Remember the good old ACT UP era? When AIDS activists blocked traffic on the San Francisco Bay Area’s Golden Gate Bridge and stormed the Food and Drug Administration’s headquarters, and screamed that drug companies valued profits over lives? Well, those fun days are back — sort of. The decibel level is lower and the disease is different, but the punch and counterpunch of the combatants are more or less the same.
This time around, hepatitis C activists are pummeling drug-maker Schering-Plough for its unorthodox — and, say the patients, despicable — marketing of Rebetron, the leading treatment for the illness. Rebetron, which costs a whopping $18,000 a year, is actually a package that includes a pill called ribavirin and an injectable drug named interferon. The medications, when taken together, produce a sustained reduction in blood levels of the virus up to 40 percent of the time. In contrast, interferon taken alone is effective in only 10 to 15 percent of hepatitis C patients.
Many patients would like to add ribavirin to their current regimen, but Schering-Plough won’t sell the drug by itself. It is bundling the pill — which it has an exclusive license to market — with its own interferon, even though other pharmaceutical companies also manufacture the drug. Although the various interferon products are relatively similar, response to the drug is highly individual and some hepatitis C patients suffer fewer of the debilitating side effects — which can include depression, irritability, nausea and fatigue — from versions made from companies such as Hoffman-LaRoche and Amgen. In addition, some patients who are already using other brands don’t want to disrupt their treatment regimen by switching to Schering-Plough’s interferon.
Brian Klein, the energetic, irrepressible and nasal-twanged co-founder of the Hepatitis C Action and Advocacy Coalition (HAAC), calls Schering-Plough’s actions “extortion.” It is, he says, the pharmaceutical equivalent of Microsoft forcing consumers to use its browser — for the simple reason that it could. Even those who prefer Schering-Plough’s interferon, he says, should have the choice to try ribavirin with other brands as a matter of principle.
“Microsoft tied its own browser to the sale of Windows,” says Klein, who lives in San Francisco and modeled his organization on ACT UP. “Schering-Plough is tying the sale of ribavirin, which they have a lock on, to the sale of interferon, which they don’t. But the decision of which drugs to use should be made by patients and their doctors, not drug companies. This is holding people hostage by forcing them to buy both drugs from Schering-Plough.”
Nonsense, retorts the New Jersey pharmaceutical firm. Far from being criticized, says Schering-Plough spokesman Robert Consalvo, the company deserves credit for recognizing the life-saving potential of the combination and investing the funds to test it and bring it to market. Moreover, he points out, the FDA only evaluated the combination of ribavirin with Schering-Plough’s interferon, called Intron A, which is what the company used in its clinical trials. “Schering-Plough is providing the best proven treatment for hepatitis C,” he says. “We put these two products together and got Rebetron through [the drug approval process] very quickly. The bottom line is it’s being marketed the way it was tested and approved.”
Like AIDS, Hepatitis C, also known as HCV, is a public health disaster of epidemic proportions — a blood-borne disease that is spreading rapidly and often leaves those infected feeling stigmatized, ostracized or abandoned by society. More than 4 million Americans are currently believed to carry the hepatitis C virus, far greater than the number of those infected with HIV. Although some never get sick, liver failure and other complications of the disease kill an estimated 8,000 a year; health authorities expect the figure to triple within two decades.
The bundling issue raises a host of thorny legal, ethical and medical questions. For a company to package two drugs together is not inherently controversial. But to package two drugs together when one of them is unavailable from any other pharmaceutical company — and can therefore only be obtained by purchasing both of them — is rare, if not unprecedented. Laura Bradbard, a FDA spokeswoman, says she does not know of any similar situations. Neither does Stefan Loren, the pharmaceutical industry analyst for Legg Mason, a Baltimore-based investment bank. “This is a very unusual phenomenon,” he says.
The stakes are high for drug companies as well as patients. Loren pegs the current annual market for HCV treatments at about $1.7 billion and says the total figure could reach $4 billion within 10 years. In the highly competitive pharmaceutical industry, firms salivate at numbers like that. Schering-Plough leads the pack at the moment, but the large firms are all pursuing their own lines of research in hopes of grabbing a bigger slice of the pie. The company’s exclusive right to market Rebetron, which it licensed from ICN Pharmaceuticals, will expire next year. But some patents on the drug extend for another 15 years, and Schering-Plough is expected to fight the efforts by other companies to product their own versions of ribavirin.
