Addressing the Needs of the Population Following the October 7th Events – Mental Health Care, Enhancing Community Resilience, Support to Victims of Hostilities, and Regulation of the Activity of Local Community Emergency and Resilience Teams
On Simchat Torah (Jewish Holiday), October 7th, 2023, the Hamas terrorist organization launched an attack on the State of Israel by firing thousands of rockets and the infiltration of thousands of terrorists into IDF bases, cities, and communities in the Western Negev (around the Gaza strip). The terrorists also attacked multi-participant parties held near the Gaza Strip. The thousands of terrorists who infiltrated Israel committed terrible acts of extreme brutality; They murdered hundreds of soldiers and about 1,000 Israeli and foreign citizens and committed horrific crimes against women, men, the elderly, children and infants, male and female soldiers. Moreover, they injured thousands of people, committed horrific sexual assaults on the victims, and abducted 251 women, men, and children into the Gaza Strip. Additionally, the terrorists damaged property – destroying, burning, and vandalizing homes in communities, factories, equipment, and other property. During the fighting in the communities, residents were forced to hide for many hours in protected areas and other hiding places, fearing for their lives, while learning about the horrors happening to family members, relatives, neighbors, and friends, and even witnessing the events unfold before their very eyes (the October 7th Events); Many others saw the horrific events broadcast live on the media and social networks.
The Iron Swords War, which broke out following these events, has thus far been characterized by the firing of thousands of rockets, missiles, and unmanned aerial vehicles (UAVs) at Israeli communities as part of a multi-arena conflict, resulting in the evacuation of a large part of the population from the communities surrounding Gaza strip and the communities in the north of Israel, and prolonged fighting compared to Israel’s recent conflicts. These extreme events affected the mental health and the functioning of the population, and the state has a moral obligation to quickly provide the victims with the best medical, therapeutic, and rehabilitation response.
This compilation of audits addresses the state’s preparedness to provide the treatment and support required for the population following the October 7th Events and the Iron Swords War to ensure the resilience of the civilian population in Israel, including mental health, and that those psychologically affected by the traumatic events receive holistic and long-term psychological treatment and rehabilitation, as well as budgetary assistance that will enable them to return, as quickly as possible, to a regular daily routine.
The compilation includes four reports:
- Mental Health Care Following the October 7th Events and the Iron Swords War
- Operation of Resilience Centers in the Frontline Communities Since the Outbreak of the Iron Swords War
- Regulating Assistance for Victims of the October 7th Attack
- The Organization of the Local Community Emergency and Resilience Teams (CERT/CER teams) Before the Iron Swords War and Their Subsequent Operations at the War’s Onset
The compilation focuses on the effects of the October 7th Events and the Iron Swords War on the psychological and rehabilitation response of the mental health services, for those reporting symptoms of post-traumatic stress, anxiety and depression, and in particular for those who were present at the events, those who were evacuated from their homes and those who provided assistance; The provision of immediate first aid to victims of psychological trauma and strengthening social and organizational resilience by Resilience Centers in frontline communities, which play a central role in maintaining and restoring the strength of the population both as individuals and as a society; The long-term economic implications for the state treasury of the unprecedented increase in the number of victims of hostilities as defined in the Victims of Hostile Actions (Pensions) Law (Pensions Law), following the October 7th Events; The need to regulate a normative response to the tens of thousands of victims suffering psychological harm from the October 7th Events who are not considered victims of hostilities under existing law because they were not physically present at the events; And the importance of the CER teams for communities of a communal nature, and in particular those near the Gaza-Israel border, in establishing a situational assessment, maintaining communication with residents under threat, and facilitating the emergency evacuation of impacted areas.
Mental Health Care Following the October 7th Events andthe Iron Swords War -
the report examines the activity of the mental health system shortly after the October 7th Events and in the following months, focusing on the system’s organization to provide treatment for those in need from amongst the entire population, including the evacuees and those who witnessed first-hand the October 7th Events, with an emphasis on the broadest possible group of people who may experience symptoms of posttrauma, anxiety, and depression. It should be noted that during the October 7th Events and the Iron Swords War, as of the audit completion date, the Minister of Health was MK Uriel Menachem Buso, and the Director-General of the Ministry of Health was Mr. Moshe Bar Siman Tov.
