Israeli medics confront new battlefield: Cluster warheads

Magen David Adom (MDA), Israel’s national emergency medical service, has been operating under wartime conditions for more than two years. The escalation following the latest round of attacks, however, has introduced complications that responders say they have rarely encountered at this scale. "We need to remember that Magen David Adom, as the whole Israeli population, is living a war situation for the last two and a half years," Rafalowski said.

What makes the current attacks particularly challenging, he said, is the widespread use of cluster munitions. According to Israeli defense assessments cited by Rafalowski, more than half of the missiles fired toward Israel now carry warheads that disperse multiple smaller bombs while still in the air and can cover a large geographical area.

"The missile itself comes with a very large number of smaller bombs," he explained. "It opens somewhere in midair and spreads the smaller bombs. Each and every one of them is around two and a half kilograms."

Instead of responding to one impact site, emergency teams may suddenly face incidents scattered across neighborhoods and towns. "They spread over about 10 kilometers," Rafalowski said. "So one such missile will give us scenes where the cluster bombs landed in many places. We are talking about 10, 12 scenes where the cluster bombs landed and exploded."

For emergency services, that means dividing personnel, ambulances, and equipment across numerous locations at once while still racing to reach victims before additional explosions occur.

The complexity of the response is not only logistical, but also dangerous for the responders themselves. Bomblets that fail to detonate immediately can explode later, turning impact zones into unpredictable environments. "This is a great operational challenge," Rafalowski said. "At the same time, it’s a great safety issue for our personnel because they might step on something that could explode."

"We’ve seen the escalation, the difference between the first missiles that came over from Iran to now these cluster bombs, these cluster missiles with multiple detonation warheads that pose a much different threat," he said. "Not only a different threat to property, but also a very different threat to lives because a detonation could be delayed and could cause further damage and loss of life."

United Hatzalah volunteers have responded to impacts across Israel since the first missile launches of the current operation. According to Allen, the scattered nature of cluster warheads creates debris fields that extend across wide areas and can remain dangerous long after the initial explosion. "We’ve seen projectile impacts, what we call shrapnel from the various missiles and from interception debris, falling over very large geographic locations," he said.

The threat does not disappear once the explosions stop. Both emergency organizations say unexploded fragments and missile debris can continue to endanger civilians who approach them. Rafalowski noted that public awareness about these dangers remains limited.

"Unfortunately, people are not well educated," he said. "We have had incidents of the general public picking up those cluster bombs." In one case earlier in the day, he said, a civilian picked up a piece of missile debris and suffered burns. "Luckily, it was a minor injury, but it could have been way, way worse."

Allen said United Hatzalah has repeatedly urged the public to stay away from missile fragments and to wait for trained personnel. "No one knows what is inside them. No one knows how dangerous they are," he said. "When people see shrapnel or a projectile, they should keep their distance and alert the authorities."

Alongside the explosives themselves, responders are now facing another unexpected danger: hazardous chemicals released when parts of missiles land intact. One such incident occurred recently in northern Israel when a missile engine fell near the city of Safed.

Rafalowski explained that the fuel used in these missiles can pose a serious toxic threat to anyone nearby. "The fuel of these missiles is highly toxic," he said. "In our terminology, we call this a hazmat incident."

In the incident in Safed, Rafalowski said responders quickly realized they were not dealing only with debris but with a hazardous chemical release from the missile’s engine.

"People who inhale nitric acid fumes will suffer from very severe burns to their airway and lungs," Rafalowski said. "And, of course, there can also be skin irritation."

For medical teams, hazardous material incidents require a completely different operational approach. Instead of rushing directly toward casualties, responders must first identify the chemical risk and coordinate with other emergency agencies.

"The most important thing is to identify it really fast and make sure civilians are away," Rafalowski said. Firefighters typically manage containment of the chemical hazard, while police secure the scene and medical teams treat potential victims.