Klein’s group, which has chapters in New York and San Francisco, has done its best to make life unpleasant for Schering-Plough. The activists have distributed leaflets and buttons denouncing the marketing of Rebetron at professional gatherings and challenged company representatives in public forums. Though Schering-Plough officials have met with activists to discuss the issue, they have refused to unbundle the product — despite an appeal from the FDA to reconsider the marketing scheme.
To Schering-Plough’s chagrin, the activists have now settled on a strategy that sidesteps the company’s lock on ribavirin. They are touting a tiny pharmacy in Pittsburgh that has taken advantage of a legal loophole to sell its own form of the medication — and at a fraction of what Schering-Plough charges. The pharmacy, which imports the ingredients from abroad, accepts prescriptions from doctors for individual patients and creates ribavirin capsules on a custom basis — a process known as “compounding.”
Regardless of whether they win the fight against Schering-Plough, the HCV activists have their work cut out for them. U.S. Surgeon General David Satcher recently said the country was suffering from a “silent epidemic” of the disease, which is far more deadly than hepatitis A or B. A huge number of Americans — perhaps a majority — have never even heard of HCV. And because the symptoms can take decades to appear, many people have no idea they are infected until they develop chronic liver disease. About a fifth of those infected with HCV develop cirrhosis and may die without a liver transplant. Before blood banks began screening for the virus a decade ago, HCV, was spread primarily through transfusions. Now most transmission occurs through the sharing of infected needles and, occasionally, through sexual contact.
Up until two years ago, the treatment outlook for HCV was bleak. The only approved drug was interferon, whose side effects earned it the nickname “demon juice.” Then, in June of 1998, the FDA approved an application from Schering-Plough for the interferon-ribavirin combination.
Patients and doctors, who had heard reports about this remarkable new regimen, were ecstatic. But once it became clear that Schering-Plough had no intention of selling ribavirin separately, patient advocates howled. Access to ribavirin wasn’t the only problem; the high price also concerned HCV advocates. Though most insurance programs pay for Rebetron, many patients complain that it costs much more than could possibly be justified by the expense of manufacturing it.
But industry analyst Loren notes that a company may invest up to $500 million to develop a drug and bring it to market. “Rebetron is very pricey, no question, but these companies have only a few drugs to recoup all the failures, the projects that never really went anywhere, the drugs that didn’t sell well,” he says. “People are saying they can make obscene profits, but the fact is they’re in a very risky business.”
Alan Franciscus, the founder of the Hepatitis C Support Project in San Francisco, praises Schering-Plough for awarding grants to many HCV groups, including his own. He adds, however, that the company was naive if it didn’t expect the vociferous reaction to its marketing plans. “It’s not like they’re the evil empire,” says Franciscus, whose group runs support groups and publishes informational material about HCV. “But their attitude is, We developed this drug, we’re going to do what we want with it and you should be happy. That’s not reality, though. The reality is that we want what’s best for the community while still allowing them to make a good profit.”
Despite their radical reputation, the HCV activists have received some support from mainstream sources. Last year the Committee on Ethical and Judicial Affairs of the American Medical Association urged the organization’s board of trustees to examine the issue, stating in a letter that “the practice of bundling raises concerns regarding limitations on choice of treatment options and potential limits on access to standard care.” The trustees have not taken up the issue, although a spokesman for the AMA says that they have simply not gotten around to it yet.
The normally staid American Liver Foundation — sometimes called the Chicken Liver Foundation by HCV activists who feel it rarely takes a controversial stand — has also gingerly stepped into the fray, even though it receives close to 10 percent of its annual budget in grants from Schering-Plough. During an interview at an HCV conference in San Francisco two weeks ago, foundation president Alan Brownstein appeared decidedly uncomfortable when asked to comment about the issue. He attempted to finesse the question with platitudes about the need for patients to have maximum treatment options, but then conceded that he was not happy with the practice of bundling.
“They’re playing hardball,” he said of the pharmaceutical company. “As far as HAAC’s position, we’re supportive. We’ve made that clear (to Schering-Plough). People with Hep C are fighting for their lives.”
Even the FDA, which approved the Rebetron package but faced immediate protests from patients, is concerned that bundling limits consumers’ options, acknowledges spokeswoman Bradbard. But the agency has no authority to force the manufacturer to unbundle the product, she adds.
