Children – even babies in diapers – suddenly are attacked by a horrific disease that turns their lives – and those of their parents and siblings – upside down.
Leukemias, lymphomas, sarcomas, brain and spinal cord cancers, neuroblastomas and other malignancies are suddenly diagnosed. Routines, schools and a normal life have to be abandoned in the interim, and thoughts of pain, suffering, disfigurement and mortality penetrate the consciousness of families whose children have only begun their lives.
Starting a year ago and for months on end, there were almost daily front-page newspaper headlines and broadcast news about the pediatric hemato-oncology department at Hadassah University Medical Center in Jerusalem’s Ein Kerem – the only hospital in the capital where children with cancer could undergo bone-marrow transplants from compatible donors.
One key figure in this tragic story is Prof. Michael Weintraub, recognized by all, even those who disagreed with his motivation for leaving Hadassah, as an extremely skilled, compassionate and dedicated pediatrician and oncologist who headed the department at there until last June 4. His devotion is described in detail in the new Schocken Books’ 245-page This Narrow Space by pediatric oncologist Dr. Elisha Waldman, an immigrant from the US who worked for seven years in the department but then left Hadassah and Israel after management failed to keep promises about opening a palliative medicine unit.
Anther main character is Hadassah Medical Organization director-general Prof. Zeev Rotstein, whom then-health minister (now deputy health minister) Ya’acov Litzman named to the post in February 2016 to save Hadassah from financial collapse – despite Rotstein’s numerous complications with the ministry during the decade when he was director-general of the profitable Sheba Medical Center at Tel Hashomer. When Rotstein made decisions that Weintraub felt were highly objectionable and potentially harmful to the children he treated, Weintraub resigned.
Rotstein reportedly wanted to combine the pediatric and adult hemato-oncology departments and to boost medical tourism, as bone-marrow transplants for Palestinians and foreigners, whose treatment was paid for (to the tune of NIS 500,000 apiece) by the Palestinian Authority and others from Eastern Europe. Weintraub argued that pediatric and adult patients are never treated together and that medical tourists’ treatment would come at the expense of young Israeli patients.
About a year ago, Weintraub announced that he would resign and leave Hadassah on June 4. As the deadline neared, five other senior physicians in the department (Prof. Shoshana Revel-Vilk, Dr. Mira Kharit, Dr. Iris Fried, Dr. Tal Ben-Ami and Dr. Yair Peled) and three pediatric oncology residents said they could not go on without Weintraub. Several nurses and others followed with their own exit.
Worried about their children’s health, parents of Israeli children treated there organized a well-publicized protest, but Litzman refused to meet with them for months, allowing the crisis to reach a boiling point.
Rotstein – who has a reputation for getting things done and saving money – shocked staff in the department and throughout the hospitals last Purim by sending to Hadassah staffers a message comparing Weintraub to “the wicked Haman” and depicting his fellow doctors as other “evil characters.” He said the missive was only a parody or joke, but he later admitted it was erroneous to have made such a comparison.
In a two-hour interview at the hospital earlier this month with Rotstein, nine new physicians and a senior nurse in the department, Rotstein told The Jerusalem Post that Weintraub met with Shaare Zedek Medical Center director-general Prof. Jonathan Halevy in November 2016 and presented a list of “60 doctors, nurses and paramedical staffers who wanted to move en masse to his hospital. It was a deal from the start, and because of that, Weintraub refused to make any compromise or even enter into negotiations,” Rotstein claimed.
But the Post found no basis for this charge. Weintraub and Halevy dismiss the accusation and even Health Ministry director-general Moshe Bar Siman Tov – who was closely involved in but failed to bring an end to the imbroglio – said he had no knowledge of such a deal.
Halevy said last year, “When, last November, the physicians said they couldn’t continue to work at Hadassah, I said I was willing to ask for permission from the ministry to open a department to take in the oncologists and the children, but when we were refused by Litzman, I dropped the matter of a department. I said months ago that we will not open our own.”
