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Health

NIH director says new Israel information is constructing case within the U.S.

New data from Israel on the effectiveness of Covid-19 vaccines over time is causing U.S. health leaders to rethink their position on vaccine booster shots in the U.S., National Institutes of Health Director Dr. Francis Collins said Tuesday.

“The people who got immunized in January are the ones that are now having more breakthrough cases,” Collins said during an interview on “The Hugh Hewitt Show,” referring to Covid infections in fully vaccinated individuals. Israel released new data Monday showing a reduction in the effectiveness of Pfizer’s Covid vaccine against severe illness among people 65 and older who were fully vaccinated in January or February.

NIH Director Fr. Francis Collins holds up a model of the coronavirus as he testifies before a hearing looking into the budget estimates for National Institute of Health (NIH) and the state of medical research on Capitol Hill in Washington, DC on May 26, 2021.

Sarah Silbiger | AFP | Getty Images

Collins said the rise in so-called breakthrough cases in Israel is likely due to a combination of the highly contagious delta variant and Covid vaccine protection waning over time.

“Mostly, of course, these are symptomatic, but not serious,” he said. “But you’re starting to see a little bit of a trend toward some of those requiring hospitalization.”

Collins’ comments come as federal health officials are expected to recommend that most people in the U.S. who are eligible for Covid vaccinations should get booster shots eight months after their second doses.

The federal guidance, which would apply only to the two-shot Pfizer and Moderna vaccines, could go into effect as early as mid-September, pending FDA authorization, a person familiar with the discussions told CNBC.

The New York Times reported Monday that federal health officials are particularly concerned about data from Israel, where Covid vaccinations began ahead of many other countries. The data reportedly showed that for people vaccinated in January who are age 65 and older, the Pfizer vaccine was less than 55% effective against severe disease and hospitalization.

Collins said Tuesday that federal officials are starting to see the same thing in U.S. data.

“Although right now, it still as if our vaccine protection is working really well,” he said. “But we don’t want to wait until it’s like oh, too late. So that’s why we’re looking at the data.”

Up until now, federal officials haven’t recommended booster doses for the general public. On Friday, they approved administering Covid booster shots of Pfizer’s and Moderna’s vaccines to Americans with weakened immune systems, which includes cancer and HIV patients and people who have had organ transplants.

Covid vaccine makers, including Pfizer and Moderna, have repeatedly contended that everyone will eventually need a booster shot and potentially extra doses every year, just like for the seasonal flu.

The NIH, Food and Drug Administration and the Centers for Disease Control and Prevention released a joint statement Tuesday saying they have a “rigorous process” to determine when boosters would be necessary.

“This process takes into account laboratory data, clinical trial data, and cohort data – which can include data from specific pharmaceutical companies, but does not rely on those data exclusively,” the agencies said. “We continue to review any new data as it becomes available and will keep the public informed.”

On Monday, Pfizer and BioNTech said they have submitted early stage clinical trial data to the FDA as part of their U.S. application seeking authorization of a Covid vaccine booster for everyone 16 and older. The companies said they would seek approval for a booster dose via a supplement to their application once the agency grants the vaccine full approval.

If the booster shots are approved, the U.S. would likely vaccinate nursing homes, health-care providers and the elderly first, Collins said Tuesday. He said “ideally” people should stick with the same manufacturer they got their first two doses from.

“But if for some reason you don’t have access to it, well, then get the other one,” he said. “Again, I’d feel more comfortable as a scientist fixing our plans on real data, and that means sticking to the same kind of vaccine that you got to begin with.”

–CNBC’s Tom Franck contributed to this report.

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Health

Israel to provide Pfizer Covid booster pictures to aged

A man receives his third dose of COVID19 vaccine at Sheba Medical Center on July 14, 2021 in Ramat Gan, Israel.

Amir Levy | Getty Images

Israeli health officials plan to offer booster shots of the Pfizer-BioNTech Covid-19 vaccine to people over age 60 as the shot’s effectiveness appears to wane as the delta variant spreads across the world, NBC News confirmed Thursday.

The heads of health maintenance organizations that have been administering the Pfizer vaccine will begin administering third shots Sunday, according to NBC News. The booster shots are available for patients above 60 who have already received their second shot at least five months earlier.

The country’s Health Ministry reported last week that the two-dose vaccine is now just 39% effective in Israel where the highly transmissible delta variant is the dominant strain. The shot still works very well in preventing people from getting seriously sick, Israeli officials said, demonstrating 88% effectiveness against hospitalization and 91% effectiveness against severe illness.

The data out of Israel, which began vaccinating its population ahead of many other countries, is bolstering arguments from drugmakers that people will eventually need to get booster shots to protect against emerging variants.

Pfizer CEO Albert Bourla on Wednesday doubled down on his comments that people will need a third dose of the vaccine to maintain its high level of protection against the virus. The U.S. drugmaker published new data Wednesday from a company-funded study that showed the vaccine’s efficacy dropped to about 84% after four to six months.

“We have seen also data from Israel that there is a waning of immunity and that starts impacting what used to be what was 100% against hospitalization. Now, after the six-month period, is becoming low 90s and mid-to-high 80s,” Bourla said on CNBC’s “The Exchange.”

The Centers for Disease Control and Prevention, the Food and Drug Administration and the World Health Organization have said they don’t recommend Covid booster shots at this time, citing a lack of data. U.S. and world health officials have said they are looking at the Israeli research, which was not peer-reviewed and was scant on details.

“We have to be mindful that, with time, the effectiveness of these vaccines may wane,” Dr. Isaac Bogoch, an infectious disease professor at the University of Toronto, said in a recent interview.

He stressed that the shots still appear to be highly effective in preventing severe infection, helping hospital systems not get too overwhelmed heading into the colder months. That being said, “we’re still in the Covid era and anything can happen,” he said.

“We have to be prepared and we have to be nimble that people may need a booster at some point,” he added. “This close surveillance that’s happening in countries like Israel, the U.K. and other parts of the world is going to be very helpful in driving policy if and when we do need boosters.

Israel’s plans to boost its population come two days after the CDC reversed course on its prior guidance and recommended fully vaccinated Americans who live in areas with high Covid infection rates begin to wear face masks indoors again. The guidelines cover about two-thirds of the U.S. population, according to a CNBC analysis.

While the delta variant is hitting unvaccinated people the hardest, some vaccinated people could be carrying higher levels of the virus than previously understood and are potentially transmitting it to others, CDC Director Dr. Rochelle Walensky said Tuesday.