However, the FDA has tried to exert some pressure. In a letter sent to Schering-Plough after the initial approval of Rebetron, Heidi Jolson, director of the division of anti-viral drug products, wrote that the agency’s decision “in no way restricts, nor precludes a request by Schering Corporation to market the individual components separately for their approved use.” The letter invited Schering-Plough “to discuss alternative marketing package options that would make available the ribavirin component alone” and noted that the agency “is open to such discussions and would be willing to work with you regarding appropriate revisions to the approved product labeling.”
Translation from bureaucrat-speak to English: Hey, guys, please do this. PLEASE! Schering-Plough’s response: No, thanks.
Schering-Plough vigorously defends its actions. Besides saying that there’s no conclusive data to support the effectiveness of using ribavirin with other brands of interferon, Consalvo notes that the company is also concerned about liability issues. Since the drug is approved for use only with Intron A, someone who used it with other brands and reacted badly to it could sue Schering-Plough, he explains. Consalvo acknowledges that the company markets the two drugs separately in Europe because of legal requirements from the European Commission. He stresses, however, that the ribavirin is clearly labeled that it is to be used in combination with Intron A.
HCV activists dismiss the liability argument as disingenuous. They point out, accurately, that it is standard medical practice to prescribe drugs “off-label” — that is, to use medications to treat conditions for which they have not been formally approved. Much of the remarkable increase in understanding of how to treat AIDS patients, in fact, stems from physicians’ freedom to fine-tune their patients’ regimes without being bound by the strict combinations, uses and doses for which the drugs are labeled.
Hoffman-LaRoche, Schering-Plough’s chief rival in the HCV market, has reportedly been lobbying behind the scenes against the bundling of Rebetron. A spokeswoman for the firm declined to comment on the controversy. But she may have offered a hint of the company’s stance when she suggested calling HAAC, the group spearheading the protest, for more information.
Some doctors who work with HCV patients understand Schering-Plough’s position. At the San Francisco hepatitis C conference earlier this month, Dr. Joanne Imperial, an associate professor of gastroenterology at Stanford University Medical Center, acknowledged that it was “frustrating” for physicians who want to prescribe ribavirin with other interferon products. But she added that since ribavirin by itself is pretty much useless in treating HCV, it wouldn’t have made medical sense for the FDA to approve it for sale separately. “I don’t see how it could have been done differently,” she said.
Since last summer, however, Fisher’s Specialty Pharmacy Services in Pittsburgh has exploited a legal loophole to offer its own version of ribavirin. Other companies are prohibited from large-scale manufacturing of generic ribavirin until Schering-Plough’s exclusivity expires. But U.S. law permits pharmacies to compound medication, just as old-time druggists used to do. Fisher sells its product for $225 a month, about a fifth of the cost for the ribavirin in Rebetron. Other compounding pharmacies have begun to follow Fisher’s lead.
The development has delighted activists and dismayed Schering-Plough. “This really does not comply with the spirit of the compounding regulations,” says Consalvo. “You’re supposed to fill an individual patient’s one prescription, not say, ‘Hey, I can make the same product this big guy is making and sell it for a lot less because I don’t have the overhead.’” Schering-Plough has complained to the FDA, but so far the agency has taken no action.
Klein and other activists are doing their best to alert doctors and HCV patients to the availability of Fisher’s product. But no one expects Fisher and the other small compounding pharmacies to make much of a dent in the market share of a pharmaceutical giant like Schering-Plough. And the activists recognize that it is not a long-term solution to the problem.
What may help is the advent of pegylated interferon, the next generation of interferon products. By delivering time-released doses of interferon, the new drugs boost efficacy and hold the potential for producing fewer side effects. Preliminary data suggest that the combination of ribavirin and the pegylated versions works even better than current treatments. Schering-Plough’s pegylated drug could be approved as monotherapy by the end of this year. Approval of its use with ribavirin should occur at some point next year.
But other companies are testing their own pegylated interferons with and without ribavirin, and given the current uproar it remains an open question how the FDA will handle Schering-Plough’s drug applications. Loren, the pharmaceutical analyst, says the backlash over Rebetron could motivate federal authorities to pressure Schering-Plough to market the two drugs separately — at least until generic ribavirin becomes available down the line.
The hepatitis C community certainly expects that to be the outcome. “I don’t think this type of bundling will happen again,” says Franciscus of the Hepatitis C Support Project. “I think Schering-Plough was taken aback by the reaction, but pharmaceutical companies now know that we won’t stand still for any of that nonsense.”
