Israelis have long faced the danger of weapons of mass destruction. How they’ve coped and the measures they’ve taken can teach Americans much when it comes to facing these frightening weapons.

In Israel, the threat of weapons of mass destruction (WMD) is not an idle one. Not only is the country threatened by WMD launched by military powers but the danger from terrorists wielding chemical, biological or radiological weapons is aconstant concern.

For example, in December 2001, Israeli policerevealed that a Hamas suicide bomber in Haifa had used an explosivecharge containing a toxic pesticide. Fortunately, most of it was destroyed in the explosion. Although Hamas chemical warfare capabilities are still rudimentary, Israeli security officials areconcerned that the group appears determined to acquire or produce more advanced chemical agents.

Response to disasters is coordinated by the police and for larger incidents by the Home Front Command (HFC), which is responsible for civil defense. The Ministry of Health has overallresponsibility for medical readiness.

HFC is responsible for distributing gas masksand atropine, a nerve gas antidote, to the general population. Itsother responsibilities include deploying biological weapon detectors,stockpiling antibiotics and vaccines, pre-vaccinating health officialsand emergency personnel, equipping first responders with protectivegear and decontamination equipment and training them to deal with allcontingencies.

In addition, HFC is deeply invested inproviding the public with information on what to do in the event of anattack in order to avoid panic. This is done in several ways, includingthrough booklets and pamphlets. Soldiers provide instructions on theuse of gas masks and atropine injectors at designated centers.

Currently headed by General Yitzhak Gershon,HFC was created in February 1992, following the Gulf War, when 40 IraqiScud missiles hit Israel. It was the first conflict since the country’sWar of Independence in 1948 in which the home front faced a significantthreat.

Until the establishment of the HFC, Israel’sCivil Defense Force and regional defense units under the Southern,Central and Northern commands bore responsibility for the home front.After the Gulf War, Defense Ministry officials concluded that combiningthese units would be a more efficient arrangement, so they were unifiedinto one body responsible for the entire country.

In August 2006, following the Second Lebanonwar, Prime Minister Ehud Olmert instructed the HFC to appoint anofficer for every city in Israel, with an emphasis on the northerncities. The officer coordinates home front assistance activities inemergency situations and responds to situations in which the localauthority finds it difficult to provide emergency services.

In accordance with recommendations submittedto him, Olmert directed that every city in Israel have a municipalemergency control center. The local authorities are to establish andmaintain these centers under the supervision and with the professionalassistance of the HFC.

Citizen protection

In the mid-1980s, the Israeli governmentinaugurated a program to provide all citizens with a free kitconsisting of an individually fitted gas mask and an atropine injector.Special masks were issued for infants, children, the elderly andindividuals with respiratory problems.

During the 1991 Gulf War, when Iraq launchedballistic missiles against Israeli targets, each warhead was considereda chemical weapon until civil defense teams located and determined itscontent. In response to this threat, Israel became the first countrysince World War II to provide the entire population with gas masks andprotection kits.

Today, HFC operates a nationwide network ofdistribution centers. Computerized records are maintained of allcitizens to whom a kit has been issued, along with the date of issue.Reminder notices are mailed out to replace the mask, air filter andauto-injector when the equipment’s operational life has expired.

Israelis were required by law to take their protective kits with them at all times when leaving their homes.

Israeli public health authorities were alsoaware of the threat of bioterrorism and stockpiled vaccines andantibiotics. In late 2001, the Israeli government placed an order for 6million additional doses of smallpox vaccine, sufficient to vaccinatethe entire population.

In October and November 2002, fearing anotheroutbreak of war, Israel conducted a program to vaccinate 15,000healthcare workers and other first responders against smallpox so thatthey could treat others in the event of an outbreak.

Although the vaccine statistically kills onein a million people and causes encephalitis (swelling of the brain) inone in 300,000, the program was considered a success because norecipient experienced serious side effects.