Walensky added new data shows the variant behaves “uniquely differently from past strains of the virus,” indicating that some vaccinated people infected with the delta variant “may be contagious and spread the virus to others.”

“This pandemic continues to pose a serious threat to the health of all Americans,” Walensky told reporters on a call. “Today, we have new science related to the delta variant that requires us to update the guidance regarding what you can do when you are fully vaccinated.”

– CNBC’s Kevin Stankiewicz contributed to this report.

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Health

Pfizer Covid vaccine 39% efficient in Israel, prevents extreme sickness

People will be given a dose of the Pfizer BioNTech Covid-19 vaccine at a Covid-19 mass vaccination center on Rabin Square in Tel Aviv, Israel on Monday January 4, 2020.

Kobi Wolf | Bloomberg | Getty Images

Pfizer and BioNTech’s Covid-19 vaccine is only 39% effective in Israel, where the Delta variant is the dominant strain, but still offers strong protection against serious illness and hospitalization, according to a new report from the country’s health ministry.

The efficacy figure, based on an unspecified number of people between June 20 and July 17, is down from a previous estimate of 64% two weeks ago and is in conflict with data from the UK that showed the Vaccination was 88% effective against symptoms, disease caused by the variant.

However, the two-dose vaccine still works very well in preventing serious illness, showing 88% effectiveness against hospitalization and 91% effectiveness against serious illness, according to Israeli data released Thursday.

“We have to keep in mind that these vaccines can become less effective over time,” said Dr. Isaac Bogoch, professor of infectious diseases at the University of Toronto.

He stressed that the syringes are still highly effective in preventing serious infections and helping hospital systems not get overwhelmed in the colder months. “We are still in the Covid era and anything can happen,” he said.

“We have to be prepared and we have to be agile that at some point people will need a booster,” he added. “This close monitoring, which is happening in places like Israel, the UK and other parts of the world, will be very helpful in moving policy forward when and when we need boosters.”

The Delta variant, which is already present in more than 104 countries, worries US health officials as they detect more breakthrough infections in fully vaccinated people, even though they are milder.

The Chief Medical Officer of the White House, Dr. Anthony Fauci said people who are fully vaccinated should consider wearing masks indoors as a precaution against the rapidly spreading variant in the US

“Of course we don’t want to see that,” said Fauci on Wednesday, referring to the so-called breakthrough infections. “This virus is very different from the viruses and variants that we have previously experienced. It has an exceptional ability to transmit from person to person.”

Dr. Paul Offit, who advises the FDA on Covid vaccines, said that while the vaccines still offer great protection against serious illness and death, they may not work as well against mild cases or the transmission of the disease to others.

He urged more Americans to get vaccinated, saying Delta was a highly contagious virus and the vaccinations would help people get seriously ill. Currently, less than half of the US population is fully vaccinated, according to data compiled by the CDC.

“This is rich and fertile soil for the virus to continue to reproduce and keep creating variants that may become increasingly resistant to vaccines or natural infections,” he said.

The report from Israel, which began vaccinating its people before many other countries, is likely to back up the arguments made by drug manufacturers that people will eventually need to be given a booster to protect themselves from new variants.

Pfizer said earlier this month that immunity is waning from its two-dose vaccine and is now planning to seek approval from the Food and Drug Administration for a booster dose. However, federal officials say that fully vaccinated Americans do not currently require additional vaccinations.

In a statement to CNBC, Pfizer said it remains confident that its two-dose regimen will protect against the coronavirus and its variants.

Still, it said a third dose might help after analysis from its Phase III study showed a decrease in effectiveness against symptomatic infections after four to six months.

“Initial data from a third dose of the current vaccine shows that a booster dose given at least 6 months after the second dose induces high neutralization titers against wild-type and beta that are 5 to 10 times higher than after two primary doses. “Said the company.

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Health

Israel, UAE, Bahrain vaccination and an infection traits

Two women in face masks walk along a shopping area on April 19, 2021 in Dubai, United Arab Emirates.

Francois Nel | Getty Images News | Getty Images

Vaccination campaigns in several Middle East nations raced ahead of the rest of the world at the beginning of 2021.

Israel, the United Arab Emirates and Bahrain topped the list when it came to doses administered per 100 people at the start of the year.

Six months later, all three are still among the top 10 most vaccinated countries — but charts show their Covid infection trends have varied greatly.

As of June 29, 57.8% of Bahrain’s population were fully vaccinated and 59.7% of Israel’s residents received both doses of the Covid vaccine, according to Our World in Data. The UAE’s data on fully vaccinated individuals was last updated on April 20, when the figure stood at 38.8%.

Israel

Israel’s new daily cases plummeted as its vaccination program ploughed on, and data showed that infections remained largely in the low double-digits for more than a month since the end of April. That was so until a resurgence emerged in late June.

Caseloads are a fraction of previous peaks, but have risen rapidly in recent days.

The highly contagious delta variant is responsible for about half the new cases, according to Nadav Davidovitch, chair of the Israeli Association of Public Health Physicians.

Still, simulations predict that even with “widespread transmission,” there will only be several hundred severe cases, he told CNBC via video call. “Not like it used to be in the third wave,” he added, referring to the spike that began late last year.

UAE

The United Arab Emirates ranks number one in terms of total doses administered per 100 people, according to Our World in Data. But new infections in the country have stubbornly hovered around 2,000 per day.

Cases have fallen from the record highs reported in January, and temporarily dipped to the mid-1,000 level in May, but have otherwise mostly stayed around the same region.

Still, the cases now remain higher than the average daily cases of about 1,200 reported in the fourth quarter of 2020.

The UAE’s National Emergency Crisis and Disaster Management Authority in May announced that it would be offering a third dose of China’s Sinopharm vaccine. It came amid questions over the efficacy of the vaccine as there were reports of infections in individuals who had received two shots.

The country later said those inoculated with Sinopharm’s vaccine can receive the Pfizer-BioNTech shot as a booster, Reuters reported.

Bahrain

Infections in Bahrain hit record highs in late May even though vaccinations were well underway in the country.

According to Our World in Data, the kingdom reported 3,273 new cases on May 29.

At that point, more than 911,000 people in Bahrain had already received at least one dose of a Covid vaccine. It has a population of around 1.76 million people.

New daily cases have since fallen to the hundreds.

