Abstract
The COVID-19 pandemic resulted in a dramatic loss of human life worldwide and presented an unprecedented challenge to health systems globally and in Israel. 1 To improve the national response to the COVID-19 pandemic, the Israeli government passed an exceptional resolution on June 17, 2020, instructing the Israeli Defense Force (IDF) to support the civilian public health response. 2
The Public Health Directorate (PHD) in Israel’s Ministry of Health is responsible for national efforts to prevent, monitor, and control infectious and noncommunicable diseases. It comprises a headquarters, 7 health departments, and 5 national laboratories.
IDF relies on a core of 170 000 active-duty personnel. 3 Military service in Israel is compulsory for both men and women upon graduation from high school, unless exempted for medical or religious reasons. IDF also includes about 460 000 reserve-duty soldiers up to age 45 years. The Home Front Command (HFC) branch of IDF is responsible for strengthening national resilience, providing civil defense, preparing the civilian population for a conflict or disaster, assisting the population during a crisis, and contributing to postcrisis reconstruction.
The first case of COVID-19 in Israel was diagnosed on February 21, 2020. 4 One month later, when more than 3000 patients had been diagnosed with COVID-19, the prime minister declared a national state of emergency, and police began enforcing social distancing and other measures to contain the spread of SARS-CoV-2. 5 In the early stages of the pandemic, contact tracing was conducted by nurses and physicians from regional health departments of the PHD. COVID-19 testing was initially performed by the national virology public health laboratory; quickly thereafter, testing capacities were built in other clinical laboratory and private laboratories. National monitoring, management, and recommendations for containment measures were performed at the PHD headquarters.
The PHD employs 3500 skilled workers, including nurses, physicians, food and environmental inspectors, laboratorians, and other allied professionals. Only about 50 of these skilled workers are trained epidemiology nurses. Because the volume of COVID-19 patients had increased exponentially, many field-level workers at the PHD abandoned their routine tasks and were deployed to augment epidemiological nurses in performing contact tracing.
In May 2020, as the number of COVID-19 cases reached 26 281 patients, 4 additional logistic support was required to conduct epidemiological investigations for all confirmed COVID-19 cases and their contacts. In response, the Israeli government assigned the HFC to support the PHD in containing the outbreak, given its operational and budgetary capabilities.
The PHD and the HFC had to merge forces and establish robust cooperation, institute a new hierarchical structure, and divide responsibilities. In this commentary, we outline the advantages and challenges of effective civil–military cooperation, differences in organizational cultures and financial and human resources, and insights into resolving inter- and intraorganizational concerns.
Building Collaboration
Following a governmental directive in May 2020, the HFC was assigned to be the national COVID-19 operator. The PHD continued to lead COVID-19 pandemic response efforts and undertake supervision and regulatory responsibilities. After 3 months of preparation, including recruiting staff, preparing modes of operation, and planning staff involvement, the COVID-19 headquarters of the HFC started functioning in November 2020 with a mission to break the chain of COVID-19 transmission. The HFC recruited nearly 3000 conscripted soldiers and reservists from various logistic areas who were assigned to 1 of 4 subdivisions: (1) epidemiological investigations, (2) testing, (3) shipping and handling of COVID-19 samples, and (4) preparing and managing quarantine facilities.
Contact tracing was performed by soldiers who were trained and supervised by experienced PHD nurses. Patients’ responses to the medical interviews were recorded electronically, and both patients and their contacts were instructed to self-isolate and given recommendations for further testing schedules. The testing unit instituted and operated multiple testing centers countrywide and at border crossings, according to the PHD directives and in line with hot spots of COVID-19 illness (see the description of the national data repository hereinafter). The shipping unit was responsible for safeguarding cold-chain deliveries of the samples from testing sites to laboratories, corresponding with the alternating capabilities of the laboratories performing COVID-19 testing across the country. The quarantine unit operated designated isolation hotels that lodged COVID-19 patients who could not isolate themselves at their own premises. The headquarters of the HFC was also supported by military intelligence officers, information technology experts, and a liaison officer (Z.M.) who coordinated the operation between the HFC and the PHD.
