for a planned holiday, she starts to hand over this blog to her colleague, Ehud Miron, who runs the district health office in Safed.

Wednesday, 16 August

A time of reconstruction
It is the 3rd day after the cease-fire. The employees of my health office have come back in almost full attendance. Some are still reorganizing and setting up their homes again and some are on scheduled leaves as it is high summer. But most of them have shown up, allowing us to open most of the mother and child health clinics operated by the ministry of health.

Later on today I will see the figures on how many mothers and children attended the clinics – a sure indicator of the growing feeling of security.

Several major tasks face us in the wake of war and limited preventive health services. One is the relocation of elderly debilitated living in the community. They were the first to be evacuated to safety – to long term care institutions in the centre of Israel. They were hospitalized at the expense of the ministry of health and now they will be returning to the community.

Coordinating this project is a major effort requiring involvement of the HMOs and the welfare units of the municipalities. I hope that today we will have finished talking with each and everyone of the elderly and obtained their consent to proceed with relocation back to the community of origin.

The other major issue is how to catch up on the lag in immunization programs. It?s been over a month that there has been a halt in immunization programs. Renewal of services was only possible partially and in the last few days of the war. There is a lot of wok to be done. There will be need for extra hours and extra staff in order to be able to bridge the gap.

Then there are the clinics themselves – 33 mother and child health clinics in the area of Safed , Kiryat Shmona and the Golan, need to be reexamined. Some of them were damaged and funding for renovation will have to be allocated with the work done as soon as possible.

The school year is scheduled to star on September 1st and the municipalities are gearing up in an attempt to have everything set up for that date.

This will be my youngest son?s first year in school – I wonder what his major impression of this year would be as he grows older – will he remember this year as the year of the war or as his first year at school.

People in the centre of Israel, who have not been exposed to the missile attacks personally, are still hesitant about the safety of travel to the north of the country. Some have asked me if it safe yet. I try to reassure them. The government has also launched a campaign promoting tourism to the north. The parts most hit by missiles are some of Israel?s loveliest places and internal tourism fills up the north during summer. The tourist industry was hard hit by the war and its reconstruction is at a priority.

Monday, 14 August 2006

Lisa Rubin?s final, pre-sabbatical, blog from Haifa
The cease fire went into effect today. As we expected there was a siren this morning. After last night?s ?rainfall? I had some difficulty sleeping in expectation that the grand finale might still be waiting. Fortunately, the grand finale was last night, and this morning was merely a small encore.

Although officially the precautions recommended by the Home Front Command have not been lifted yet, the citizens of the city seem to think otherwise. A quick foray to the neighborhood shopping center for some sundry items before our trip was enough to convince me of that. There are many more people out and the age distribution has changed. There were children and babies in cars and strolling with their parents. The sense in the air is of normalcy, as if this nightmare had never taken place. I never cease to be amazed by the resiliency of our population.

At the shopping center I meet my good friend, CF, a professor emeritus of Public Health from the States. She lost one of her sons 24 years ago in that war in Lebanon. For me she is a paragon of mental and spiritual health. After his death, she spent a few years living in Israel and since then spends extended periods here.

She relates that last night after the news of the nature of the cease fire, she cried for her son who died for nothing. After one month of missiles, rockets, and soldiers fighting we are intensely aware that the danger from the north is ever present and threatening.

GS, my friend from Kiryat Shemona, has returned home to a neighborhood with severely damaged homes on each side. She comments that she would have gladly sat in her shelter for another 2 weeks in exchange for a knowing that she and her family would no longer be in continuous danger from capricious missile launchings from across the border. I realize that last night?s incessant barrage of missiles is something that she has survived nonstop for over a month. They live long term with that threat, which is frequently not only a threat but played out, day after day. We know this, cognitively, but we rarely spend much time pondering it. One good thing about war, it has the capacity to increase man?s compassion and understanding for the plight of his fellow man.

By tomorrow I suppose health services will kick back into regular gear in much of the north. There are still people hospitalized with their physical injuries but elective and ambulatory services will be reinstated. Rehabilitation both physical and emotional will become the order of the day. Routine means reassurance, it helps us get on with life.