Bahrain is also offering third doses of Sinopharm’s vaccine. Booster shots of the Pfizer-BioNTech vaccine are available to more vulnerable groups such as those above the age of 50, three months after they receive a second dose of Sinopharm.

Deaths attributed to Covid

Infections are not the only indicator of a country’s coronavirus situation, and vaccinations are not the only factor at play.

Besides inoculation, a country’s demographics and Covid restrictions also play a part in the severity of illness and how quickly the virus spreads.

Deaths in Israel and the UAE have fallen and stayed low, while daily new Covid-related deaths per million in Bahrain went as high as 17 in June.

Are Covid spikes a concern?

The outbreaks in the Middle East countries are not worrying, said Paul Tambyah, president of the Asia Pacific Society of Clinical Microbiology and Infection.

“I do not think that we should be too concerned,” he told CNBC in an email. “The majority, or at least a significant proportion of cases have reportedly been in those who have not been vaccinated.”

“The main concern is that it does not look like we can get away without vaccinating a very significant proportion of the population,” he said.

I think that as long as the virus is circulating globally and borders remain open, there will be occasional outbreaks of the virus even in highly vaccinated populations.

Paul Tambyah

Asia Pacific Society of Clinical Microbiology and Infection

Virus clusters expected

High vaccination rates will not rule out clusters of cases in future, medical experts said.

“I think that as long as the virus is circulating globally and borders remain open, there will be occasional outbreaks of the virus even in highly vaccinated populations,” said Tambyah.

Davidovitch said “localized outbreaks” among children who are not vaccinated will probably continue.

He said it’s “hard to tell” if a reliance on Chinese vaccines — as seen in the UAE and Bahrain — may be linked to dramatic spikes in Covid cases.

Tambyah noted that Israel, which has used mainly Pfizer vaccines, is seeing a resurgence in cases as well.

He said there are no scientific publications comparing traditional vaccines developed by China against vaccines that rely on messenger RNA technology, which instructs the body to produce a harmless piece of the virus that helps trigger an immune response.

“I think that, unfortunately, higher vaccination rates are required,” Tambyah said.

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World News

Israel Parliament votes in new authorities, ending Netanyahu rule

Israeli Prime Minister Benjamin Netanyahu.

ABIR SULTAN | AFP | Getty Images

The Israeli parliament, the Knesset, approved its new government – and for the first time in 12 years a new prime minister – with a wafer-thin 60:59 votes on Sunday.

The vote that ushered in the leadership of a very diverse and cobbled together coalition of right, left, centrist and Islamist parties ousted Israel’s longest-serving leader, Benjamin Netanyahu. It also saves Israel the prospect of a fifth election in less than two years.

Now, after fighting back and trying several policy options to stay in power, Netanyahu will step aside and Israeli tech millionaire and lawmaker Naftali Bennett, whom many consider more right-wing predecessor, to take over as prime minister.

Sunday’s Knesset vote was shrouded in chaos and derision as some right-wing lawmakers, including those of Netanyahu’s Likud party, insulted Bennett, calling him a “traitor” and “liar” for the alliance with left and Arab parties. At least four politicians were kicked out of the meeting by spokesman Yariv Levin.

Bennett, a former Netanyahu adviser, continued his pre-vote speech amid the heckling heckling, praising Netanyahu as “working hard and faithfully for the State of Israel”. But he also pushed for the need for new leadership.

“We stopped the train at the edge,” said Mr. Bennett. “It is time for various leaders from all parts of the people to stop trying to stop this madness.”

In a statement, US President Joe Biden congratulated Bennett and other leaders of the new administration and cabinet.

“I look forward to working with Prime Minister Bennett to strengthen all aspects of the close and lasting relationship between our two nations. Israel has no better friend than the United States working closely together, and as we continue to strengthen our partnership, the United States remains steadfast in its support for Israel’s security. “

‘We’ll be back soon’

The 71-year-old right-wing leader is a lightning rod in its twelfth year and has long been a dividing line in Israeli society. An Israeli expert told CNBC that the country’s last elections in March – the fourth in less than two years due to the complex and polarized nature of Israeli politics – really came down to whether the country wanted “Bibi or no Bibi”. where the outgoing Prime was used became the minister’s popular nickname.

Speaking to the Knesset in English, Netanyahu said: “We’ll be back soon.”

“If we have to be in the opposition, we will keep this up – until we overthrow this dangerous government and return to run the state,” he said in a defiant address, saying he spoke for millions of Israelis who are for him have voted.

A combination of file photos shows Israeli Education Minister Naftali Bennett giving a speech in Jerusalem on May 14, 2018, and Yesh Atid Party leader Yair Lapid giving a speech in Tel Aviv, Israel, on March 24, 2021.

Ammar Awad; Amir Cohen | Reuters

He also slammed a bill proposed by the new government that would limit a prime minister’s term to eight years, four years less than his term in office.

Netanyahu himself faces several allegations of corruption, which he denies. He had been looking for ways to avoid prosecution, which would have been a lot easier if he had stayed in power. Meanwhile, he can still remain the leader of the Likud party.

The outgoing prime minister attracted international criticism and attention for his persistent military action against Gaza in May, in which Israeli air strikes killed more than 250 Palestinians, including 66 children, in response to rocket volleys by Hamas that killed Israel during course 12 of the fighting .

Future challenges

The new coalition that is now taking power is led by centrist lawmaker Yair Lapid, a former television presenter and former finance minister and head of the Yesh Atid party, and his unlikely government partner, Naftali Bennett, who leads the minority Yamina party.

It is very unusual for a minority party leader to become prime minister, but that was what it took Bennett to join Lapid’s coalition – and his alliance with Lapid was the only way the coalition could get enough Knesset seats to hold one To have majority.

So the deal for Lapid and Bennett is based on the agreement that Bennett will become Prime Minister by 2023, with centrist Lapid as Secretary of State. At this point, if the party alliance survives, Lapid will assume the office of prime minister.

It is also the first time in Israeli history that its government includes an Arab party that aims to represent the country’s 21% Arab minority.

The government is expected to focus on social and economic issues that foster consensus among its disparate members rather than divisive ones such as the Israeli-Palestinian conflict and Palestinian statehood.

But there are serious challenges ahead. The fragile coalition between Lapid and Bennett and the parties whose support they had to win to achieve the magic number of a majority of 61 seats in the Knesset is a risk to itself, analysts say. The only thing that seems to hold them together is a shared desire to take Netanyahu off the bench. But because of the incredibly narrow majority of 61 seats in the 120-member parliament, it would only take one move for the government to collapse.