In a letter to the Prime Minister dated November 13, 2023, the State Comptroller presented the current situation and the main failures and gaps in the treatment of the civilian home front, as raised from his tours of the frontline communities in the south and north of the country immediately following the October 7th Events. The State Comptroller noted in his letter that visits to the hotels that accommodated evacuees from the southern communities raised that “the public-governmental mental health system failed to treat the evacuees, as the treatment was largely based on volunteers.” The mental health system “operated without a methodological approach, alongside local volunteer initiatives, and without maintaining continuity of the treatment or its documentation”.
The audit raised that among participants of the State Comptroller’s Office survey about six months after October 7th, with the participation of 1,010 individuals aged 18 and older, representing a sample of the adult population in Israel, about one-third reported medium to severe symptoms of post-trauma or depression (34% and 32%, respectively), and around one-fifth (21%) reported symptoms of anxiety. However, a large majority (90%) of the participants in the survey did not seek psychological treatment, with the most common reason being the waiting time for appointments with the HMOs, which was six and a half months as of the survey date.
Previous audits conducted by the State Comptroller found that even before the war, waiting times for psychotherapy treatment were prolonged. Thus, the State Comptroller’s 2020 report2 noted that the average waiting time for psychotherapy treatment in 2018 was about five months. Said report, published four years before the war, already highlighted at the time the significant shortage of mental health professionals, including therapists and psychiatrists. Regarding the waiting time for a psychiatrist, another report3 found that the waiting time for such an appointment in 2022 was about a month and a half4. Presently, it is imperative to adapt the response in the mental health to the needs of Israeli residents, given the intensity of the events, the large number of victims, and the expected consequences if the issue is not addressed.
The National Emergency Authority (NEMA) reference scenario states that the number of evacuees expected in a war scenario could reach about 100,000 people, to which should be added about 200,000 people evacuating independently, not by the state, but who will need services from state institutions in the places to which they evacuate. The scenario also states that those who evacuate independently will do so to less threatened areas, such as the Dead Sea region and Eilat, which may burden the infrastructure there. The audit also raised that the Ministry of Health was not prepared in advance to provide mental health services to evacuated and self-evacuating populations, even though such a scenario was known.
Thus, in the first week after the evacuation of the population to the hotels, the Ministry of Health was still not prepared to provide services to the evacuees, and these were provided using volunteers whose identity, training, and professional background the Ministry had no information about. The Ministry of Health then decided that psychiatric hospitals and not the HMOs (Health Maintenance Organizations) would manage mental health services in the hotels for four weeks. This decision involves a change in the policy established for times of emergency, with considerable wide-ranging implications as the psychiatric hospitals were not prepared to provide services to evacuees, either in terms of work processes or in terms of workforce. For example, they were required to divert doctors and staff from their regular hospital duties to treat evacuees, but they were not prepared for this in advance. Nor were any regular processes determined in advance with which they were familiar that would allow for the documentation of treatment, continuity of care, and enabling access to the evacuee’s medical file; These actions are possible for HMOs but not for psychiatric hospitals.
It was found that in the six months after the October 7th Events, only about 11% of all evacuees from southern and northern communities (about 23,000 out of about 210,000 adults and children evacuees) received mental health treatment from HMOs and Resilience Centers, including about 4% of the evacuee children from Sderot, despite the extreme traumatic events they experienced and their increased risk of moderate and severe post-traumatic symptoms.
The State Comptroller’s Office noted to the Supreme Authority for Emergency Hospitalization and Health and the Director General of the Ministry of Health, who heads it, for not ensuring the health system can operate according to the scenario predicting the evacuation of about 300,000 people to relatively safe areas such as the Dead Sea region and Eilat, for failing to ensure it is prepared to provide mental health services required following the emergency events, and for not formulating a dedicated mental health work plan for emergencies in general and in the event of a large-scale evacuation of the population, in particular. The State Comptroller’s Office also notes that the Minister of Health, who is responsible for operations in his Ministry, is not ensuring that the Ministry is prepared and ready concerning the mental health system in emergencies.