I leave tonight for a year?s sabbatical having only started to pack sometime late last night. My colleague Ehud Miron will continue these reports.

Sunday, 13 August

Lisa Rubin in Haifa
The hours before the proposed cease fire are probably the most dangerous as each side tries to garner maximum advantage in the last hours from the situation. I leave work a few minutes late as I take leave of all the staff before my long planned trip in less than 36 hours. Experience teaches us that the afternoon hours are those with the most attacks; none of us want to be on the road during an alert.

My lift leaves me off and I walk upstairs. No one appears to be home. My 16 y.o. daughter is out with friends somewhere. No sooner do I enter the house and the siren starts wailing. I rush downstairs to our shelter. When the siren finally stops, 6 deafening explosions shake my house. This sounded as close as my closest call heretofore when I stopped for five minutes to buy cherries in the market three weeks ago and I got caught outside with no real shelter for a missile that hit 100-150 meters away. This one had an obviously bigger payload. Where is my family? Where is my colleague who was probably out on the road because I delayed our leaving? I begin to do an inventory of those near and dear to me.

I go upstairs, try to put myself together and write and I no sooner finish 5 sentences and we experience a repeat. Again several deafening explosions, the house shakes and still no one home. I know that my daughter is supposed to be on the way home soon. Soon is not soon enough.

Michal arrives home, thank God. Third and fourth sirens. The third is accompanied by ear shattering explosions that again shake the house, followed by sirens of police, fire workers. After the fourth we hear no explosions; my husband notifies us that two missiles have hit near his place of work. He is alive and well.

I have been home for two hours, running up and down the stairs to the shelter and back. Stairs are considered excellent cardiovascular exercise; persistent tachycardia from increased state stress probably not. My heart is still racing as I write this. One of the senior social worker?s of the Carmel Hospital rings the bell to say goodbye. She is on call for the Casualty Department tonight and has just returned from being called in a person with an acute stress reaction. It is a 40 y.o Arab Haifa professional who complains of ringing in his ears. He says that he is not stressed but he has just made a cup of coffee by putting the instant powder in the sugar bowl. His brother is one of the senior staff in Casualty who has seen a lot of action lately. He relates a close call. Stress reactions aren?t always predictable. Proximity to an incident however is definitely not helpful.

I have returned from another foray to the shelter for the 10th alert today, the fifth since coming home. Another sixth alert and we run down again. This time it lands very very close. When I come upstairs I see black smoke billowing in front of the living room window. I quickly call my husband who has since come home to take a picture. I call my friends who live near to where I see the smoke to make sure that they are well. They live down the street from where the missile fell.

More alerts. I have lost count already. Maybe we should just stay downstairs. Michal and I have begun playing the animal game, name an animal that begins with the last letter of animal just named, something on the level of third or fourth grade. It is just about the level that we can bring ourselves up to. ?N? and I can?t seem to conjure up an animal. We look at each other and say ?Nasrallah? simultaneously and laugh. Another important lesson, humor is protective.

I reflect back to my half hour surprise visit with my friend the social worker. It was over two hours ago, and I can?t figure out if it seems hours ago or minutes ago. She arrived just when I was beginning to feel the twinges of anxiety with all this activity. One half hour, mercifully uninterrupted and I put myself together. E relates how she got caught the other day in the street between the two buildings of the hospital during an alert and when she finally arrived inside to shelter she broke into tears. Being alone, another risk factor. A risk for not taking the precautions necessary to save one?s life, and a risk for stress related reactions. So she arrives at my home just in the nick of time to provide the necessary antidote to anxiety. Health care workers are subject to the same stresses and risks as the population that they care for and they are similarly at risk for stress related responses. Despite this, the staff turnout is very high. E relates how she knows of only one nurse who didn?t show up for work. Workers come to the hospital where she works from areas that are less affected by these attacks, but this does not deter them. A protective factor, having a meaningful job with responsibility.

