New Article: Schreiber, Building an Emergency Mental Health System for Israel

Schreiber, Merritt D. “Toward the Way Forward: Building an Emergency Mental Health System for Israel.” Israel Journal of Health Policy Research (early view; online first).





A number of related changes have evolved over the past 25 years: the development of a truly national disaster mental health service in Israel; progress in the science of risk, resilience and evidence base care for those suffering from traumatic stress related disorders; and the development of conceptual models of population level disaster mental health response in the context of emergency management systems such as the Incident Command System.
In a recent IJHPR article, Bodas, et al. report on the dynamic history of disaster mental health response in Israel, which informed by the all too numerous real world events affecting the region. What is most striking is that the system now in place reflects true “lessons learned” in that problems and issues identified in incidents informed deliberative planning, and the current system reflects many iterations of “lessons observed and learned”. There appears to be commitment across sectors of government in Israel that the mental health consequences of disasters and terrorism are important and a priority. This is advanced thinking and sound policy.
As the system in Israel continues to evolve, additional possibilities are offered for further consideration, based on the author’s US-centric experience, to advance emergency response systems in Israel, the Middle East and around the world.



New Article: Bodas et al, Perception of the Threat of War in Israel

Bodas, Moran, Maya Siman-Tov, Shulamith Kreitler, and Kobi Peleg. “Perception of the Threat of War in Israel – Implications for Future Preparedness Planning.” Israel Journal of Health Policy Research (early view; online first).





It has been recently reported that the preparedness of the Israeli public to a war scenario is mediocre. These findings suggest a need to study the psychosocial mechanisms behind individual motivation to engage in preparedness behavior. One component of these mechanisms is the perception of threat. The purpose of this study is to portray the perception of the threat of war by the Israeli public and to deduce possible implications for resilience-promoting policies.

Portions of the data accumulated in a telephone-based random sampling of 503 households (representing the Israeli population) performed in October 2013 were utilized to examine the perception of the threat of war by Israelis. The questionnaire was used to examine the level of household preparedness, as well as attitudes toward perception of threat, preparedness responsibility, willingness to search for information, and sense of preparedness. Statistical analysis was performed to determine the correlations between different components of threat perception, and to evaluate the preparedness promoting features of specific perception factors.

The data suggest that the perception of threat is influenced by different socio-demographic factors. In particular, age, religion and education seem to play an important role in the perception of threat. Compared to data collected almost a decade ago, the likelihood perception and threat intrusiveness rates were significantly reduced. The regression analysis suggests that perception of the severity of the impact on a family’s routine and willingness to search for information, two known preparedness promoting factors, can be predicted by various socio-demographic and threat perception components.

The data suggest that the Israeli public, post the Second Lebanon War (2006) and the Gaza conflicts of 2009 and 2012, perceives the probabilities of war and being affected by it as diminished. The Israeli public demonstrates what can be considered as the unique characteristics of a war-victimized population. Implications for a future resilience-promoting policy were discussed.



New Article: Pines and Bernstein, Solving the Worldwide Emergency Department Crowding Problem – What Can We Learn from an Israeli ED?

Pines, Jesse M., and Steven L. Bernstein. “Solving the Worldwide Emergency Department Crowding Problem – What Can We Learn from an Israeli ED?” Israel Journal of Health Policy Research 4 (2015): 52.





ED crowding is a prevalent and important issue facing hospitals in Israel and around the world, including North and South America, Europe, Australia, Asia and Africa. ED crowding is associated with poorer quality of care and poorer health outcomes, along with extended waits for care. Crowding is caused by a periodic mismatch between the supply of ED and hospital resources and the demand for patient care. In a recent article in the Israel Journal of Health Policy Research, Bashkin et al. present an Ishikawa diagram describing several factors related to longer length of stay (LOS), and higher levels of ED crowding, including management, process, environmental, human factors, and resource issues. Several solutions exist to reduce ED crowding, which involve addressing several of the issues identified by Bashkin et al. This includes reducing the demand for and variation in care, and better matching the supply of resources to demands in care in real time. However, what is needed to reduce crowding is an institutional imperative from senior leadership, implemented by engaged ED and hospital leadership with multi-disciplinary cross-unit collaboration, sufficient resources to implement effective interventions, access to data, and a sustained commitment over time. This may move the culture of a hospital to facilitate improved flow within and across units and ultimately improve quality and safety over the long-term.