On October 7th, three large-scale events took place around the Gaza Strip, the largest of which was the “Nova” dance party. The number of people murdered at the dance parties was about 400, and thousands more suffered physical and emotional harm. In addition, 44 of the parties’ participants were kidnapped. The massacre of the participants lasted for hours and included brutal and shocking sexual assaults, at least some of which were committed in front of the survivors. Many of the survivors lost family members and friends, some more than one, and their lives changed significantly. A survey by the State Comptroller raised that among those who were present at the October 7th Events, the rate of reporting post-traumatic, depression, and anxiety symptoms was almost double the rate of those who were not present. The audit found that in the six months following October 7th, over half of the parties’ survivors (52%, which is about 1,900 people) did not receive psychological treatment at the Resilience Centers or HMOs, despite the extreme traumatic events they experienced and their increased risk of moderate and severe post-traumatic symptoms.
In the course of their work, volunteers of the ZAKA (Disaster Victim Identification) organization are frequently exposed to complex scenes that may seriously affect their mental state, and the October 7th Events are a severe and extreme example of this. Despite this, only 1% of ZAKA Tel Aviv volunteers and 13% of ZAKA Israel volunteers who volunteered on October 7th and in the following weeks received treatment from HMOs or the National Resilience Center. The Ministry of Health also did not regulate the mental health care of all volunteers, including ZAKA volunteers.
As part of applying for and renewing a firearms license, the applicant must submit a health declaration that includes questions regarding their general medical and mental fitness. The audit found that the rate of health declarations submitted by the Ministry of National Security to the Ministry of Health, which examines the mental fitness of license applicants in the period after October 7th, was 3% compared to 4% to 10% in the preceding years, despite the sharp increase in the harm to the population’s mental health. Moreover, the Ministry of National Security and the Ministry of Health have not made the necessary adjustments to tighten control and supervision over granting licenses despite the sharp increase in the rate of those in need of mental health care compared to the pre-war period.
The Ministry of Health, responsible for providing mental health services during both routine and emergencies and the Ministry of Finance, which supervises the state budget, in collaboration with the National Insurance Institute, should prepare for the treatment of those impacted by the October 7th attack and the Iron Swords War, addressing both economic and psychological rehabilitation needs.
The relevant audited bodies – the Ministry of Health, the Ministry of Finance, and the National Insurance Institute – should consider establishing a dedicated mental rehabilitation administration that would provide a comprehensive support package for those suffering mental injuries from the October 7th Events and the Iron Swords War, facilitating their reintegration into daily life.
Operation of Resilience Centers in the Frontline Communities Since the Outbreak of the Iron Swords War –
the October 7th Events and the following events severely affected the population’s sense of personal and community resilience, increasing the need to use the services of the Resilience Centers. However, from the outbreak of the Iron Swords War until the end of 2023 – 15,750 people, constituting only 0.16% of the total population of the State of Israel in 2023, received 50,734 treatments from the Resilience Centers. During this period, the Ministry of Health approved an additional budget of NIS 34.66 million for the Resilience Centers (in addition to the annual budget of NIS 31.87 million approved for them at the beginning of the year) and the Resilience Centers’ budget for 2024 was NIS 149.6 million.
The State Comptroller noted in his letter to the Prime Minister dated November 13, 2023, that the Resilience Centers attempting to respond in this area are few, operating with minimal resources and providing many treatments remotely – via phone or online.
Despite the importance of the Resilience Centers in providing a key and vital response both at the level of emergency preparedness and the strengthening of social resilience and at the level of treatment of victims of anxiety during emergencies, especially in the southern and northern regions, the centers faced budgetary uncertainty and a shortage of workforce – thus, limiting their ability to respond. The audit raised that funds intended to finance the coping of all Resilience Centers in emergencies in the last quarter of 2023 were transferred by the Ministry of Health to the Resilience Centers’ operators a few weeks after the activity was carried out, and in some cases months later, when some were not transferred to the operators at all by the audit end date in April 2024.
As of the audit completion date, April 2024, about three years after the publication of the recommendations of a previous audit report addressing the Resilience Centers, and despite attempts to set the Resilience Centers’ budgets in the Ministry of Health’s budget base, the Budget Division of the Ministry of Finance did not establish an annual framework for all Resilience Centers, which would be set in the Ministry of Health’s budget base nor the budgets of other government ministries, due, among other things, to the opposition of some ministries to this measure, and did not set in advance a designated budget for emergencies. This creates budgetary uncertainty and operational problems among the Resilience Centers and may adversely affect the service provided and even lead to their closure.