The local radio station, Radio Haifa, which we keep on continuously reports that the missiles hitting Haifa now are ?Hiber? with a diameter of 302 cm. That?s one hell of a big missile. It can bring down entire buildings. The populace has been remarkably compliant with Home Command instructions and thankfully there are few injuries. The local radio station puts the siren on the radio, provides information to the population about what happened, and where, and serves as a support system for the Haifa area. From the news I understand that the social worker has not been able to go home but has most certainly returned to the Casualty Department.

Darkness is enveloping the city, usually a sign that the attacks will cease. It is easier to trace the origins of missiles fired at night. We don?t know if that will be the case tonight. In any event, for those who, despite their experiences in medical training continue to wonder, yes some stress is cumulative. After a month of war, it is harder to be resilient both at home and at work.

Saturday, 12 August

Ehud Miron in Safed
It?s a beautiful day. The streets mostly quiet. Have the people gone out today, perhaps a little encouraged by the upcoming cease fire? I doubt it. I had gone to sleep last night with the constantly changing headlines regarding the Security Council discussions on the one hand and the IDF (Israeli Defense Forces) poised for massive engagement on the other hand. The headlines greeting me today speak of at least four more days of fighting.

There have been no sirens yet. Last week all was quiet until 4:30 P.M and we had just reached our home from an outing to the restaurant located in downtown Haifa when the sirens started wailing. 2 hours later the sirens wailed again and the death toll rose once more.

I think of tomorrow when I will be escorting a group of volunteer physicians into one of our most heavily bombarded cities to go from shelter to shelter and visit the people who may be sitting in there for over a month now. There have been other visits to the shelters but the need is constant – not so much a medical one but also a psychological one.

Two major issues face us with the people in the shelters – medications and medical services. Some of the people in the shelters have chronic diseases requiring constant medications. In the shelter they have neither prescriptions nor money to buy the medications. In some of the cities you can move around and go to the clinics which are mostly open and get what you need. But there are those cities where the bombardment is constant and there is no safe time to get anything. Moving around in the open in those places is hazardous at best. So we have to get the list of people with chronic diseases, check their medications in the clinics (in their files) so we don?t make mistakes, and then dispense and distribute them in the shelters – everyone getting his personal medications.

And then there is the issue of seeing a doctor – how do you go about that? Get them to the doctor or get the doctor to them? Who do you put at risk? No easy answer there.

I consider again the volunteer doctors? visit and the extent to which I can discuss it. In the early days of the war the reporters showed footage of where the missiles landed and mentioned exact locations. This served the Hezbollah who just aimed accordingly. It took a few days before reporters were required to stop giving exact locations or film landmarks that would be a giveaway.

Then the missiles started landing in ten-twenty minute intervals on the same environment and we realized it was meant to hit the salvation teams arriving at the spot of a missile landing to retrieve the injured and give medical aid.

Medical teams as a strategic target
So I won?t be saying where the doctors will be visiting. As I plan the distribution of the group and the shelters they will be seeing I take into account the fact that they will be moving on foot, between the shelters, and a terrible thought comes to mind. I banish it.

They will be checking the population in the shelter – taking notes of the physical conditions as well and any other issue which may impact on the health. If they find conditions lacking – I?ll be talking to the municipality to get it fixed. I hope they have the manpower to do it quickly. If they find anyone requiring medical attention beyond what they can offer we?ll have to evacuate or follow-up on that person. They will be told not to distribute any medications beyond OTC drugs – again, I would like to avoid errors in medications. The volunteers may be the best doctors but they are not familiar with the patients and they can not case-manage them properly.

Friday, 11 August

Ehud Miron in Safed: Days fly by
I just finished reading Lisa’s blog from yesterday.

It’s 11 a.m and yesterday already seems so far away. Something which has never happened to me is happening now on a daily basis – I am under the constant impression of being a day earlier than the real date – a symptom of the days flying very fast.

I spoke to the Director of the hospital in Safed yesterday. A thing which I could not accomplish for the past 4 weeks. He spoke of the balance between the personal and the professional, the difficulty to step away even for a few moments from the job to rest. Everyone who is working needs to feel his work is important, otherwise what is the use of endangering oneself. And it is important.