Conference Program: APHA, Chicago, November 2015

Annual Meeting of the American Public Health Association, Chicago, 2015

Papers related to Israel:


Daoud, Nihaya. “Challenges for Maternal and Child Health Research in The Bedouin Indigenous Minority In Israel.” November 2, 2015, 8:50am.

This presentation focuses on the challenges and opportunities of maternal and child health research among Indigenous Arab Bedouin mothers in Israel.

Bedouins are Israeli citizens who have been living in the south for many decades. They are Israel’s most economically deprived minority and have poor health status. Bedouin infants have higher morbidity and mortality rates compared to their counterparts.

We conducted this study in 2007-2008 to better understand maternal experiences of infant care while drawing on social-ecological approaches to raise Bedouin mothers’ voices and inform policy and interventions.

Multiple factors embedded in Bedouins’ political and historical context complicate research, mainly land disputes with Israeli governments, changes in societal socioeconomic structure from monadic to semi-urban, and socio-cultural transitions including family structure and gender relations. Israeli governments do not recognize Bedouins as an indigenous minority, 40% of them live in legally unrecognized villages with houses that are continually threatened with demolition. These villages lack basic infrastructure including water, electricity, primary care clinics and social services. Conducting research among Bedouins requires building trust and recognizing their health and human rights while understanding their complex political, historical, and social contexts. Building on local knowledge is crucial and requires outstanding research methods. Other issues include attaining ethics approval, maintaining confidentiality, and overcoming language barriers as mothers lack basic reading and writing skills. Funding opportunities and scholarly publication requires additional effort and time. Recognizing these challenges might provide an opportunity for more advanced research among Bedouins and other indigenous populations.


Shapiro, Ephraim and Irit Elroy. “Mental Health Care Utilization Among the Most Traditionally Religious Jews and Muslims in Israel in an Era of Reform.” November 3, 2015, 2:30pm.

Background: Israel recently implemented mental healthcare system policy reform, with uncertain impact on utilization among subgroups. The most traditionally religious segments of Israeli society, including both Jews and Muslims,  have distinctive attitudes, behaviors and demographics, all of which can impact mental healthcare usage and the reform’s success. Prior research found some underutilization among the most religious Israelis despite universal health insurance ,  for reasons such as stigma,   yet the topic has been understudied.

Research Questions: 1) To what extent do Haredi/ultraorthodox Jews and traditional Arab Muslims in Israel seek and/or receive mental healthcare 2) Do results vary by key subgroups including religion and socioeconomic status?  3)What interventions can potentially be developed to increase use of needed mental health services among religious groups?

Methodology/Results: A random-sample survey of health utilization among all Israelis conducted in 2013 was analyzed. Outcomes included Mental healthcare utilization measures and attitudinal measures related to potential barriers. Religious group was categorized by self-report. Univariate and bivariate analyses were performed using health, religious, and socioeconomic factors. Chi-square statistics were produced. Over 2000 Israelis were surveyed including 275 Haredi/ultraorthodox  Jews and 225 traditional Muslims.  Variations were found by some but not all religious and socioeconomic subgroups. In addition, key informant interviews with religious, community and medical leaders were conducted and faith-based intervention opportunities identified

Conclusions:  Culturally-sensitive interventions can potentially be developed to increase appropriate mental health care utilization for religious Israelis. This issue is particularly timely after mental health reform when opportunities to change relevant attitudes and behaviors exist.


Shapira, Stav, Limor Aharonson-Daniel,Yaron Bar-Dayan, Deanna Sykes, and Bruria Adini. “Is Earthquake Preparedness a Generic Achievement? Similarities and Differences between Preparedness of Canadian and Israeli Hospital Personnel.” November 3, 2015, 4:30pm.

Background: Healthcare workers (HCW) willingness to report to work (WTR) during a disaster is essential to implementing an efficient response. A better understanding of the mechanisms underlying this matter may contribute to reduced absenteeism in future disasters. Assessing preparedness and WTR in an earthquake scenario, in different social contexts and preparedness approaches (Canada and Israel) may shed light on the complexity of these issues.