Despite the scale of the attacks, the number of fatalities remains relatively limited compared with what many analysts initially feared. According to figures cited by Rafalowski, hospitals across Israel have treated more than 3,000 people since the current escalation began. "So far, the Healthy Ministry reports 3,079 people who have been treated at hospitals," he said. "Among them, 16 were killed."

Some of those deaths occurred from direct missile impacts, while others were indirect consequences of the emergency conditions. Rafalowski described one case involving an elderly man who was injured while trying to reach shelter during an alert. "One of them is a 90-year-old gentleman who fell on his way to the shelter, suffered a severe head injury, and died," he said. "Some of them died during car accidents that occurred during the alerts."

Most of the people treated by emergency teams have not suffered life-threatening injuries, Rafalowski said, but the numbers still illustrate the scale of the attacks. Nineteen people were classified as severely injured and 71 as moderately injured, while nearly 3,000 others were treated for minor injuries or anxiety reactions linked to the repeated missile alerts across the country.

Allen said the relatively low number of severe casualties reflects the discipline of the Israeli public in following civil defense guidelines. "The Israeli public, even on day 18 of the war, is holding very strictly to the guidelines of the Home Front Command," he said. "Those guidelines have been proven to literally save lives."

Yet the psychological toll of living under repeated missile attacks is becoming increasingly visible. Allen said the entire population is operating under constant pressure as sirens interrupt daily life and force people to repeatedly rush to shelters. "The population has been under constant stress," he said. "The entire country is on edge."

That anxiety often manifests itself in medical emergencies, even when missiles do not strike directly. United Hatzalah responders have reported numerous cases of civilians injured while running for shelter. "We’re seeing people falling while rushing to the safe areas," Allen said. "They’re so anxious and so nervous that they’re literally falling over their own feet and suffering fractures and minor injuries."

To address those cases, United Hatzalah has expanded the deployment of its Psychotrauma and Crisis Unit, which provides emotional support and psychological first aid at impact zones and in surrounding communities. "We’ve seen an increased number of anxiety cases," Allen said, noting that the psychological dimension of the war has become an increasingly significant part of emergency response work.

Emergency responders themselves are not immune to exhaustion after years of continuous conflict. Rafalowski said the repeated missile alerts, often occurring throughout the night, are part of a strategy aimed at wearing down the population. "Everyone is tired," he said. "Clearly, the Iranian tactic is to try and exhaust people by not letting you sleep."

He described nights when alarms sound every few hours, forcing families repeatedly into shelters. "When the sirens go off every two hours, people don’t sleep well enough," he said. "Everyone is tired."

Yet for emergency workers, the alarms also trigger a different reaction: a call to action. Rafalowski explained that many MDA volunteers keep ambulances at home and respond directly from their neighborhoods. "When the alarm goes off, they put their family in the shelter, and they tell their family, ‘You stay in the shelter,’" he said. "They put on their helmet, their flak jacket, and wait for the dispatcher to call them."

MDA operates with approximately 4,000 staff members and more than 30,000 volunteers across Israel, forming one of the largest volunteer emergency networks in the world. Because of that network, responders are often able to reach an incident within minutes, even while missile alerts are still active.

Allen said United Hatzalah volunteers are operating under those conditions across the country, including in northern communities that face additional threats from rockets fired from Lebanon. "In fact, in the north, there is no warning," he said. "You hear a boom before the first siren goes off. There is zero time to seek shelter."

That reality has forced many families to alter their daily routines. "Many of them have resolved to just sleep in their safe rooms throughout the night in order to protect themselves," he said.

Despite the dangers and exhaustion, both responders said the resilience of Israeli society has been a crucial factor in preventing a larger humanitarian disaster. Rafalowski described how residents often find ways to support each other while waiting in shelters during missile alerts. "You see people sitting together, singing songs together and playing together," he said. "Sometimes people who never knew each other become friends after some nights in the shelter."

Even as the attacks continue, the ability of communities to follow safety instructions has prevented far higher casualties. "The Israeli public is holding very strictly to the guidelines," Allen said. "And those guidelines have literally saved lives."