In a recent exchange of e-mails with the head of the association of Israeli Public Health Physicians I told her some of my conclusions from our work in Safed in the past few days and she told me that it just brings to light the importance of Public Health. I was reminded of how a few weeks ago, ages ago, we wrote in a paper that one of the functions of Public Health is in coping with disasters and emergencies and reducing their impact on health. Sometimes the theory is vague until implementation is required. But boy, does it become clear when you’re on the spot.

I ask myself occasionally if my coping mechanisms are in order. I have become more aggressive than usual – trying to get things done and not getting bogged down in bureaucracy or trivia. Are my 3 children coping? Two of them are currently at an ad-hoc 4 day summer camp organized by the medical association for doctors’ children from the north. My 11 year old daughter and my youngest son who isn’t yet 6 and it’s his first time away from his parents. The first time ever that he’s not sleeping at home. In other times we would have fussed over it but now we’re just grateful he’s safe and having fun.

Earlier today I found myself at the auto repair shop looking for shelter during the air-raid alarm with my 9 year old autistic son. He seems not to mind the alarms but ever since the first in the chain of four alarms he was restless to get back home. When the alarm sounds off at home he gets annoyed of having to drop everything he’s doing to go to the shelter.
Tomorrow is Saturday. Every Saturday I’d find something to do with my children – taking them out to hike or the beach, a restaurant maybe. Tomorrow doesn’t seem to be good for that. I wonder if they’ll deliver pizzas. We had one three weeks ago on a Saturday when everything else was closed.

My sense of humor has become much darker and my immediate thought was of a slogan saying:”As long as you deliver the pizza – we’ll stay in the shelter”?

I watch very little television these days – it seems the media have it so wrong always showing the people who complain about this or that. Most of the people I meet have one thing to say – “war is hell but we can’t afford to remain under threat. If it has to be done let it be done right so the threat is removed”. If the war is over and the threat still there it will be worse. We may find ourselves going through similar cycles periodically. A war of attrition. God forbid.

I started writing this after Lisa told me she was going on sabbatical. I also read what Imad is writing in his Beirut blog. I cannot but sympathize with much of what he has written – there is no quarrel there. His people and mine are hostages of a group of several thousand. Perhaps the greatest terrorist action of all times – several thousand holding several million as hostages and the world at bay?

Lisa Rubin’s Haifa blog

Lisa Rubin is a physician and public health officer in northern Israel.

Friday, 11 August

A day of rest?
Many believe that one of the gifts of the Jewish people to the world is the concept of a day of rest. As a land held holy by three religions, Israel has three days of rest: Friday for Moslems, Saturday for Jews and Sunday for Christians. As the economy improved, many organizations moved to a five day work week which usually means Friday and Saturday off. For those of us who still work Fridays, it is a short day with a skeleton staff. Since Friday is usually a quiet day, I can frequently get a lot of work packed into that half day.

Today however was an exception, not unexpected, to that rule. People who work under stressful war conditions need to be rotated and given a chance to decompress. A few too many people were given that opportunity today and I arrived in my office to discover to my dismay that I would be girl Friday with one other nurse. In coordinating ongoing ambulatory services for the community we have learned that sitting in one large protected room is preferable. No need to constantly get up and move to a shelter when there is an air raid alarm, no need to try to get through to telephones that are constantly busy. The buzz of a large work room provides social support for staff who need it no less than the people that they serve. In addition I was told early on to evacuate my north facing office with panoramic windows from where I can see straight beyond the white cliffs of Rosh Hanikra on the border to Lebanon. These are the windows from which, on the first day of the war, when there were no sirens, my staff actually saw waves of missiles falling onto parts of Haifa and the surroundings. Missiles once shot follow a set trajectory; they go up and then down in a pure arc, thus they always strike from the north. I have chosen to move my office to safer quarters downstairs and not facing north. I prefer in the short term the risk of the passive smoke that pervades the area we have taken over to that of the missiles.