This success was the result of the HealthMinistry’s carefully screening of those vaccinated, avoiding peoplewith immune deficiencies, on steroids, those who had undergone an organor bone marrow transplant and those who were not previously inoculatedagainst smallpox. The success was also attributable to a decision tominimize the numbers vaccinated. Manfred Green, director of Israel’sCenter for Disease Control, stated that if all Israeli residents hadbeen vaccinated, an estimated six to 12 people could have died from thevaccine.

In the event of an immediate threat of attack,the government has another plan to inoculate the entire populationwithin four days by opening vaccination clinics at 200 schools andvaccinating around the clock.

The 2001 anthrax scare in the United Statesalso highlighted the need for rapid testing of suspicious substances,such as powder found in envelopes.

Technological innovation

Israel is also active in developing innovative new technologies and products to confront its WMD threat.

Retired Colonel Gili Shenhar, a senior HFCemergency and disaster management advisor, developed the IsoArk, amobile air purification container that can provide a totally isolatedenvironment and be quickly erected in areas infected by biologicalweapons. It can be used as a rapid response isolation unit or as analternative to building a permanent isolation room.

According to Shenhar, the IsoArk is airtightand meets European standards for safety and technical performance. Itexceeds the current guidelines for infection control and provides asignificant boost against biological hazards and infectious organisms.It recently completed successful testing at Harvard’s Institute forInternational Emergency Medicine and Health to determine its effect onthe performance of emergency life saving operation procedures.

“Israel faces many threats and we have to be ready for them. If not, the consequences will be grave,” Shenhar told HSToday.“The main idea of the IsoArk is to enable hospitals and otherfacilities to provide surge capacity in isolating large numbers ofpatients very rapidly. Many hospitals don’t have permanent isolationrooms, as they are very costly, both in terms of construction andmaintenance. This will provide them with a cost-effective alternativeto the huge investment in infrastructure.”

Nathan Citri, a professor emeritus at HebrewUniversity’s faculty of Medicine, invented a kit for the rapiddetection of anthrax. Lacking a brand name or title, one element of itis a black box that flashes a red light if anthrax is detected when apatient is first admitted into the hospital, allowing accuratediagnosis and providing all crucial information in less than 60minutes. If anthrax is detected, a second device tests for anydrug-resistant variants and identifies the antibiotics that should beused against the variant. The two kits can be used concurrently,consecutively or independently. Since anthrax treatment should beadministered within two hours of exposure, fast assessment is critical.

Citri is convinced that his system is a breakthrough, telling HSToday that it “will provide a concrete solution to the problem of anthrax in the fight against bioterrorism.”

This invention, as well as Citri’s 15 otherpatents, is being commercialized by Yissum Technology Transfer Companyof the Hebrew University of Jerusalem at Givat Ram.

Civil defense

In addition to HFC and the work of its scientists, Israel has been actively implementing a variety of civil defense measures.

One of the most important was a change in thebuilding code. Beginning in 1992, the law required that all newlyconstructed public buildings, apartment complexes and single-familyhomes incorporate a “protective room” that is both bomb-resistant andcapable of an airtight seal. The walls must be concrete and the doorsteel, and windows must have a brass shield enabling the room to behermetically sealed against a chemical or biological attack. It mustalso withstand conventional weapon attacks. The outer concrete wallmust be 30 cm (about 1 foot) thick, and interior concrete walls,ceilings and floors must be 15 cm (about 6 inches) thick.

In newer buildings, the protective rooms areequipped with electricity, running water and a telephone hookup to makethem more comfortable in the event of a long stay. More luxurious unitshave a bathroom and a TV connection.

 Mass notification is extremely important inIsrael. When authorities realized that air raid sirens were not heardin some parts of the country, citizens were instructed to turn on theirradios before going to sleep and tune in to a special station thatwould commence a live broadcast in the event of an attack, alertingthem to don their gas masks and enter their sealed rooms.

Magen David Adom (MDA), Israel’s emergencymedical service, has not been idle. According to MDA’s InternationalDirector Jonathan Yagodovsky, when a call is received and the number ofinjured is unknown, MDA sends about 42 ambulances with different levelsof medium and advanced life support and treatment capabilities. All MDAambulances carry respiratory filtering systems, masks and personalprotective equipment against chemical weapons. On average, 116 medicalpersonnel respond to each event, most of them doctors and paramedics.