So there I was reporting from the scene in the operating room of a Moscow hospital, staring with creepy fascination as the surgeons prepared to give Oksana, a Russian transsexual, the vagina she’d always craved. First they extracted two plump masses of dark red pulp — her testicles, I gathered — and tossed them right by me into a bloody trash bin. Then they deftly whittled the penis away layer by layer, peeling down thin slices of skin as if it were an onion, leaving the flaps of flesh attached at the bottom of the dwindling shaft for use in constructing Oksana’s new genitalia …
Has anyone clicked off yet? Probably, but I’ll bet many more — grossed out though they might be — would gobble up any further details I chose to divulge.
Gore is hot these days. I’m referring, of course, to the dripping-blood-with-bits-of-flesh-and-internal-organs variety, not the deathly wooden presidential wannabe. We’ll leave the vivisection of that particular corpse to the Republicans. But real gore seems to be a vernacular of increasing obsession; lately it’s been oozing out all over the place, from slasher movies and rap lyrics to medical dramas and cop shows.
Now the success of shows like “ER” and “Chicago Hope” has spawned a whole literary genre: the blood-soaked memoirs of emergency room and intensive care doctors. Out last month was Pamela Grim’s “Just Here Trying to Save a Few Lives: Tales of Life and Death From the ER,” and “Intensive Care: A Doctor’s Journal” by John Murray, an attending physician at San Francisco General Hospital. William Bonadio’s “Julia’s Mother: Life Lessons in the Pediatric ER,” was published this spring, and last year’s “The Blood of Strangers: Stories from Emergency Medicine,” by Albuquerque physician and poet Frank Huyler, is due out in paperback in October.
These four books approach their subjects in different ways, but blood, sputum and decaying or bullet-ridden body parts play a central role in all of them. By turns harrowing, tender, sardonic, informative, funny and emotionally draining, they offer enough horrific tales to sustain the interest of even the most morbidly inclined readers. In the past few days, I’ve learned more about the sound a chest makes when it’s cracked open to reach the heart, the corrosive long-term effect of vomiting on a bulimic’s esophagus and the smell of burning flesh produced by defibrillation than anyone (aside from a health care professional) would want to know. Yet I couldn’t stop reading.
Somehow this sort of information never made it into the antiseptic, feel-good hospital dramas of my childhood, like “Medical Center” and “Marcus Welby, M.D.” Those shows treated medical professionals with the hushed reverence reserved for Catholic priests in the pre-pedophile era. Doctors knew everything then; life — and death — were under control. That’s a far cry from the adrenaline-fueled, blood-splattered, AIDS-haunted, bullet-addled, smack-happy universe of “ER,” “Just Here Trying to Save a Few Lives” and “Julia’s Mother.”
Take this passage from “Just Here to Save a Few Lives,” in which Grim — and what an apt surname that is — is treating a teenager shot in the chest: “Blood splashes against your goggles and all over your jacket. You’ve unloosened a torrent of blood that quickly fills the chest cavity and overflows onto the floor … You are up to your coat sleeves in the blood in this boy’s chest. The blood has cascaded down onto the floor. There are two inches of blood where you are standing. Your shoes are soaked with it.”
What’s going on here? We clearly crave having our faces shoved into guts and chest cavities and other bodily orifices. Maybe we’re so comfortably cocooned these days in our cappuccino worlds that the reality of decay and death seems a distant echo, and these works allow us to indulge our ghoulish tastes while feeling like we learn something in the process. This is gruesomeness with purpose. Guilt-free gore. Morally sanctioned rubbernecking. When I watch “Halloween Hatchet Murders on Elm Street: Part 11,” I feel the need to take a three-hour shower afterwards and purify myself with PBS documentaries about macrame workshops in Appalachia. But after reading these books — four of them in a row, in fact — I can lounge back on the couch and sip my espresso, thinking deep thoughts about life and death and the wisp of fate that separates them.
Certainly the publishers claim that their offerings deliver something better that Peeping Tom pleasure. According to the jacket of “Julia’s Mother,” readers will “share in the nobility of a parent’s unending search to find meaning in tragedy.” The cover copy for Grim’s book informs you that it will “lead you to appreciate the resilience of the human body and human spirit as never before”; “The Blood of Strangers” touts its “lyrical meditations on the world of ER medicine — and the world at large.” Intensive care apparently offers more prosaic benefits. A press release from the publisher assures that you will receive “a comprehensive understanding of what an ICU is, what it does, who gets admitted, and how doctors and nurses make decisions concerning life-threatening medical problems.”