Now that the room has been equipped with a large number of telephones they ring all at once and someone needs to answer them. We re-organize and forward the phones to people sitting elsewhere, an alternative but less preferable setup. I mention to one of the senior staff who calls to see what is happening that we are understaffed today; she appears in 10 minutes. There is no traffic on the roads (the roads being the most dangerous place to be) and it takes almost no time to get around our usually much more congested city. No sooner does she arrive than the round of sirens begins. Although underground we can hear and feel the missiles fall. We continue to work, arranging for evacuation, finding medications, referring to clinics.

Elsewhere, the civil defense sets up according to plan a clinic in a shelter in the Krayot area for treatment of stress disorders, this to avoid flooding emergency rooms with persons who can be treated elsewhere. One of the senior nurses is sent to help in triage and evaluation. People flood the shelter, arriving by foot, ambulance and stretcher.

Friday, as I mentioned, is a short day and the regular clinics close early, we need to locate pharmacies still open to provide supplies. As with many makeshift arrangements, the organization of this clinic leaves much to be desired. Another nurse is found to run to one of our other clinics to bring basic equipment so they can function. We much prefer to provide services in arrangements that function routinely. Services that need to be set up special in response to the crisis take a while to get to function smoothly, if ever. After a few hours most of the people have been seen and cared for, and the staff retires to wait for the next rush. Later the district health officer with I work, and who lives near one of the many areas that was hit describes the extensive damage to homes that he sees when driving by.

I ask Prof. Shimon Pollack for an update on Rambam Medical Center. Many of the workers in the largest hospital in the area live north of the hospital and have to traverse areas which have suffered many attacks. To permit the staff to continue to function, transport has been arranged as well as safe child care in the basement of the medical school which is on campus. Closed wards have been opened up to accommodate the families of the injured. There are still injured hospitalized from Sunday night’s lethal attack. One woman who will probably remain paraplegic, another with 80% burns. Companies and individuals have been incredibly forthcoming in many ways to ease the plight of the wounded. Computers have been donated to ease communication for the wounded and their families. This willingness to help, the feeling of mutual responsibility and care is one of the things that makes this bearable.

This note will be of necessity short having been interrupted too many times by the wail of sirens and the inevitable sound of rockets falling.

Thursday, 10 August 06

A black day. The headlines announce the death of 15 Israeli soldiers, many ?older? reservists. This translates to mean that 15 young men will be missed, and the lives of many of their family members– their parents, siblings, wives, and children — altered forever. No names yet, only the dread of waiting and then reading.

On the train home from Tel Aviv reports of the death of a toddler and his mother from a missile attack on Dir el Assad, an Arab village near Carmiel. The toddler?s corneas are to be transplanted to two children waiting for transplants, thankfully without regard to religion or ethnicity. The train northbound from Tel Aviv has many soldiers returning north after brief furloughs from the fighting. Unfortunately I don?t have any difficulty in imagining what it must be like for their mothers; I have two sons of my own, one who is somewhere on the 2200 mile Appalachian Trail in the US walking off a difficult three year compulsory army service, the other a student in Tel Aviv. The son in Tel Aviv told me to store his army reserve uniforms in a place where he can get to them as I packed in preparation for leaving for a much awaited sabbatical next week.

I think about what permits these young men to willingly go to fight, knowing the danger that awaits them. I recall that yesterday one of nurse supervisors, related an incident with one her sons. He called his mother after a particularly violent exchange of fire, crying, and asking for a lawyer. He had broken the camera of a television camera man who had disregarded his request not to photograph the disfigured body of his friend who had been killed in battle. ?How could I let my friend?s mother see that picture?? The juxtaposition of lethality, willingness to risk one?s life, and interpersonal sensitivity are confusing, but also leave room for hope.

In the afternoon, when I arrive at work, the staff are up in arms. Most of our Arab nurses, after hearing Nasrallah?s speech last night urging the Arab population to leave Haifa and promising to destroy the city, have packed their bags and left. They called their supervisors to say that they were leaving, but left. In addition to physical reconstruction, there are relationships that will need to be rebuilt after the war. While our health policy is to try to provide ambulatory services to our clients in their first language, the maternal and child health station in the largest Arab neighborhood in Haifa today was staffed by native Russian and Hebrew speakers. Those who remain are in this together.