When it became clear that the department staffers would indeed make good their threat, MKs, mediators, rabbis, the High Court of Justice and even President Reuven Rivlin were enlisted to get them to change their plans. Over 30 sets of Israeli parents, receiving contributions and hiring a public relations company to voice their objections to Hadassah and demanding ministry approval to open a competing department at Shaare Zedek, erected a “field hospital” in a tent in Sacher Park. Although it was clear that it was merely a protest and no child was treated there for cancer by the protesting doctors, Litzman and Bar Siman Tov charged that it was “immoral for physicians to treat children under such unsterile conditions.”
The resulting brouhaha and mishandling of the crisis by the ministry will undoubtedly be taught in medical administration curricula as an example of failure to defuse a life-and-death crisis in the health system. It involves carelessness, inexperience, apathy, money, politics, livelihoods, egos, fears, rumors, falsehoods and charges of “fake news.”
The Jerusalem Labor Court ruled that the doctors’ resignations were justified and refused to issue orders requested by Hadassah to force them to return to work. After retired Supreme Court Justice Elyakim Rubinstein failed to reach an agreement between the sides in mediation, the High Court of Justice said it did “not find reason to issue restraining orders” to force the ministry to open a new pediatric hemato-oncology department at Shaare Zedek, but at the same time, it did not order the resigning doctors to return to Hadassah against their will.
The first few weeks after the resignations took effect were chaotic, as Sheba physicians brought by Rotstein part-time at high wages were unfamiliar with the young patients and their treatment protocols. The Hadassah director-general today recalls the doctors’ “desertion” with much bitterness. Some of the 15 nurses who remained worried that mistakes were being made in patients’ treatment.
“They [the nine doctors who resigned] left children with infusions in their arms and no doctors to take care of them,” Rotstein told the Post, but he insisted that everything was now “under control.” Among the new doctors hired by the department are its director, Dr. Gal Goldstein, brought from Sheba; cancer center head Prof. Yossi Laver, an Israel pediatrician who had worked at Assaf Harofeh Medical Center in Tzrifin, moved to the US and was brought back by Rotstein; bone marrow transplant expert Prof. Polina Stepensky; hemato-oncologists Dr. Irina Zaidman, Dr. Udi Even Or, Dr. Dan Har-Lev, Dr. Tzippy Kornfeld, Dr. Shirley Saieg, Dr. Dror Raviv and Dr. Rakefet Sidlik-Muskatel; and pediatrician Dr. Hodaya Cohen.
It was widely reported last year that Litzman forbade any other Israeli public hospital from hiring the resigning doctors as pediatric oncologists, a charge that had never before been denied by the ministry, although Bar Siman Tov told the Post recently that it was “not true.” Yet not one of the nine doctors has been treating children for cancer since their resignations. Weintraub has not worked since June 4 as an oncologist; instead, he was hired by Jerusalem’s Alyn Hospital for physically disabled children as head of a new brain-injury clinic there.
NOW, A year after the crisis was seared into the public consciousness, no Hebrew media representative has bothered to follow up and find out how the pediatric hemato-oncology department is functioning after the doctors – who constitute 15% of pediatric cancer experts in the country – left. With no chance for offering highly paid private medical service to Israeli patients who can’t afford it, pediatricians are not eager to go into the sub-specialty, and many find it difficult to cope with heartrending deaths of children.
In the middle of January, Hadassah spokeswoman Hadar Elboim sent a WhatsApp message to all health reporters quoting Prof. Eitan Kerem, head of its pediatric division, at a national pediatric conference at Hadassah Medical Center on Mount Scopus that it would be a “crime to send children with cancer from Jerusalem for treatment in the center of the country.” She also quoted Goldstein, the new head of the department, who surveyed “innovations in treating children, including the experimental use of antibodies whose first results are good and promising.”
In the center of the country there are three functioning pediatric hemato-oncology departments – at Schneider’s Children’s Medical Center in Petah Tikva, Sheba at Tel Hashomer and Dana Hospital at Tel Aviv Sourasky Medical Center.
I asked the three medical centers to comment on how the Hadassah crisis had affected them. The Schneider spokeswoman said that the crisis was “a national one whose burden has fallen mostly on our hospital. Indeed, there is a significant increase in new [pediatric cancer] patients here. We have and are continuing to make every effort to boost our staffs of doctors, nurses and administrative and paramedical workers. We thank all those for their joining us and their dedication to treat children from all over the country. We believe that a national effort is needed to solve the distress that was created.”