Some of these claims are more accurate than others. The books do offer epiphanies and insights, but they are not necessarily what the publicists tempt us with. “Just Here To Save a Few Lives” is a well-written, often-riveting account of emergency medicine by a conscientious doctor who has seen it all, and then some. Bitchy, honest and brutally funny, Grim is a cross between Anne Lamott and Dr. Kildare. But I’m not sure where the moral uplift comes in. At one point the good physician feels so depressed and burned out that she considers leaving emergency room medicine for the soft Muzak world of hair transplants, although we suspect she ultimately won’t.
Grim does reveal moments of transcendence, but even those are shot through with a haunting self-knowledge, like her emotions after the hellish birth of a crack baby: “Right now the baby is alive, moving, wiggling those little hands in the air. A live baby. And what they say is true, you do feel like God — no, not God, really — just like a manifestly great human being. Carol, the pretty nurse, looks beautiful now and she is glowing at you. Even Helen, the nurse who hates you, is glowing a bit, though not specifically in your direction.”
The most striking element in that passage is the author’s ironic awareness of her own grandiosity and her gnawing sense that the power she suspects she holds over life and death means almost as much to her as the healthy delivery of this specific baby. And that aching ambivalence and uncertainty, perhaps, is what gives the books their special hold on the imagination. It’s not the triumph of the human spirit we’re witnessing, as rewarding as that might be, so much as the struggle to comprehend the essence of life — and the human role in it — through a total immersion in the most intimate anatomical processes.
“In Intensive Care,” Murray immerses himself in this world in a different way. If he has screamed at crack users in frustration the way Grim has, we won’t learn about it from him. Whereas Grim’s language shoots off sparks at every juncture, Murray’s is measured and dry. “The budding yeast in the first samples of his sputum and peritoneal fluid are Candida albicans, a ubiquitous fungus that commonly causes superficial infections of the skin (diaper rash) or internal membranes (oral thrush, vaginitis),” he writes of one patient. “Similar organisms are growing in the two newly submitted specimens from his lung and belly, and also in his urine.”
This is great stuff for medical students who want to understand what ICUs are like. It’s great for ethicists and public policy wonks who study the factors impacting health care decisions. But a page-turner it’s not. The average Jill wants drama; she wants the edification alongside the hardcore stuff, not instead of it.
Yet not even the clinical tone of a work as earnest as “Intensive Care” can offer the comforting illusion of control over physical processes. Our bodies are in free fall every moment of our lives. Murray and the other docs know that, and so do we all. This invites the question: If I die because blood gushes out from a bullet hole, does my life really amount to more than that blood? Is it more than the appendix that just ruptured or the liver destroyed by hepatitis C? If I soak up images of gore and disaster from a safe enough distance, can I learn anything at all about what’s going on? Can I understand life better by dwelling on death? When these books work best — at least for me — is when the doctors grapple with that dilemma and allow us to witness their awe, fear or fascination at the incomprehensibility of it all.
“It’s eerie, to look down and see your hands lost deep working inside a human body cavity,” William Bonadio writes of dissecting a cadaver in his medical school anatomy class. “Exposing the internal mechanism to the light of day for the first time, like an archeologist shining a torch on a cave wall filled with hieroglyphics.” Although I’ve never had my hands where he has, this sounds about right to me. So do the questions that his exploration of the cadaver’s body organs make him want to ask the woman it used to be: “How did it all turn out? If I could ask her, what would she say was the most important thing? Her biggest regret? Tell medoes any of it really matter, after it all passes?”
Those are not questions the all-knowing Dr. Welby — or even my father, a retired physician who once ran the intensive care unit at a county hospital — would ever have asked. But they would certainly occur to Frank Huyler. “The Blood of Strangers” is an eerily seductive account of emotionally disconnected E.R. doctors and their quirky patients, and the brief vignettes that compose the volume read like perfectly constructed short stories.