The audit further found that the Ministry of Health did not maintain regular control procedures at the Resilience Centers; It did not prepare for the transfer of confidential information concerning patients between the various mental health care providers; It did not set guidelines for the Resilience Centers to provide services and treatments online; And it did not formulate a regular plan to assist and support the therapists of the Resilience Centers in times of crisis – a matter highlighted as the result of the therapist being exposed to of the horrible stories and events. Although the procedure for operating the Resilience Centers states that during periods of emergency or in special situations on the home front, patients should receive a response without waiting, a problem arose in which hundreds of patients (450 people) waited in February 2024 at the Ashkelon Resilience Center for an initial interview to determine their treatment needs; And the waiting times at the Resilience Center in the Bedouin society were increased from 24 hours in the first two weeks of the war to a week from November to the end of December 2023.
To ensure the optimal and continuous functioning of the Resilience Centers during routine and in emergencies, the Ministry of Health should guarantee the certainty of the Resilience Centers’ budgets and facilitate the timely transfer of essential funds for their operation during emergencies. A professional and budgetary control mechanism should also be established to supervise the Centers’ activities. The Supreme Steering Committee5, in collaboration with the Ministry of Finance and the Prime Minister’s Office, should define an annual budgetary framework for all Resilience Centers, which will be integrated into the Ministry of Health’s budget. Given the pivotal role of Resilience Centers in enhancing the state’s population’s resilience, the Minister of Health, alongside the Minister of Finance and the Prime Minister’s Office, including other members of the Supreme Steering Committee, should promote an action framework ensuring the existence, strengthening, expansion, and professionalism of the Resilience Centers for the benefit of all citizens of Israel. This framework should also include a budgeting mechanism aligned with the operational requirements of the Resilience Centers during emergencies. Recognizing the critical importance of saving and protecting lives, the Ministry of Health, the Supreme Steering Committee, and the Prime Minister’s Office should integrate Resilience Centers into all organizational structures of local government and health systems. This integration is essential for providing professional and effective care to all citizens affected by wars, hostilities, and natural disasters. Achieving full integration among all stakeholders and prioritizing Resilience Centers in treating mental health issues and strengthening community resilience and emergency preparedness will contribute significantly to robust national resilience, particularly given the challenges posed by the ongoing Iron Sword War and potential future emergencies.
Regulating Assistance for Victims of the October 7th Attack –
the Victims of Hostile Action Pensions Law regulates the rights of both citizens and foreign nationals who sustain injuries during hostilities, as well as the rights of bereaved families of individuals killed in such events. The law entitles them with the equivalent to those of disabled personnel of the Israel Defense Forces (IDF) and the families of deceased soldiers. This multidisciplinary support persists throughout their lifetimes. For an individual to be recognized as a victim of a hostile action, it must be demonstrated that there exists an honest and direct causal link between the claimed injury and a specific hostile act, as well as that the victim was physically present during that event and was not merely affected by its aftermath or implications. The October 7th Events presented significant challenges regarding the support for victims of hostilities, particularly concerning the required budgetary assistance, due in part to an unprecedented rise in the number of recognized victims – about 61,100 individuals by the audit completion date (March 2024), compared to the annual average of about 450 from 2009 to 2022. Additionally, current legislation does not address the needs of tens of thousands of individuals who, while not physically present, experienced mental trauma from witnessing the events inflicted upon their loved ones, sometimes in real-time, through mobile devices and social media.
The audit assessed the long-term financial implications for the state treasury resulting from the significant increase in victims following the October 7th Events. Findings indicated that the additional expenditure for victim compensation under the Pensions Law would be substantially higher than prior expenditures. Estimates for this additional compensation range from about NIS 1 billion annually, based on the State Comptroller’s Office minimum estimate, to as much as NIS 1.7 billion, following its maximum estimate and the updated projection from the Budget Division of the Ministry of Finance, which is about NIS 1.8 billion per year. To this should be added an estimated NIS 525 million for those recognized as victims before October 7th, along with one-time grants for individuals whose disability level awards them such entitlement.