Objectives: 1) To assess knowledge, perceptions, attitudes and WTR of HCW in Canada and Israel concerning earthquakes and 2) To evaluate the relationship between these factors and WTR.

Methods: A validated questionnaire including questions about demographic characteristics, knowledge, perceptions, attitudes and WTR in an earthquake scenario was distributed in two tertiary care hospitals located in risk regions, to a random sample of 131 Israeli and 381 Canadian HCW.

Results: Knowledge, perceptions of efficacy, as well as WTR were generally higher among Israeli HCWs. ‘Concern for family’s well-being’ and ‘professional commitment to care’ were reported by the largest proportion of HCW as factors that might influence WTR. Significant predictors of WTR amongst both Israeli and Canadian HCW were the belief that ‘colleagues will also report to work’ and ‘professional commitment’.

Conclusions: Significant differences were found in levels of knowledge, perceptions, attitudes and WTR in an earthquake scenario between Israeli and Canadian HCW. Social and professional solidarity seems to be cross-cultural factors that mitigate other potential barriers to WTR. This may help formulate new methods of improving hospital personnel preparedness to future events.


Shapiro, Ephraim and Rachel Nisanholtz. “Community Nurses and Chronic Disease in Israel, the United States, and the United Kingdom: A Comparative Analysis.” November 4, 2015, 11:00am.

Background: The growing worldwide trend of chronic disease harms not only the public’s health but increases costs. Public health and other community nurses can play important roles in its prevention and control. These nurses can play vital roles in advancing national health system objectives. However, despite this there has been inadequate comparative study of community nurses’ role in preventing and controlling chronic disease.

Objectives: 1)What roles do public health and other community nurses play for  chronic disease prevention and control? 2)What trends and related challenges exist for these nurses in terms of chronic disease prevention and control? 3)How do these nurses’ roles, trends and challenges vary across Israel, the U.S., and the U.K and what lessons can be learned?

Methodology:  Key informant interviews and a comprehensive literature review were performed and themes related to the objectives analyzed. An average of 10 interviews was performed among nursing leaders and/or academic experts in each of the three countries.

Key Findings/Conclusions: The role of nurses in non-hospital settings has grown rapidly; further growth is expected to occur, with variations by type of nurse. They have a multiplicity of roles and can reach a wide variety of groups. There are important implications for reducing health disparities as nurses can play important roles in monitoring social determinants. While there is much overlap, important differences exist between community nurses in different settings; countries can learn from each other’s successes and challenges although contextual differences such as cultural, institutional, and policy and differences need to be understood.

New Article: Pinsky, Israel’s Earthquake Early Warning System

Pinsky, Vladimir. “Modeling Warning Times for the Israel’s Earthquake Early Warning System.” Journal of Seismology 19.1 (2015): 121-39.





In June 2012, the Israeli government approved the offer of the creation of an earthquake early warning system (EEWS) that would provide timely alarms for schools and colleges in Israel. A network configuration was chosen, consisting of a staggered line of ∼100 stations along the main regional faults: the Dead Sea fault and the Carmel fault, and an additional ∼40 stations spread more or less evenly over the country. A hybrid approach to the EEWS alarm was suggested, where a P-wave-based system will be combined with the S-threshold method. The former utilizes first arrivals to several stations closest to the event for prompt location and determination of the earthquake’s magnitude from the first 3 s of the waveform data. The latter issues alarms, when the acceleration of the surface movement exceeds a threshold for at least two neighboring stations. The threshold will be chosen to be a peak acceleration level corresponding to a magnitude 5 earthquake at a short distance range (5–10 km). The warning times or lead times, i.e., times between the alarm signal arrival and arrival of the damaging S-waves, are considered for the P, S, and hybrid EEWS methods. For each of the approaches, the P- and the S-wave travel times and the alarm times were calculated using a standard 1D velocity model and some assumptions regarding the EEWS data latencies. Then, a definition of alarm effectiveness was introduced as a measure of the trade-off between the warning time and the shaking intensity. A number of strong earthquake scenarios, together with anticipated shaking intensities at important targets, namely cities with high populations, are considered. The scenarios demonstrated in probabilistic terms how the alarm effectiveness varies depending on the target distance from the epicenter and event magnitude.