 MDA and other emergency services areconstantly exercising, and all emergency personnel are trained for masscasualty scenarios as part of their ongoing training programs.

“The Israeli system is unique in that we havelearned how to work together in mass casualty incidents. Everyorganization knows its abilities, as well as the other organizations,from constant training together. Nobody can do it alone. It’s a teameffort,” Yagodovsky told HSToday.

Analysis

“In terms of Israel’s experience with civildefense, one can point to numerous successes and occasional failures.For several decades, Israel has equipped its military with gas masks,protective suits, nerve gas antidotes and other defensive equipment andhas made training using this equipment a routine part of militaryexercises,” pointed out Cameron Brown, assistant director of the GlobalResearch Center in International Affairs (GLORIA) at theInterdisciplinary Center (IDC) at Herzliya.

“Up until now, the failures and successes havebeen in the preparation stages only, because we haven’t had to dealwith a non-conventional attack,” said Brown. “One of the majorsuccesses was the introduction of the building code in 1992 that madeit compulsory to build a protective room in apartments and publicbuildings.” These rooms, in Brown’s words, “saved the day for manypeople.” In terms of comfort, they enable people to remain shelteredfor lengthy periods.

Prior to the requirement for protective rooms,people used older types of shelters in the basements of apartmentbuildings. These were not airtight and, while effective againstconventional rockets, they were unsuitable for chemical attacks. Sincepoison gases are heavier than air and tend to settle downward, theseolder shelters were the worst places to be during an attack. Also, theywere not conducive to a lengthy stay.

Another success was the program to vaccinate15,000 health care workers and first responders. This program wasexecuted with minimum bureaucracy and maximum efficiency. 

But there were failures. The gas mask programwas the worst. Because the masks were distributed in the period priorto the Gulf War in 1991, there are doubts about their effectivenesstoday. Large volumes of carbon dioxide have accumulated inside themasks, and wearers report a choking sensation if they’re worn now. Todate, the developers have not found a solution to this problem. Also,there was difficulty fitting them to all shapes and sizes of heads, notto mention covering beards and spectacles. A new type of mask is nowbeing developed in order to overcome these problems.

Another failure, Brown pointed out, was thelack of supervision in preparing the new shelters. People use them tostore junk and unused furniture.

“It was a bureaucratic nightmare. The localauthorities said it wasn’t their responsibility, and at governmentlevel the buck was passed back to the local authorities, resulting intotal inaction,” Brown recounted. The state comptroller placed most ofthe blame for the lack of preparedness on local authorities.

What can the United States learn from Israel’s experience in preparing for WMD?

The experience of the two countries issignificantly different. Israel is a tiny country, about the size ofNew Jersey, while the United States is a vast continental power. Israelis surrounded by potential enemies, while the United States isprotected by two oceans and has friendly neighbors to the north andsouth. It’s just a short shot for a rocket to hit an Israeli target;for the United States, only Russia has the capability of reaching itshomeland with missiles—and when the old Soviet Union tried to bring theUS homeland under the threat of short range missiles, the United Statesthreatened war, and the missiles were removed from Cuba, never toreturn.

Terrorism, however, is an equalizer, and bothcountries face the potential of terrorist WMD, although with nearbyhostile populations, Israel’s threat is more immediate.

Given that a rocket attack on the Americanhomeland is extremely unlikely, bomb shelters and missile defenseshould be a low priority. Biological or chemical terror, at this stage,would seem to be a more likely threat to the United States.

Israeli preparedness and coordination do havesome lessons for the United States: Following the Israeli practice,protocols for WMD response should be established at all governmentlevels and in the most at-risk cities, and regular drills should beorganized, supervised by the National Guard. The ability to handle masscasualty events, no matter where they occur, is particularly importantand is a key element in having an effective WMD defense. Quickdetection of chemical, biological and radiological contamination isalso key, and work continues on earlier and more accurate detectionmethods in both countries.