And in view of the sometimes extreme differences of opinion between the parties, especially between right-wing and Islamist politicians in Israel, this danger of standstill and collapse remains a constant threat.

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Politics

Historical past-Making Vote on Israel Coalition Comes With a Skinny Margin

The political fate of Israel’s longest serving leader, Benjamin Netanyahu, is set to be decided on Sunday afternoon, when Parliament will hold a vote of confidence in a new government that would topple Mr. Netanyahu from power for the first time in 12 years.

Mr. Netanyahu’s opponents hope that the vote, if it passes, will ease a political stalemate that has produced four elections since 2019 and left Israel without a state budget for more than a year. It will also end, at least for now, the dominance of a politician who has shaped 21st-century Israel more than any other, shifted its politics to the right and overseen the fizzling of Israeli-Palestinian peace negotiations.

Mr. Netanyahu is set to be replaced by his former chief of staff and now political rival, Naftali Bennett. A former high-tech entrepreneur and settler leader, Mr. Bennett opposes a Palestinian state and believes Israel should annex much of the occupied West Bank.

If confirmed by Parliament, Mr. Bennett would lead an ideologically diffuse coalition that is united only by its antipathy toward Mr. Netanyahu. The bloc ranges from the far left to the hard right and includes — for the first time in Israeli history — an independent Arab party.

On Sunday, one hard-right lawmaker was considering whether to resign from his party, but still vote for the coalition. And an Arab lawmaker was debating whether to abstain in the vote.

If it holds, the coalition will control just 61 of Parliament’s 120 seats, and its fragility has prompted many commentators to wonder whether it can last a full term. Should it hold until 2023, Mr. Bennett will be replaced as prime minister by Yair Lapid, a centrist former television host, for the remaining two years of the term.

The parliamentary session to confirm the new government is scheduled to begin at 4 p.m. local time. Mr. Bennett is expected to speak first, followed by Mr. Lapid and then Mr. Netanyahu.

Parliament is then expected to vote for a new speaker — likely to be Mickey Levy, from Mr. Lapid’s centrist party — and finally for the government itself. If the vote passes, the government will be sworn in immediately, formally replacing Mr. Netanyahu’s administration.

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World News

Deliberate Israel Coalition Brings Palestinians Aid however No Rejoicing

The agreement on a coalition that would oust Prime Minister Benjamin Netanyahu and include an Arab party in government has prompted indignation and relief in roughly equal measure among Palestinian citizens of Israel.

Indignation because Naftali Bennett, who will become prime minister until 2023 if Parliament approves the proposed eight-party coalition, is a right-wing leader aligned with religious nationalists in strong opposition to a Palestinian state.

Relief because Mr. Netanyahu, while sometimes courting Israeli Arabs of late, has often used their presence to generate fear among his base, famously warning in 2015 that they were voting “in droves.” He has fanned division where possible and declared that Israel is “the nation-state, not of all its citizens, but only of the Jewish people.”

These provocations, and the passing of a nation-state bill in 2018 that said the right to exercise self-determination was “unique to the Jewish people,” contributed to the anger evident in violent confrontations in several cities last month between Arabs and Jews.

That a small Arab party known by its Hebrew acronym, Raam, agreed to join the government so soon after the clashes reflected a growing realization that marginalization of Arab parties brings only paralysis. It also suggested a desire among some Palestinians citizens, who account for 20 percent of the Israeli population, to exert more political influence.

Raam, with four seats in the current Parliament, would be the first independent Arab party in an Israeli government, although it would not have any cabinet members.

“I do not think that the two-state solution or reconciliation with the Palestinians will be achieved in the coming year or two,” said Jafar Farah, the director of the Mossawa Center, an advocacy group for Arab citizens of Israel. “But I do think that it is an opportunity for the Palestinian community in Israel to become a game changer.”

Others were more sceptical. “I have debated Bennett, and he says quite openly, ‘You are not my equal,’” said Diana Buttu, a prominent Palestinian lawyer based in Haifa. “Did I want Netanyahu out? Yes. To the extent of wanting Bennett as prime minister? No.”

Alluding to Mansour Abbas, the leader of the small Arab party that signed an agreement to join the government, she added: “He has done this to make his mark, but he will not get anything. He is effectively backing a government led by an ultranationalist who wants to expand settlements.”

How Mr. Bennett would exercise power in a coalition with many members well to the left of him, including the chief architect of the agreement, Yair Lapid, remains unclear. But Mr. Netanyahu’s hold on Israeli society and the Israeli imagination has been such over the past dozen years that his eventual departure inevitably seems synonymous with new possibility.

Commenting in the newspaper Yedioth, Merav Batito wrote: “Abbas’ signature is much more than a formal token of agreement. It symbolizes the possibility of a return to normalcy of Israeli society.” She added, “The first concrete wall built between Arabs and Jews by the Parliament deep in Israeli society has been breached.”

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Netanyahu’s Problem: Israel Dwell Updates

Here’s what you need to know:

Credit…Ronen Zvulun/Reuters

JERUSALEM — Israeli opposition parties on Wednesday reached a coalition agreement to form a government and oust Benjamin Netanyahu, the longest-serving prime minister in Israeli history and a dominant figure who has pushed his nation’s politics to the right.

The announcement by the parties could lead to the easing of a political impasse that has produced four elections in two years and left Israel without a stable government or a state budget. If Parliament ratifies the fragile agreement in a confidence vote in the coming days, it will also bring down the curtain, if only for an intermission, on the premiership of a leader who has defined contemporary Israel more than any other.

The new coalition is an unusual and awkward alliance between eight political parties from a diverse array of ideologies, from the left to the far right. It includes the membership of a small Arab party called Raam, which would become the first Arab group to join a right-leaning coalition in Israeli history.

While some analysts have hailed the coalition as reflecting the breadth and complexity of contemporary society, others say its members are too incompatible for their compact to last, and consider it the embodiment of Israel’s political dysfunction.

The alliance would be led until 2023 by Naftali Bennett, a religiously observant former settler leader who opposes a Palestinian state and wants Israel to annex the majority of the occupied West Bank. He is a former ally of Mr. Netanyahu often described as more right-wing than the prime minister.