The Sourasky spokesman said that “as a result of what happened at Hadassah, dozens of children have come to us for treatment. Our team took on the challenge of giving them excellent and high-quality treatment with the backing from management, including hiring additional manpower for the department. We all hope that a proper solution will be found, so that Hadassah will recover and treat children in the Jerusalem area.”
The Sheba spokesman quoted Prof. Arnon Afek, a former ministry director-general who is now associate director-general of the country’s largest hospital, that “we are open to treat patients who come from all over the country. More than 50% of our patients are not from the metropolitan Tel Aviv) region. It’s difficult to say how many patients came to Sheba from Hadassah, because of the growth and expertise of Sheba’s hemato-oncology department. Sheba is always increasing the capacity in the department, and there are plans to build an even larger one,” He added that “as we know the director of Hadassah, Prof. Rotstein, who was formerly the head of Sheba, we are positive that he will bring the department to a full recovery.”
Kerem, in a solo interview in his office, told the Post that he had “followed the crisis from outside, as head of the pediatric branch. I was not involved. There was an earthquake in our department. Prof. Weintraub told Rotstein that if he didn’t make the changes he wanted, he would go to Shaare Zedek. It was a done deal that Mickey had initiated. He told me he had lost faith in Hadassah management.”
But Kerem, who had previously worked in Shaare Zedek for a decade, said that Rotstein had no intention of treating children with cancer together with adults. Kerem said the infamous Purim letter denigrating Weintraub was a big mistake. “I even told Zeev, and he said he was sorry he had done it.”
Now, “there is a war against this department. It is unprecedented,” said Kerem. “Parents were enlisted to fight us, and they delegitimized us. After the resignations, we have had to build a new department from nothing.”
Asked to comment about charges that Hadassah lacks experts who are specialists in brain cancer, sarcomas and ALL (childhood acute lymphoblastic leukemia, the most common type of blood cancer in which the bone marrow makes too many immature lymphocytes), Kerem said, “In Israel, there are no special board-certified examinations and recognition for expertise in such specific cancers. There are too few cases. Jerusalem has only 20 to 30 new pediatric cancer cases per year. But oncologists in our department coordinate specific conditions such as these and treat them. This has given them much experience.”
Asked if he would object to Shaare Zedek opening its own pediatric hemato-oncology department, Kerem said: “I have no problem with that, and Mickey should have been allowed by the ministry to work as an oncologist in another hospital.”
When invited to a different floor to interview Rotstein, I found him with the new department doctors, headed by the mild-mannered bone-marrow-transplant expert Goldstein, and with Muriel Cohen, the nurse in charge of the inpatient hemato-oncology department (not including the outpatient clinic nearby). The hospital director-general strongly objected to competition from Shaare Zedek, saying that there was enough volume of young patients only for one Jerusalem hospital.
Rotstein insisted that the department was in very good shape and able to cope with any illness.
“We consult with outside experts only if necessary. We did 53 bone-marrow transplants in 2017, our crisis year.” He said that “four of the 33 children whose parents took them from Hadassah have died, but I don’t know if it was from the course of the disease or because they left.”
Rotstein conceded that many of the current patients in the inpatient department and outpatient clinic are Palestinian medical tourists (six). There were also “six Arabs from east Jerusalem and medical tourists from Eastern Europe (one). We treat them all equally.” He also said that no other hospital beats Hadassah in the amount of basic and clinic research done by its staff.
Asked if he had something positive to say about Weintraub, Rotstein was willing to say only that he was an “excellent physician.” Weintraub himself declined to be interviewed for this article.
When queries why every general hospital in the country has been allowed by the ministry to open in-vitro fertilization units when the lower volume reduces success rates, Rotstein said: “IVF should be permitted in fewer places, but every hospital wants it. When the ministry allowed a neurosurgery department to open at Shaare Zedek – whose closer location has saved numerous stroke victims who might have died if they had had to reach Hadassah in Ein Kerem – our volume in that specialty went down 40%. But when Jerusalem’s population grows even more, there will be enough work for everyone.”