In a dangerous world, both countries facesimilar threats from similar foes, and similar solutions can work forboth. Israel and the United States have much to teach each other—andalways, much to learn. HST

Joe Charlaff is a freelance writer based in Jerusalem. His previous work includes articles on homeland security for Monitor magazine, which is part of the Jane’s Defense Weekly group of publications in London.

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How Hadassah Hospital prepares

“It is a fact of life that medical systems allover the world responsible for dealing with mass casualties are facingthe reality of the question ‘when’ and not ‘if,’” said Shmuel Shapira,deputy director general of Hadassah University Hospital and director ofthe Hebrew University School of Public Health. Shapira is also chairmanand chief executive officer of the International Center of TerrorMedicine. At one time, he served as head of the Trauma Terror Branch ofthe Israel Defense Forces.

Under Shapira’s direction, the HadassahMedical Organization and the International Institute forCounter-Terrorism run joint weeklong mass casualty event workshops.

The workshops cover both terror medicine anddisaster management, with courses such as “Principles of Mass CasualtyManagement,” “Pre-Hospital Strategy,” “Chemical, Biological andRadiological Events”; and “Medical Implications of Biological Terror.”

Participants come from all over the world. Atone session I attended in July 2007, one of the participants was Dr.Howard Morgan, a professor of neurological surgery from SouthwesternMedical Center at the University of Texas. “I’m really impressed to seehow the medical community in Israel is organizing itself, and also tosee the resilience of the Israelis adapting to the threats,” hecommented.

In the past, Hadassah prepared for eitherfull-scale war or terrorist incidents, but since 1991, when SaddamHussein threatened Israel with what were thought to be biologicalwarheads on ballistic missiles, the hospital and all other hospitals inIsrael have prepared for the possibility of biological warfare.

“Smart” drills

Drills directly related to biological orchemical threats are carried out once or twice a year, explained JulieBenbenishty, coordinator of the workshops and a former intensive careunit nurse. Such exercises are required at all Israeli hospitals.

“Smart” drills are those in which medicalstudents are assigned injuries or symptoms and act them out. Otherstudents act as medical staff and treat them. Magen David Adom (MDA),Israel’s emergency medical service, evacuates them, and emergency room(ER) staff must diagnose them.

“We’ve developed a system where all ambulanceshave digital cameras; ambulance crews photograph the scene and bring itto the hospital, where it’s displayed on the screen,” said Benbenishty.“Seeing the color of gaseous material can give clues as to what thesubstance may be. This can drastically shorten the diagnosis time.”

At the beginning of the drills, participantsare told what takes place at a mass casualty event. Then, everyone isgiven specific tasks, including managing the scene of the incident andorganizing the hospital, ER and operating theater. Logistics are workedout regarding who takes charge, who reports to whom, when the army iscalled in and how to coordinate the various services.

An entire morning is devoted to working outalternate methods of communication between the command station andmedical staff, should the telephone and cell phone network fail. Incases like that, volunteers can be used to run messages and carryinstructions between departments. An entire lecture is devoted to usingvolunteers effectively.

The live drills are timed to see how quicklythe response is executed and the length of time necessary to reach adiagnosis. The time taken to don personal protective equipment and useit is also evaluated.

In addition to the large-scale drills, which,in Hadassah’s case, usually take place in Jerusalem’s largest soccerstadium, surprise drills are carried out to test the alertness of ERstaff. During one such drill, a woman soldier appeared in the ER andpassed through all the procedures and reached the X-ray departmentbefore someone realized that her symptoms indicated anthrax exposure.Had the exposure been real, the ER staff would have been seriouslyaffected.

In another drill, someone threw an envelope atone of the hospital desk clerks and said, “This is anthrax powder” inorder to test her reaction.

Recognizing the importance of decontaminationin WMD events, Hadassah Hospital has at least 50 outdoor showers anddozens of metal stretchers, and staff is taught to use the facilities.

“I’m confident that my staff is fully preparedfor any eventuality, but the only way to maintain the status quo is tocontinue carrying out drills,” said Shapira. “Protocols should beconstantly reviewed and updated. I think that other hospitals couldlearn a thing or two from us.”