If the government lasts a whole term, it would then be led between 2023 and 2025 by Yair Lapid, a centrist former television host considered a standard-bearer for secular Israelis.

The son of American immigrants, Mr. Bennett, 49, is a former software entrepreneur, army commando, chief of staff to Mr. Netanyahu and defense minister. His home is in central Israel, but he was once chief executive of an umbrella group, the Yesha Council, that represents Jewish settlements in the occupied West Bank. Until the most recent election cycle, Mr. Bennett was part of a political alliance with Bezalel Smotrich, a far-right leader.

Though Mr. Bennett’s party, Yamina, won just seven of the 120 seats in Parliament, the anti-Netanyahu forces could not form a government without his support, allowing him to set the terms of his involvement in the coalition.

Mr. Lapid, 57, is a former news anchor and journalist who became a politician nine years ago and later served as finance minister in a Netanyahu-led coalition. His party placed second in the general election in March, winning 17 seats. But Mr. Lapid considered the ouster of Mr. Netanyahu more important than demanding to go first as prime minister.

Credit…United Arab List Raam, via Agence France-Presse — Getty Images

Yair Lapid, the leader of the Israeli opposition, had until midnight on Wednesday to cobble together an unlikely coalition to topple Benjamin Netanyahu. He needed almost every minute — leaving it until 11:22 p.m. to inform Reuven Rivlin, Israel’s largely ceremonial president, that he had assembled an eight-party alliance.

“The government will do everything it can to unite every part of Israeli society,” Mr. Lapid said in a statement released shortly after his call with Mr. Rivlin.

Mr. Lapid’s celebrations will be put on hold for several days, however. The Speaker of the Israeli Parliament, Yariv Levin, is a member of Mr. Netanyahu’s party, Likud, and can use parliamentary procedure to delay the confidence vote until Monday, June 14, constitutional experts said.

In the meantime, Mr. Netanyahu’s party has promised to pile pressure on wavering members of Mr. Lapid’s fragile coalition, formed of hard-right parties, leftists, centrists and Arab Islamists, in a bid to persuade them to abandon the coalition. Many of them already feel uncomfortable about working with each other, and have made difficult compromises to join forces in order to push Mr. Netanyahu from office.

Mr. Lapid himself agreed to give Naftali Bennett, a hard-right former settler leader who opposes Palestinian statehood, the chance to lead the government until 2023, at which point Mr. Lapid will take over.

In a sign of the friction to come, Raam, the Arab Islamist party, announced that it had joined the coalition after receiving assurances about improvements to the Arab minority’s land and housing rights that many hard-right Israelis deem unacceptable, including the regularization of three illegally constructed Arab towns in the Negev desert.

An hour before the deal was announced, one hard-right lawmaker, Nir Orbach, whose party colleagues say he has been particularly unsure about joining the coalition, tweeted: “We are not abandoning the Negev. Period.”

The fact that these tensions were on full display even before the coalition was officially formed has left many Israelis wondering whether it will last more than a few months, let alone its full term.

Should the coalition collapse, analysts believe Mr. Lapid may emerge with more credit than Mr. Bennett. While Mr. Bennett gets first crack at the premiership, his decision to work with centrists and leftists has angered his already small following.

“Lapid has made a very strong set of decisions, conveyed an amazing level of maturity and really made a big statement about a different kind of leadership,” said Dahlia Scheindlin, an Israeli political analyst and pollster at the Century Foundation, a New York-based research group. “That will not be lost on the Israeli public.”

Credit…Gil Cohen-Magen/Agence France-Presse — Getty Images

Now that opposition parties have reached agreement on a coalition government, it has up to seven days to present the government to Parliament for a vote of confidence.

Some disagreements within the fractious coalition were still being ironed out until shortly before the deadline on Wednesday, at midnight in Israel.

And with the fate of the new coalition dependent on a narrow margin and hanging on every single vote, Prime Minister Benjamin Netanyahu and his allies were on the hunt for potential defectors leading up to the announcement, and signaled that they would continue until the vote of confidence.

The coalition, ranging from right to left, is united primarily by its opposition to Mr. Netanyahu, the prime minister since 2009.

Israel has held four parliamentary elections in two years, all of them inconclusive, leaving it without a stable government or state budget. If the opposition fails to form a government, it could lead to yet another election.

Credit…Sebastian Scheiner/Associated Press

Naftali Bennett, who is poised to become Israel’s next prime minister, is a former high-tech entrepreneur best known for insisting that there must never be a full-fledged Palestinian state and that Israel should annex much of the occupied West Bank.

The independently wealthy son of immigrants from the United States, Mr. Bennett, 49, first entered the Israeli Parliament eight years ago and is relatively unknown and inexperienced on the international stage. That has left much of the world — and many Israelis — wondering what kind of leader he might be.

A former chief of staff to Prime Minister Benjamin Netanyahu, Israel’s longest-serving prime minister, Mr. Bennett is often described as more right-wing than his old boss. Shifting between seemingly contradictory alliances, Mr. Bennett has been called an extremist and an opportunist. Allies say he is merely a pragmatist, less ideological than he appears, and lacking Mr. Netanyahu’s penchant for demonizing opponents.

In a measure of Mr. Bennett’s talents, he has now pulled off a feat that is extraordinary even by the perplexing standards of Israeli politics. He has all but maneuvered himself into the top office even though his party, Yamina, won just seven of the 120 seats in the Parliament.

Mr. Bennett leveraged his modest but pivotal electoral weight after the inconclusive March election, Israel’s fourth in two years. He entered coalition talks as a kingmaker, and appears ready to emerge as the one wearing the crown.

Mr. Bennett has long championed West Bank settlers and once led the council representing them, though he is not a settler, himself. He is religiously observant — he would be the first prime minister to wear a kipa — but he will head a governing coalition that is largely secular.

He would lead a precarious coalition that spans Israel’s fractious political spectrum from left to right, and includes a small Arab, Islamist party — much of which opposes his ideas on settlement and annexation. That coalition proposes to paper over its differences on Israeli-Palestinian relations by focusing on domestic matters.

Mr. Bennett has explained his motives for teaming up with such ideological opposites as an act of last resort to end the political impasse that has paralyzed Israel.

“The political crisis in Israel is unprecedented on a global level,” he said in a televised speech on Sunday. “We could end up with fifth, sixth, even 10th elections, dismantling the walls of the country, brick by brick, until our house falls in on us. Or we can stop the madness and take responsibility.”