Setting the national data repository was an additional challenge faced by the 2 organizations. The national data repository was used to collect and merge information from epidemiological investigations, COVID-19 testing results, and vaccination status. This data repository played a crucial role in the ability of the PHD to evaluate the daily incidence and mortality of COVID-19 and facilitated timely, data-driven decision-making.
The decision to merge forces between the PHD and the HFC was based on the relative advantage of each partner. The PHD has been controlling infectious diseases countrywide for many years by monitoring infectious and noncommunicable diseases, analyzing data, understanding the needs of local populations, and responding in a culturally sensitive way. The PHD’s strengths also include tight interorganizational links, connections with other health care providers and hospitals, continuous communication with municipalities, and the ability to collaborate with other external organizations. The HFC as a military unit is a dynamic, flexible, integrative, innovative organization. The HFC’s strengths also include logistical capabilities, operational skills, and the ability to move deployable manpower and equipment swiftly and efficiently. The HFC was supported by high-level intelligence and information technology capabilities and was budgeted appropriately to support its mission. The HFC’s experience with civilian populations in controlling natural disasters in Israel and other countries was an additional advantage.
Each organization also has its drawbacks. For example, the PHD, as part of the public sector, is characterized by inflexible civilian bureaucracy, limited resources, a tight budget, and limited staff ability to respond quickly to alternating or urgent needs. The PHD workforce is relatively older than soldiers in the HFC. Disadvantages of the HFC included high staff turnover and limited long-term planning capabilities.
The synthesis of the operation between the 2 organizations required mutual understanding at all levels while maximizing the essential capabilities of the PHD and the HFC toward boosting the national response to the COVID-19 pandemic.
Attributes That Favor Collaboration
Chain of command
Both the PHD and the HFC are top-down organizations. The health system in Israel is centralized, and during health emergencies such as the COVID-19 pandemic, the Ministry of Health is responsible for strategic planning, governing, regulating, and coordinating the national response of the entire health care system and allocating human resources and budget. On a smaller scale, clinical teams inherently work hierarchically in health care settings.
The HFC is a “mission command” military division. In other words, the interorganizational decisions of the senior officers are formulated into the actions of the subordinates and compliance, ensuring that orders to respond to the COVID-19 pandemic are followed.
Acquaintance with the counterorganizational culture
Israel has been under a constant security threat, and many of the PHD workforce conscript to the IDF as soldiers for their mandatory service or reservists after they have been discharged from compulsory service.
At the HFC, many enlisted personnel were reservists who were familiar with the challenges of the civilian health system. The HFC is entrusted with civil defense, especially during a state of emergency, and as a civilian-oriented branch of the army, it is experienced with population behaviors.
Sense of urgency
The threat of COVID-19, with its unprecedented health, financial, and social toll, increased the sense of solidarity in working together to save lives. Both partners shared the feeling of being part of a greater national effort and striving to achieve a common goal.
Attributes That Did Not Favor Collaboration
Organizational culture
The HFC comprises young, mainly male soldiers who are assigned a mission and lead autonomous efforts to achieve it. However, while being part of a collaboration with the PHD, they could not complete all duties alone because they lacked the required professional knowledge. The workforce of the PHD, comprising professional, mainly older, females, had to balance family duties and work responsibilities.
At times, the relatively “macho” environment at the HFC made it difficult for military personnel to face criticism or manage disagreements. Even the rhetoric used by military personnel emphasized their cultural differences. For example, the HFC applied military battlefield metaphors, such as “combating” COVID-19, “nailing” a date, “killing” a mission, and “terminating” the germ, when referring to the COVID-19 pandemic.
Loss of professional position
The PHD shared its knowledge and experience with the HFC in conducting epidemiological investigations. The HFC, with its abundant workforce, took the forefront and was portrayed by the media as the nation’s savior, while the PHD workforce felt underappreciated.
A different business plan
The PHD provides long-standing, adoptable plans that focus on continuous health protection of the population as being part of the public sector. The PHD’s strategic plan focuses on long-term planning to ensure a high level of vaccine coverage, achieve health promotion interventions, and foster compliance with health messages. Trust building is therefore a critical domain in the interactions between the public and the PHD. On a broader scale, concerns were raised about being too dependent on the armed forces for disaster relief and disincentives to upgrade the civil infrastructure to be better equipped to respond to future catastrophic events.