Sidlik-Muskatel, a physician who is doing a doctorate at the Weizmann Institute of Science in Rehovot and travels to Hadassah to treat patients one day a week, said she focuses on neuroblastoma cases. “It took time for faces of staffers to be less angry and to smile more, but now it’s a good experience for me to come here.”
Laver said that the department suffers from “nasty rumors and claims that our department doesn’t exist or function anymore. But they are not true.” Goldstein added that he “came from Sheba to treat children. There is no reason for patients to go anywhere else.”
I was then accompanied to the inpatient department and outpatient clinic where I found two Jewish parents with their sick children. Almost all the rest were Arab, mostly Palestinians. Naomi, a religious Jewish woman, held her six-month-old daughter, who, she said, is being treated for neuroblastoma. When I asked why she was one of the few Israelis remaining in the department, she said: “I have experience here. My son, who is now six, also had neuroblastoma [which has a genetic background], and he has recovered.” Asked how the department is now, she said: “It isn’t the same as it was [with Prof. Weintraub], but there is professionalism.”
The HMO spokeswoman invited me to return to the department “any time.” Two days later, I decided to return to the department and see it for myself again without being chaperoned. I didn’t interview any patients or physicians, but the beds seemed more empty than before and filled almost entirely by Palestinians.
Later in the day, I called Bar Siman Tov, the ministry director-general, who as a former Finance Ministry economist was appointed by Litzman to become the first in his position who was not a physician.
Bar Siman Tov said the rehabilitation of Hadassah’s department “will be long and hard. It is not perfect today, and they have a long way to go, but treatment there is proper. It underwent trauma after the horrible act of doctors abandoning it. But it happened. We consulted experts in Israel and abroad about what to do.” But he did not note how close and frequent ministry supervisors are watching the department and its quality.
Asked what errors were made in the handling of the affair, Bar Siman Tov said: “We should have gotten involved early in the dispute between Rotstein and the doctors and make sure that they stay.”
Two of the people that the Health Ministry consulted when it dealt with the question of whether to allow Shaare Zedek to open its own pediatric hemato-oncology department were emeritus Prof. Eliezer Robinson, a veteran oncologist in the north who was vice president of the Israel Cancer Association (ICA) and now – almost 87 years old – is chairman of the association.
Robinson said that he regarded the Hadassah affair as a “judgment of Solomon” in which the biblical king Solomon ruled between two women who both claimed to be the mother of a child. He tricked the parties into revealing their true feelings by making believe that he wanted to cut the baby into two. “So if you have two such departments in Jerusalem, both will collapse.”
ICA director-general Miri Ziv, who lost her teenage son to melanoma (serious skin cancer) in the 1980s, told the Post that “we don’t prefer one hospital over another. All are equal in our eyes, and we give those that excel financial and other aid for psychosocial services, advanced training and research. We care about the children in this crisis.”
When her own son, Oren, took ill and there were no known experts in his illness, she took him to Houston for months, leaving a teenage daughter at home,” and that was farther than the one hour it takes to drive to the center of the country, said Ziv.
Ziv said it was convenient for parents to take ailing children to a medical center close to home, but there are too many pediatric hemato-oncology departments in the country. Experts in Israel and abroad have found that the more patients a department has, more experience leads to higher success rates. In Holland, she added, there were many centers, but the authorities decided to close all but one so that one hospital could specialize in pediatric oncology.
She added that it was “not necessary to have specialists in every type of cancer. They all go according to protocols which are the same in Memorial Sloan-Kettering in New York.”
Asked why three departments have been allowed to continue functioning in the center of the country but not to have two in Jerusalem, Ziv explained: “Once they open here, it’s impossible to close any down. But it would be better to have one or two in the center.”
She said she did not understand why Weintraub and his colleagues insisted on resigning, as Litzman promised to see to it that Hadassah meet all their demands. But they refused. The department is still suffering from rumors and gossip, as if it is not functioning or incapable of treating patients. If it is allowed to work as it should, and the ministry watches it, it will recover. I don’t think it will take years.”
Ultimately, parents of cancer children will continue to vote with their feet whether they trust Hadassah with their loved ones’ lives and the Health Ministry’s supervision.