Credit…Dan Balilty for The New York Times

One of the most unlikely kingmakers involved in the formation of a new government is Mansour Abbas, the leader of the small Arab party known by its Hebrew acronym, Raam, with four seats in the current Parliament.

Under an 11th-hour deal, Raam formally agreed to join a Lapid-Bennett coalition government, though it would not hold any Cabinet seats. That was something of a surprise, as the party was expected to remain outside the coalition, while supporting it in a confidence vote in the Parliament. Some Arab lawmakers played a similar role by supporting Yitzhak Rabin’s government from the outside in the 1990s.

For decades, Arab parties have not been directly involved in Israeli governments. They have been mostly shunned by other parties, and are leery of joining a government that oversees occupation of the Palestinian territories and Israel’s military actions.

But after decades of political marginalization, many Palestinian citizens, who make up a fifth of Israel’s population, have been seeking fuller integration.

Israel’s early, leftist governments included Arab parties that were closely affiliated with the mostly Jewish parties. Raam would be the first independent Arab party in government, and the first Arab party of any kind in a right-leaning government.

Raam has been willing to work with both the pro- and anti-Netanyahu camps since the March election and to use its leverage to wrest concessions for the Arab public. The party has refused to commit to a deal unless it gets assurances for greater resources and rights for Israel’s Arab minority, including reforms to housing legislation that potential hard-right coalition partners do not accept.

Credit…Corinna Kern/Reuters

Sitting in her office in Parliament on Wednesday afternoon, Idit Silman, a hard-right lawmaker, flicked through hundreds of recent text messages from unknown numbers.

Some were laced with abusive language. Some warned she was going to hell. All of them demanded that her party abandon coalition negotiations with an alliance of centrist, leftist and right-wing lawmakers seeking to replace Prime Minister Benjamin Netanyahu for the first time in 12 years.

“It’s very hard,” Ms. Silman said. “People would rather put pressure on Idit Silman than see Benjamin Netanyahu leave Balfour Street,” she added, in a reference to the location of the prime minister’s official residence.

As opposition negotiators race to meet a midnight deadline to agree on a new government, supporters of Mr. Netanyahu and his Likud party were working overtime to pressure Ms. Silman and other members of the right-wing Yamina party.

Many right-wing Israelis see Yamina’s turn against Mr. Netanyahu as a betrayal.

This onslaught gave Ms. Silman and her colleagues pause for thought — and an incentive to be seen as prolonging the negotiations for as long as possible. Though Yamina did finally join the coalition on Wednesday night, Mr. Netanyahu’s party, Likud, is likely to continue to play on these fears.

Parliament might not hold a vote of confidence in a new government for another 10 days, giving Mr. Netanyahu more time to persuade Yamina lawmakers to reverse course.

His party has already promised to keep goading Ms. Silman and her colleagues.

“Behind the scenes,” said a senior Likud official, speaking on the condition of anonymity, “the Likud party is ramping up the pressure, particularly on the weakest links.”

The pressure has been relentless for days, since the phone numbers of Ms. Silman and her colleagues, they say, were posted on several WhatsApp and Facebook groups. That has prompted a barrage of messages — and not just from Israelis. Evangelical pastors in the United States have weighed in, and so have Hasidic activists in Britain, among many others.

The Likud party denies accusations that it posted any numbers publicly.

When Ms. Silman turned up at her local synagogue last week, she found several slick posters outside, each with her portrait overlaid with the slogan: “Idit Silman stitched together a government with terror supporters.”

For days, protesters have picketed her home, shouted abuse at her children, and trailed her by car in a menacing fashion, she said.

Yamina’s leader, Naftali Bennett, decided to negotiate with the opposition on Sunday night, after months of wavering. His calculus was based on realism, analysts say: Mr. Netanyahu cannot form a coalition, even with Mr. Bennett’s support. So Mr. Bennett can either fall in with the opposition, who have offered him the chance to be prime minister — or force the country to a fifth election in little more than two years.

“We always ask ourselves this question,” Ms. Silman said on Wednesday afternoon. “Is it right? Can we do something else?”

Credit…Pool photo by Yonatan Sindel

Naftali Bennett, who leads a small right-wing party, and Yair Lapid, the centrist leader of the Israeli opposition, have joined forces to try to form a diverse coalition to unseat Benjamin Netanyahu, Israel’s longest-serving prime minister.

Spanning Israel’s fractious political spectrum from left to right, and relying on the support of a small Arab, Islamist party, the proposed coalition, dubbed the “change government” by supporters, could signal a profound shift for Israel. Its leaders have pledged to end the cycle of divisive politics and inconclusive elections.

The opposition parties announced a coalition agreement on Wednesday. But even if they survive a vote of confidence in the Parliament and form a government, toppling Mr. Netanyahu, how much change would their “change government” bring, when some of the parties agree on little else besides antipathy for Israel’s longest-serving leader?

Mr. Bennett, whose party won seven seats in Parliament, is often described as further to the right than Mr. Netanyahu. While Mr. Netanyahu eroded the idea of a two-state solution to the Israeli-Palestinian conflict, Mr. Bennett, a religiously observant champion of Jewish settlement in the occupied West Bank, openly rejects the concept of a sovereign Palestinian state and has advocated annexing West Bank territory.

Still, though the coalition will include several parties that disagree on both those issues, they have agreed to allow Mr. Bennett to become prime minister first.

If the coalition deal holds, Mr. Bennett would be replaced for the second part of the four-year term by Mr. Lapid, who advocates for secular, middle-class Israelis and whose party won 17 seats.

By conceding the first turn in the rotation, Mr. Lapid, who has been branded as a dangerous leftist by his opponents on the right, smoothed the way for other right-wing politicians to join the new anti-Netanyahu alliance.

In a measure of the plot twists and tumult behind this political turnaround, Mr. Bennett had pledged before the election not to enable a Lapid government of any kind or any government reliant on the Islamist party, called Raam.

The coalition would stand or fall on the cooperation between eight parties with disparate ideologies and, on many issues, clashing agendas.

In a televised address on Sunday night, Mr. Bennett said he was committed to fostering national unity.

“Two thousand years ago, there was a Jewish state which fell here because of internal quarrels,” he said. “This will not happen again. Not on my watch.”

Credit…Pool photo by Ronen Zvulun

Even as the country and its Parliament remained deeply divided over the formation of a new government, Israeli lawmakers came together on Wednesday to elect a new president, Isaac Herzog, a former leader of the Labor party and government minister.