In addition, the audit raised the urgent need to amend existing legislation to adequately address the needs of the October 7th victims, given the extreme nature of those events. Numerous victims suffering from mental trauma who were not physically present yet were exposed to scenes of horror find no recourse under the Pensions Law, which formerly served as the comprehensive legal framework for assisting victims of specific hostilities. In April 2024, the Minister of Finance appointed a public committee to form a tailored response for the October 7th Events victims to provide supplementary assistance to the current legal framework. The committee recommended offering shortterm financial support and treatment options for those not present during the incidents; However, no comprehensive medium or long-term rehabilitation strategy has been established for these individuals, raising concerns regarding their recovery and ability to reintegrate into daily life.
It is recommended that the Ministry of Finance, the National Insurance Institute, and the Ministry of Justice evaluate the necessity of establishing an updated policy regarding the application of the Pensions Law to individuals currently excluded from the classification of “victims of hostile actions,” and assess the need for legislative amendments to ensure an adequate response to the victims of the October 7th Events, the ongoing war, and future hostilities.
The Organization of the Local Community Emergency and Resilience Teams Before the Iron Swords War and Their Subsequent Operations at the War’s Onset –
on October 7th, the critical role of the Community Emergency and Resilience Teams (CERT/ CER teams) in providing an initial and immediate response during an emergency became evident, particularly in establishing a situational assessment, maintaining communication with residents under threat, and facilitating the emergency evacuation of impacted areas. After the evacuation, the CER teams played an essential role in organizing the requisite response to the needs of the evacuated communities at the designated intake points vis-à-vis governmental and public bodies. The audit found that there is no statutory mandate for establishing a CER team, and no regulatory body has been constituted to supervise them. CER teams are formed at the behest and initiative of the regional councils or the local authorities within the councils, with support from the Ministry of Welfare or other discretionary means.
Despite the essential role of a CER team as a coordination center from which directives and information are disseminated during emergencies, CER teams reported that they were not provided with guidance by the Home Front Command regarding their responsibilities during emergency evacuations. The assistance the Ministry of Welfare supplied for maintaining CER teams’ activities in 2024 is relatively modest, at about NIS 8,250 per local authority. This budget is uniformly allocated across local authorities nationwide without consideration of varying risk levels and does not accommodate personal compensation for CERT members, particularly for sustained efforts during emergencies such as the Iron Swords War. Furthermore, an annual survey conducted by the Ministry of Welfare in 2023 indicated that 24% of responding local authorities assessed their CER team’s readiness as unsatisfactory before the October 7th Events.
All bodies responsible for evacuation – the IDF (HFC), the Ministry of Defense through the National Emergency Authority (NEMA), the Ministry of Welfare, the Ministry of Interior, and the regional councils should evaluate the incorporation of the CER team as an official body, with clearly defined roles in both routine and emergency times and that they collaborate to determine a budget framework that encompasses the operational needs of the Community Emergency and Resilience Teams, motivate local authorities to establish such teams and enhance their readiness, particularly in high-risk areas. It is further recommended that these bodies identify the training necessary to ensure the preparedness of the CER teams for emergency evacuation and facilitate such training accordingly. Additionally, the Ministry of Welfare and the Ministry of Interior should investigate methods of compensating the efforts of CER teams for their voluntary contributions, especially during ongoing emergencies. This compensation can be facilitated directly or through the regional councils, and organized guidelines should be issued to local authorities. This could encourage more significant actions by the CER teams and their formation in areas where such teams have yet to be established.
To ensure Israel’s resilience and address the repercussions of the October 7th Events and the Iron Swords War on community and mental resilience of its citizens, it is significantly important that all relevant bodies promptly rectify the deficiencies noted in the reports. A swift and effective response to the unique needs of the victims is essential for their return to a regular routine.
In conclusion, I wish to extend my gratitude to the State Comptroller and Ombudsman personnel for their professional, thorough, and in-depth execution of the audit. We will continue to pray and hope for the safe return of the hostages to their homes, the safe return of residents from both the south and north to their homes, the safety of our soldiers, and the success of the defense forces in defending our nation.
Matanyahu Englman
State Comptroller
and Ombudsman
Jerusalem,
February 2025