The Israeli ethos that looked down upon people who fled areas affected by hostilities, seems to be a thing of the past. Not only have thousands of people left the northern cities, towns and villages that have experienced almost unending attacks, even Haifa has emptied out. My daughter?s best friend is a student living in a student apartment in Beer Sheva in the south. Last week she had 13 of her boyfriend?s family living with them. His family comes from the Krayot, a group of towns in the Haifa bay where many missiles have fallen. The wife and infant son of our computer support person, are living with a family in Tel Mond, just south of Netanya. This is a family that they had never met but who had advertised on the internet, offering to take in families from the north who needed a place to live. Our many friends in Jerusalem and environs report having taken in people, and if their guests leave we receive telephone calls asking to send more. That is not to say that everyone has a satisfactory solution to their present housing problem. As I reported yesterday, there is a government effort to evacuate the families remaining in Kiryat Shemona; these people will be housed in a tent city in the exhibition grounds in the center of Tel Aviv I am learning that there are many ways to experience becoming a refugee, and that much of it can be too subtle for media portrayal.

Dr. Ehud Miron, my colleague who runs the District Health Office in the hard hit historic Safed says that he traveled up to Kiryat Shemona today. The fear (including his own) was palpable. He wore a protective vest but no helmet. Abiding by the official recommendations is important not only for one?s personal safety, but also to provide an appropriate example for one?s workers. The woman who cleans the office in Safed does so wearing a protective vest. One of our difficult dilemmas these days is how to continue to provide essential services to a stressed population without unnecessarily endangering our workers. What is an essential service? How long can one delay ambulatory and elective procedures without beginning to endanger our patients?

My colleague, a neurologist who works the emergency room at the Rambam Hospital, the largest hospital in the Haifa area, reports that almost all ambulatory and elective services have ceased. The hospital moved almost all departments into the basement several days ago. The missiles hitting Haifa have hit every street surrounding the hospital. Our human resources worker, whose husband manages the Health Ministry?s emergency warehouse, reports that they personally brought 50 screens to this 900 bed hospital to provide a modicum of privacy for the patients. My neurologist colleague relates that some of the veteran Russian-born physicians say that the hospital now resembles pictures they remember of Crimean war hospitals. It is so much easier to go backward rather than forward, to destroy rather than to build, and so the challenges remain for those who will seek to further forward momentum and future building.

Wednesday, 9 August 2006

The sirens started early this morning. The first one I heard was actually that of a fire engine; the woman in the car next to me motions that she hears a siren. I point out the fire engine and she shows visible relief. Being on the road, particularly in the neighborhood where many missiles have hit, is anxiety producing. One of the missiles that does fall today hits the roof of a nursing home some 100 meters from where this first ?false alarm? occurred. The nursing home is a temporary sanctuary to tens of frail and disabled elderly whom we have evacuated in addition to a large number of original residents. The missile is one of the largest missiles sent so far; miraculously it did not explode and only a car is destroyed. I shudder to think of the number of lives that could have been lost not to speak about wounded should the attack have been more ?successful?.

The front page of the newspaper today notes that the residents of Kiryat Shmona, one of the northernmost cities, will be helped to evacuate after having spent one month unabated in underground shelters. Good friends of ours from this city called some three weeks ago to offer support when the attacks on Haifa commenced. Residents of that city have many years? history of enduring katyusha attacks; they know the importance of social support for survival. During the present fighting they had not as yet been subject to attacks, and little did they know that in the subsequent weeks they would be subject to an intensity of missile attacks previously unheard of. In Haifa, from where these notes are being written, we have the specious privilege of a thirty second alert. In Kiryat Shemona that sits on the border, there is no advance warning of a missile attack. When the danger is assessed to be high, the instructions are to stay at all times in the shelter. Such has been the case for the past month. As a country that has known too many wars, all homes in Israel are supposed to be equipped with shelters or reinforced safe rooms. In times of peace these shelters are frequently used for storage; the streets in Haifa since the beginning of the war became littered with telltale signs of items that had been cleared out of now in use shelters. The homes along the border are in much more frequent use and thus better equipped for prolonged stays. While the shelters save lives, the prolonged periods of time spent underground are extremely difficult on the population psychologically, emotionally, physically and otherwise.