Displaying a rare degree of consensus in a secret ballot, they voted overwhelmingly for Mr. Herzog, who currently serves as the chairman of the quasi-governmental Jewish Agency for Israel, which helps deal with immigration, interacts with the Jewish diaspora and runs social programs.

The president plays a mostly symbolic role as a national unifier in Israel’s fractious parliamentary democracy, where the prime minister wields the most power.

One of a president’s main responsibilities is to grant a candidate the task of forming a government after elections. In Israel’s current, fragmented politics, which have produced four inconclusive elections in two years, that involves more than the usual level of skill, legal interpretation and discretion.

The president can also play an important role in Israeli diplomacy and has the power to pardon convicted criminals and exercise clemency by reducing or commuting sentences.

Mr. Herzog, 60, the grandson of the first chief rabbi of Israel and the son of one of the country’s earlier presidents, Chaim Herzog, will take over from the current president, Reuven Rivlin, in July.

“Our challenges are many and should not be taken lightly,” Mr. Herzog said in his acceptance speech. “I intend to be the president of all Israelis, to lend an attentive ear to every position and respect every person.”

Credit…Mohammed Saber/EPA, via Shutterstock

Less than a month ago, an eruption of intense fighting between Israel and Hamas militants in the Gaza Strip plunged Israeli and Palestinian communities into chaos. As the civilian casualties grew, overwhelmingly on the Gaza side, the conflict polarized Israeli society, and the world, in ways seldom seen before.

At least 230 people were killed in Gaza during the war, including at least 65 children, while in Israel at least 12 were killed, including two children. Gaza’s infrastructure, already ailing, was gutted by Israeli airstrikes on the densely populated territory. And Israeli towns and cities within range of Hamas rockets went into repeated, frightening lockdowns in shelters.

The war also spurred unrest within Israel and the occupied territories that has been more explosive than any in years. It has inspired a new era of Palestinian activism, and has shifted the ground politically, coloring the drama that was playing out in Israel on Wednesday.

Here is what to know about the 11-day war, and its lasting effects.

JERUSALEM — For Israelis, the possible downfall of Prime Minister Benjamin Netanyahu, the country’s longest-serving leader, is an epochal moment. Israeli media have barraged their audiences with reports and commentary on the opposition attempts to form a government.

But for many Palestinians, the political drama has prompted little more than a shrug and a resurgence of bitter memories.

During Mr. Netanyahu’s current 12-year tenure, the Israeli-Palestinian peace process fizzled, as Israeli and Palestinian leaders accused each other of obstructing the process, and Mr. Netanyahu expressed increasing skepticism about the possibility of a sovereign Palestinian state.

But to many Palestinians, his likely replacement as prime minister, Naftali Bennett, would be no improvement. Mr. Bennett is Mr. Netanyahu’s former chief of staff, and a former settler leader who outright rejects Palestinian statehood.

Instead, many Palestinians are consumed by their own political moment, which some activists have framed as the most pivotal in decades.

The Palestinian polity has long been physically and politically fragmented between the American-backed Palestinian Authority in the occupied West Bank; its archrival, Hamas, the Islamic militant group that rules Gaza; a Palestinian minority inside Israel whose votes might make or break an Israeli government; and a sprawling diaspora.

But spurred by last month’s 11-day war between Israel and Hamas in Gaza, and the worst bout of intercommunal Arab-Jewish violence to have convulsed Israel in decades, these disparate parts suddenly came together in a seemingly leaderless eruption of shared identity and purpose.

In a rare display of unity, hundreds of thousands of Palestinians observed a general strike on May 12 across Gaza, the West Bank, the refugee camps of Lebanon and inside Israel itself.

“I don’t think whoever is in charge in Israel will make a great deal of difference to the Palestinians,” said Ahmad Aweidah, the former head of the Palestinian stock exchange. “There might be slight differences and nuances, but all mainstream Israeli parties, with slight exceptions on the extreme left, share pretty much the same ideology.”

The strike in mid-May, Mr. Aweidah said, “showed that we are united no matter what the Israelis have tried to do for 73 years: categorizing us into Israeli Arabs, West Bankers, Jerusalemites, Gazans, refugees and diaspora.”

“None of that has worked,” he said. “We are back to square one.”

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Politics

Israel and Hamas conform to cease-fire over Gaza battle

Palestinians inspect a location hit during an Israeli air strike in Gaza City on May 20, 2021.

Mahmud Hams | AFP | Getty Images

WASHINGTON – Israel’s security cabinet voted in favor of a provisional ceasefire on Thursday after 11 days of fighting with Hamas in Israel and the Gaza Strip.

A Hamas official confirmed to Reuters that a “mutual and simultaneous” ceasefire with Israel would begin at 2:00 am on Friday

The White House is expected to respond to the news shortly.

The news follows a call Wednesday between President Joe Biden and Israeli Prime Minister Benjamin Netanyahu. During the call, Biden said he expected “significant de-escalation” of the violence, according to the White House report.

It was their fourth conversation since the outbreak of violence between Israel and Hamas, a Palestinian-Islamic political party with an armed wing of the same name that controls the Gaza Strip.

The tone from Washington to Tel Aviv has grown impatient in recent days as the death toll in Gaza from Israeli air strikes surpassed 200, including more than 100 women and children. In Israel, 12 people were killed by rockets fired by Hamas on Thursday afternoon.

The latest round of fighting was the worst outbreak of violence since the war between Israel and Hamas in 2014.

The White House has followed what it calls “calm, intense diplomacy” behind the scenes.

“We have received over 60 calls from the President downwards to senior leaders in Israel, the Palestinian Authority and other leaders in the region since the conflict began,” White House deputy press secretary Karine Jean-Pierre told reporters on Wednesday.

“The President has been doing this for a long time, for decades, he believes this is the approach we need to take,” she added.

A demolished 6-story building in the Al-Rimal neighborhood houses libraries, youth centers, training courses for university students and a mosque that was bombed by Israeli planes during raids in Gaza City, Gaza, on May 18, 2021.

Momen Faiz | NurPhoto | Getty Images

Biden appeared unwilling to publicly pressure Netanyahu to stop air strikes on what Israel says are military targets embedded in civilian neighborhoods in the Gaza Strip.

As a result, progressive Democrats in Congress and US allies abroad have urged the president to take on a more visible role and put more diplomatic pressure on Israel, which is heavily dependent on the United States for weapons and military equipment.