The HFC was expected to present swift results to justify the resources spent, and, therefore, the goals were set as short- or medium-term missions. The mutual efforts of the PHD and the HFC had to be synchronized to allow each organization to demonstrate expertise.
Social acceptance and the consequences of militarization
Citizens are accustomed to getting their routine health care from physicians or nurses in medical settings. The army is viewed as a different entity than usual health care providers. As the HFC became involved in COVID-19 operations, civilians were contacted by soldiers who performed contact tracing and met the soldiers in testing sites, vaccination centers, and isolation hotels.
From a wider perspective, the involvement of the HFC, as a uniformed army branch, could have jeopardized the delicate balance in military–civilian relations and been conceptualized as a threat to democratic rule. These relations are more sensitive among the Arab population, who comprise approximately 25% of the Israeli population, and among the small community of irregular migrants who stay in Israel without a legal permit. Concerns were raised that the HFC’s coerced assignments, such as recommending isolation, enforcing lockdowns, and using electronic methods to follow COVID-19 patients and their contacts, could provoke mistrust or antagonism. Therefore, it was important to clarify that the HFC’s role was to support the logistics of the operation rather than lead the national COVID-19 policy. The possible loss of solidarity in the community may have resulted in an uncooperative response or amplified the tension between the civilian population and the army.
Macro-fiscal level
The workforce of the PHD is understaffed, and its budget is constrained. The support of the HFC in the national response was required to allow large-scale operations. However, the cost of establishing and maintaining this temporary mission of the HFC for 2 years of the COVID-19 pandemic was substantial. It is possible that an alternative future investment in strengthening the PHD’s infrastructure could improve its professional response to health challenges, either for routine or unexpected health threats.
Public Health Implications
The interagency civil–military cooperation required strong leadership skills from each partner to galvanize and coordinate the missions and persuade subordinates that merging forces would achieve the best results. The civil–military leadership also internally restrained the operational autonomy of the HFC. Interestingly, the terms of cooperation between the PHD and the HFC were not rigidly formalized in a signed contract, which left room for flexibility. However, the shared values and common commitment provided a strong foundation for establishing interorganizational personal contacts, synchronizing planning, and building mutual solidarity and cross-agency trust.
Several other countries engaged the armed forces (eg, army, police, national guard) to respond to the COVID-19 pandemic. Major differences in the extent of involvement were related to the scale of disaster, the goals set by the armed forces, and the context in which the armed forces were used. The allocation of military capabilities to national response varied from minimal technical support (Japan, New Zealand, Canada) to blended civil–military response (United States, China, Singapore) and to military-led response (Brazil, Iran, Peru).6,7 Countries also varied in the way they deployed their military forces. The French military, for example, deployed equipment and staff to treat COVID-19 patients, 8 whereas Israel used the HFC for logistical support and epidemiological investigations.
The COVID-19 pandemic presented a challenge to Israeli society and its health system and offered new opportunities for a collaboration in command and control between military and civilian authorities. The civil–military cooperation combined the advantages and capabilities of the PHD and the HFC in augmenting the national response to the COVID-19 pandemic. The integration between the 2 partners was not trivial and unfolded insights for policy makers into potential pathways for closer amalgamation of subordinates, who nevertheless worked to achieve the same goal. Managers and subordinates from each organization had to demarcate responsibilities, define the boundaries between accountability and authority, and formalize channels to facilitate successful cooperation. At the interpersonal level, teams had to build mutual trust and understanding. Unity of efforts, shared values, and common experiences further fortified the informal personal interlinks.
Successful civil–military collaboration in managing future crises requires using trusted interorganizational relationships; creating mutual administrative activities with similar goals and planning; facilitating interaction through meetings, discussion, training, and practical work; increasing mutual research and teaching activities to intensify interest; sharing data; and informing the public about the need for civil–military cooperation. 9
Although military involvement in the civil health system may not be commonly used during routine times, civil–military and other multisectoral cooperation can amplify the response to unprecedented extensive national threats and increase civilian preparedness and community resilience.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