New Article: Alpert et al, Volunteer First Responders to Mass-Casualty Terrorist Attacks in Israel

Alpert, Evan Avraham Alpert, Ari M. Lipsky, Navid Daniel Elie, and Eli Jaffe. “The Contribution of On-Call, Volunteer First Responders to Mass-Casualty Terrorist Attacks in Israel.” American Journal of Disaster Medicine 10.1 (2015): 35-39.





To describe the contributions of on-call, volunteer first responders to mass-casualty terrorist attacks in Israel during the Second Intifada.


Descriptive study evaluating data obtained from postevent debriefings after 15 terrorist attacks in Israel between 2001 and 2004.


An average of 7.9 deaths (median 7.0, interquartile range [IQR] 2.5-12.5) and 53.8 injuries (median 50.0, IQR 34.0-62.0) occurred in each of these attacks. The average number of volunteers responding to each event was 50.3 (median 43.0, IQR 27.5-55.5). The volunteers were involved in extricating victims from imminent danger, and performing emergent tasks such as bag-valve ventilation, tourniquet application, and intravenous line insertion. They were also integral to the rapid evacuation of casualties from the scene.


On-call, volunteer first responders are an integral part of Israel’s emergency medical response to mass-casualty terrorist attacks. This system may be used as a model for the development of similar services worldwide.


New Article: Goldman et al, Contribution of the Israeli Trauma System to the Survival of Road Traffic Casualties

Goldman, Sharon, Maya Siman-Tov, H. Bahouth, B. Kessel, Y. Klein, M. Michaelson, B. Miklosh, A. Rivkind, G. Shaked, D. Simon, D. Soffer, M. Stein, and Kobi Peleg. “The Contribution of the Israeli Trauma System to the Survival of Road Traffic Casualties.” Traffic Injury Prevention 16.4 (2015): 368-73.





Background: According to the World Health Organization, over one million people die annually from traffic crashes, in which over half are pedestrians, bicycle riders and two-wheel motor vehicles. In Israel, during the last decade, mortality from traffic crashes has decreased from 636 in 1998 to 288 in 2011. Professionals attribute the decrease in mortality to enforcement, improved infrastructure and roads and behavioral changes among road users, while no credit is given to the trauma system. Trauma systems which care for severe and critical casualties improve the injury outcomes and reduce mortality among road casualties.

Goals: 1) To evaluate the contribution of the Israeli Health System, especially the trauma system, on the reduction in mortality among traffic casualties. 2) To evaluate the chance of survival among hospitalized traffic casualties, according to age, gender, injury severity and type of road user.

Methods: A retrospective study based on the National Trauma Registry, 1998–2011, including hospitalization data from eight hospitals.

Outcomes: During the study period, the Trauma Registry included 262,947 hospitalized trauma patients, of which 25.3% were due to a road accident. During the study period, a 25% reduction in traffic related mortality was reported, from 3.6% in 1998 to 2.7% in 2011. Among severe and critical (ISS 16+) casualties the reduction in mortality rates was even more significant, 41%; from 18.6% in 1998 to 11.0% in 2011. Among severe and critical pedestrian injuries, a 44% decrease was reported (from 29.1% in 1998 to 16.2% in 2011) and a 65% reduction among bicycle injuries. During the study period, the risk of mortality decreased by over 50% from 1998 to 2011 (OR 0.44 95% 0.33–0.59. In addition, a simulation was conducted to determine the impact of the trauma system on mortality of hospitalized road casualties. Presuming that the mortality rate remained constant at 18.6% and without any improvement in the trauma system, in 2011 there would have been 182 in-hospital deaths compared to the actual 108 traffic related deaths. A 41% difference was noted between the actual number of deaths and the expected number.

Conclusions: This study clearly shows that without any improvement in the health system, specifically the trauma system, the number of traffic deaths would be considerably greater. Although the health system has a significant contribution on reducing mortality, it does not receive the appropriate acknowledgment or resources for its proportion in the fight against traffic accidents.