In Tel Aviv on Wednesday, Netanyahu briefed foreign diplomats and ambassadors on the worsening violence and reiterated previous claims that the Israeli military “is trying to attack” those who attack us with great precision.

“There is no army in the world that does more than the Israeli army, in the Israeli security services and in the Israeli intelligence service to prevent collateral damage,” said Netanyahu.

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Business

Mob Violence In opposition to Palestinians in Israel Is Fueled by Teams on WhatsApp

Last Wednesday a message appeared on a new WhatsApp channel called “Death to the Arabs”. The embassy urged the Israelis to join a mass brawl against Palestinian citizens of Israel.

Within hours, dozens of other new WhatsApp groups appeared with variations of the same name and message. The groups soon organized a start time at 6 p.m. for a clash in Bat Yam, a town on the Israeli coast.

“Together we organize and together we act,” says one of the WhatsApp groups. “Tell your friends to join the group because this is where we know how to defend Jewish honor.”

That evening, live scenes were broadcast of Israelis dressed in black breaking car windows and roaming the streets of Bat Yam. The mob pulled a man they suspected was an Arab out of his car and knocked him unconscious. He was hospitalized in serious condition.

The episode was one of dozens across Israel that authorities have linked to a surge in activity by Jewish extremists on WhatsApp, Facebook’s encrypted messaging service. According to analysis by the New York Times and by FakeReporter, an Israeli surveillance group that investigates misinformation, at least 100 new WhatsApp groups have been formed to commit violence against Palestinians since the violence between Israelis and Palestinians escalated last week.

WhatsApp groups with names like “The Jewish Guard” and “The Revenge Troops” added hundreds of new members daily over the past week, according to the Times analysis. The Hebrew groups have also been featured on email lists and online forums used by right-wing extremists in Israel.

While social media and messaging apps have been used in the past to spread hate speech and incite violence, these WhatsApp groups go even further, according to researchers. This is because the groups explicitly plan and carry out acts of violence against Palestinian citizens of Israel, who make up around 20 percent of the population and lead a largely integrated life with Jewish neighbors.

This is far more specific than previous WhatsApp mob attacks in India, which calls for violence were vague and generally not directed at individuals or companies, the researchers said. Even the Stop the Steal groups in the US that organized the January 6 protests in Washington did not openly target attacks through social media or messaging apps.

The proliferation of these WhatsApp groups has alarmed Israeli security officials and disinformation researchers. Attacks have been carefully documented in the groups, and members are often happy to be involved in the violence, according to The Times. Some said they would take revenge for rockets being fired at Israel by militants in Gaza, while others cited various grievances. Many asked for names of Arab-owned companies that they could target next.

“It’s a perfect storm of people empowered to use their own names and phone numbers to openly call for violence and have a tool like WhatsApp to organize themselves into mobs,” said Achiya Schatz, director of FakeReporter .

He said his organization had reported many of the new WhatsApp groups to the Israeli police, which initially took no action “but are now starting to act and try to prevent the violence”.

Israeli police did not respond to a request for comment, but Israeli security officials said law enforcement began monitoring the WhatsApp groups after being alerted by FakeReporter. The police, Schatz said, believed attacks by the Jewish extremists were inflamed and organized by the WhatsApp groups.

An official, who spoke on condition of anonymity, added that police had not seen any similar WhatsApp groups among Palestinians. Islamist movements, including Hamas, the militant Palestinian organization that controls the Gaza Strip, have long organized and recruited followers on social media but are not planning any attacks on the services for fear of being discovered.

The Israeli-Palestinian conflict

Updated

May 19, 2021, 6:37 p.m. ET

A WhatsApp spokeswoman said the intelligence service was concerned about the activities of Israeli extremists. She said the company removed some accounts from people who participated in the groups. WhatsApp cannot read the encrypted messages on its service, she added, but it acted when accounts were reported to it for violating its Terms of Service.

“We are taking steps to ban accounts that we believe could cause imminent harm,” she said.

In Israel, WhatsApp has long been used to form groups so that people can communicate and share interests or plan school activities. When violence between Israel’s military and Palestinian militants in Gaza increased last week, WhatsApp was also one of the platforms on which false information about the conflict was spread.

Tensions in the region were so high that new groups seeking revenge on Palestinians appeared on WhatsApp and other news outlets like Telegram. The first WhatsApp groups appeared last Tuesday, Schatz said. By last Wednesday, his organization had found dozens of groups.

People can join the groups through a link, many of which are shared in existing WhatsApp groups. As soon as they join a group, other groups will be announced to them.

The groups have grown steadily since then, Schatz said. Some have grown so large that they have branched into local chapters dedicated to specific cities. To avoid detection by WhatsApp, the group’s organizers are asking people to screen new members, he said.

According to FakeReporter, Israelis have formed around 20 channels in the Telegram to commit and plan violence against Palestinians. Much of the content and messages in these groups mimics the content of the WhatsApp channels.

In a new WhatsApp group that reviewed The Times, “The Revenge Troops,” people recently shared instructions on building Molotov cocktails and makeshift explosives. The group asked its 400 members to also provide addresses of Arab-owned companies that could be targeted.

In another group of just under 100 members, people exchanged photos of guns, knives, and other weapons while discussing street fighting in mixed Jewish-Arab cities. Another new WhatsApp group was dubbed “The Non-Apologetic Right-Wing Group”.

After participating in attacks, members of the groups posted photos of their exploits and encouraged others to emulate them.

“We destroyed them, we left them in pieces,” said a person in the WhatsApp group “The Revenge Troops” next to a photo showing the broken car window. Another group uploaded a video of Jewish youths dressed in black stopping cars on an unnamed street and asking drivers if they were Jewish or Arab.

We have “defeated the enemy car for car,” said a comment below the video with an expletive.

Over the weekend, Israeli Prime Minister Benjamin Netanyahu visited Lod, a mixed Jewish-Arab city in central Israel that was the site of the recent clashes.

“There is currently no greater threat than this unrest and it is important to restore law and order,” said Netanyahu.

In some WhatsApp groups, Mr. Netanyahu’s calls for peace have been ridiculed.

“Our government is too weak to do what is necessary, so we take it into our own hands,” wrote one person on a WhatsApp group dedicated to the city of Ramle, central Israel. “Now that we are organized, they can no longer stop us.”

Ben Decker contributed to the research.