Israel is a country with a large immigrant population. Since 1990 over one million persons have immigrated to this country of now some 7 million people, the majority came from the former Soviet Union and Ethiopia. For these immigrants who are frequently poor, not fluent in Hebrew and have not yet integrated fully into Israeli society, the present state of missile attacks from the sky and unending tension is particularly stressful. While up until recently the instructions in Haifa had been to seek appropriate shelter when sirens sounded their alert, social services have found groups of people who like in Kiryat Shemona have spent the duration of the war in public shelters. These people are invariably poor, recent immigrants and many know no or almost no Hebrew. The togetherness of the shelter provides a sense of security that they lack (sometimes in actuality) in their homes— as well as an opportunity for outbreaks of intercurrent disease and other health risks. The people who are in the shelters frequently will not seek care for acute or chronic health problems even when necessity dictates it. While for the most part, the most pressing problems in the shelters are social and psychological, teams of physicians and nurses that have systematically visited hundreds of shelters have consistently identified persons in need of acute health care that would otherwise have gone untreated.

Outbreaks of gastrointestinal diseases or food poisoning from food distribution are not uncommon and typically have a high attack rate. The public health department has arranged for a contribution of alcohol based hand wipes to try to improve, if even only in a small way, the welfare of the people who are spending extended periods in the shelters. The real challenge will be helping these people when they come out of their shelters. Some will return to homes that have been damaged or destroyed, to jobs that have disappeared, burdened by illnesses that have been ignored, and with few remaining emotional resources to cope adequately with these major life crises. The social services will no doubt be overwhelmed by the multitude of problems to be dealt with.

When these individual problem situations repeat in varied ways across a broad swathe of the country, it becomes clear that Israel will face serious social challenges in the months following the end of the war. Rebuilding will take time, money, and determination. The need for leadership and compassion during peacetime are as necessary as wisdom and courage during war.

Tuesday, 8 August

Every morning begins with scanning the newspaper for reports of the previous day?s casualties. Names of the wounded are almost never announced, they are too numerous, but we always check if one of those killed is someone we know. The social fabric of Israel is such that one almost always knows someone who knows someone?This morning?s number of dead is three, less than yesterday, still three too many.

An interesting bittersweet item on the front page: someone has arranged for a wedding for 40 young couples in Tel Aviv tomorrow. The war has dashed the dreams of these young couples to wed as planned with their families and friends, the rocket attacks making it unsafe to congregate and in some instances destroying the wedding halls where the ceremonies were to take place.

Tonight, Tu B?av on the Jewish calendar is one of the most popular wedding dates in Israel, a day on which, according to a centuries old tradition, opposing factions in the biblical Israel were appeased and marriages subsequently permitted between persons of the different tribes.

The war has seemed to bring about its own modern day version of Tu B?av in the arena of provision of health care services. The advent of the 1995 National Health Insurance Law not only assured health services for all residents but also brought in its wake fierce competition between the 4 health funds providing the services. Since the outbreak of unabated missile attacks, the Ministry of Health has coordinated the continuous and uninterrupted provision of ambulatory health services everywhere in the North, a feat that could never have been accomplished were it not for the unfailing dedication, resourcefulness of and cooperation between the normally competing health funds.

Clinics from the very start opened their doors to all residents regardless of the health fund affiliation. The funds which are chronically underfunded — and not usually wont to forego any income which permit them to stay with their heads above water— quickly agreed to supply medications for chronically ill without receiving the usual mandated co-payments. Clalit Health Services, the largest fund, even changed its computer program so as to enable it to supply chronic medications without charge.

Although the home front command permitted opening clinics in buildings without shelters or reinforced safe areas, the health funds combined efforts so that all ambulatory services would be provided in buildings that could offer some protection in case of attack. Given the number of health care facilities damaged in missile attacks this seemed the wiser alternative.

In a few rural and outlying towns where no such buildings were available were services provided in clinics that did not have protected areas. Harried staff braved traveling sometimes long distances on the roads, all the while knowing that most lethal casualties occurred out in the open. As result of these remarkable efforts, uninterrupted health services have been provided even in Nahariya, Safed and Kiryat Shmona, cities which have borne a disproportionate burden of the attacks and suffered significant damage to buildings and infrastructure. The continued presence of health care workers and services in these areas provides some reassurance for the population that chooses to stay in their homes despite the constant danger to which they are exposed.

Monday, 7 August

Following a day working as deputy district health officer in the Haifa region, I make it home and look to see how the family fared during the day?s air raids. My 16 year old daughter and I leave the house just before 7 p.m. to get to a follow up appointment for her temporo-mandibular joint pains. It is no surprise that she doesn?t seem to get much relief from the splint or the muscle relaxants. The siren finds us halfway between our home and the shopping center just past our house. We quickly rush for cover and wait. As we attempt to leave we hear and feel a barrage of rockets falling. They are obviously close enough. Another siren sounds and we wait again. Only when we get caught in the same building on the way home do we learn of the damage wrought. A collapsed building, persons trapped within, hundreds of wounded and the number of dead as yet unknown. We try to identify the locations from the night television footage, usually fairly simple in a city as small as ours. In the morning, in addition to the names and pictures of the dead announced on the front page, the personal addresses of the missiles become known. Like many of the long time residents, I know most streets and neighborhoods in Haifa, and am dismayed that the Arab neighborhood associated with opening their homes for the holiday season of Christians, Jews, and Muslims has been hit and residents killed.

A rocket landed across the street from the home of our geriatrician who has been working extra hours making sure that all elderly and frail persons whose support systems have failed are cared for. His windows have been shattered by thousands of ball bearings in the payload of the rocket, designed to kill from a kilometer?s distance. He and his family are safe, sequestered in a more interior room of the house. Today he will continue to drive unprotected from one overbooked nursing home to another to give support and help to overworked, tired and frightened staff who are filling in now for home based caretakers whose nerves shattered and fled. Our staff?s efforts to provide the frail and elderly with adequate care have succeeded in filling all care facilities beyond capacity. Staff stress is intensified by the rapidly disseminated knowledge that a caretaker was killed from shrapnel of a rocket while driving to work.

Last night?s missile barrage floods all three general hospitals in Haifa with hundreds of wounded and many more with acute stress reactions. Agitated relatives and friends crowd to the hospital to get word of the fate of their loved ones contributing to the burden of the emergency room staff. All this in addition to the morning?s volley of those ?lucky? only seriously wounded soldiers who survived a particularly deadly rocket barrage and were airlifted to Haifa for treatment. Virtually all of the social work and psychological staff of the hospitals work the emergency room with reinforcement teams organized in advance. The home front finds itself executing contingency plans developed during years of civil defense exercises preparing for showers of rockets on the north of Israel. Hospitals work at overload capacity while moving entire departments to lower levels and non-Northern exposures so as to provide protection from rockets which have hit an unprecedented number of health care facilities and caused several to be evacuated. The exercises aided some to prepare for the reality that we now have to deal with but as usual were insufficient in predicting the almost infinite challenges that beset us. A home for wheelchair-bound elderly is evacuated unbelievably in the course of 1/2 hour when it is virtually engulfed in flames set off by a rocket landing meters away and setting fire to the bone dry brush in the surrounding fields. Unfortunately, we understand that the true crises are only before us, what with hundreds of thousands of people sitting in bomb shelters for over a month now, many of them with no homes to return to, a damaged economy and some of the greenest and most beautiful countryside in the country burnt from incendiary fire.

The importance of keeping a command structure in the field of public health serves to keep the staff working even though they many of them would prefer to be with their families, perhaps in a safer part of the country. The challenge for health personnel, balancing self protection with upholding their duty to heal and prevent illness is easier for the doctors and nurses. But the administrative and support staff of secretaries also provide a surprising number of people who put the needs of the community above their own. It is impressive.