Spare in tone but richly observed, the tales convey the requisite graphic details in homespun language that heightens the effect. Here is Huyler on shaving flaps of healthy skin off a burn victim so they can be grafted elsewhere: “When you do it right, there is a curious pleasure there, the skin rising, curling up like a slice of cheese from the blade.” In the case of a car accident victim, “his head, the bones of his skull, felt loose, like gravel and warm bread.” It’s surely no accident that the title of his book would be equally fitting for a biography of a serial killer.
Refreshingly, Huyler does not disguise his own squeamish interest in bodily decay. When a nurse beckons the medical team to view what she declares is “the grossest thing” she ever saw, they gather round as she shines a flashlight into a patient’s mouth.
“His mouth was like a little pink cave,” writes Huyler. “Inside were dozens of tiny white worms. As we watched, they began to move, to retreat into the darker recesses, away from the light … The room erupted. We were horrified, but also excited, exhaustion washed away … We took turns, switching off the light for a minute or two until the maggots came back, then illuminating them, transfixed by their retreat into the dark.”
Riveting? Yes. True and funny in a dark and really disgusting sort of way? Absolutely. A portrait of the triumph of the human spirit? Gee, I’ll have to get back to you on that one.
Imagine, for a moment, that since 1989 the United States has granted citizenship to 50 million immigrants. Imagine that these new citizens are highly educated and highly opinionated, but speak little English and have little or no experience living in a democratic society. Imagine that they have now discovered the power of the vote and have transformed their yearnings and grievances into political muscle, and you will have some notion of the complex and contentious relationship between refugees from the former Soviet Union and their new homeland, Israel.
Since the end of the 1980s, about 800,000 immigrants have arrived from Russia and the other countries of the former Soviet Union. Including those who emigrated to Israel in the pre-Gorbachev era, the Russian-speaking immigrants now number around one million and account for 17 percent of the electorate. Their arrival has injected a highly volatile element into a country already struggling with gaping social, cultural and political divides between secular and religious Jews, and between Ashkenazi Jews of Eastern European origins and Sephardic Jews with roots in North Africa and the Middle East. Perhaps the most prominent political schism is between those who favor territorial compromise with the Palestinians and those who oppose it.
Against this backdrop, the new immigrant block has emerged as a critical group of swing voters in Israels political landscape. As Israel prepares for national elections on May 17 — elections that will determine the future course of negotiations with the Palestinians — it is clear that the new immigrants will play a key role in determining the outcome. Both major parties - the right of center Likud Party led by Prime Minister Benjamin Netanyahu and the Labor Party led by Ehud Barak - are belatedly recognizing the power of the new immigrant vote.
Whatever the outcome of the current elections, political instability in Russia and the other former Soviet republics assures that the inflow of new immigrants will not end anytime soon. And Natan Sharansky, for one, warns that it would be a mistake for anyone to take the Russians for granted.
“The bulk of [Israeli] voters have been here for years or generations, so a relatively small percentage change their position,” says Natan Sharansky, a former Soviet dissident who shocked Israeli pundits in 1996 when his newly formed Israel B’aliyah party won seven seats in the 120-member Israeli parliament. “But the Russians are newcomers, and their vote is not yet firmly ideological. It is a floating vote, not linked too closely with any party, which makes them very attractive for all the parties.”
The surprising success of Sharansky’s party in 1996 — when Israelis for the first time cast separate votes for prime
minister and for political parties in the parliament — gave Russian immigrants their first taste of voting power. Now, they realize they are key players in Israeli electoral politics. “There are so many of us here now that the politicians all realize that they can’t win an election without us, they can’t form a government without our support,” said Shurik Lifshitz, a middle-aged photographer who emigrated from the former Soviet Union in 1991.
If pre-election polls are
accurate, a majority of the Russians will again cast their vote for
Netanyahu for prime minister. Netanyahu’s slogan — “A strong leader for a strong nation” — has powerful appeal to former citizens of a totalitarian superpower, and many immigrants explain their support for him with one word: byezopacnost (security). Having witnessed firsthand the traumatic collapse of their previous homeland, the Russians say that ensuring Israel’s future is their tantamount concern. Raised on empty Soviet slogans extolling “the brotherhood of nations,” they are highly distrustful of Israel’s neighbors and believe a Likud government is far more likely to resist Palestinian demands.
“We must think about our interests, but Labor thinks more about the Arabs’ interests,” says Alexander Pesen, who arrived from the former Soviet republic of Kazakhstan in 1990 and now owns a Russian bookstore in Ashkelon that sells translations of Danielle Steel alongside Pushkin and Tolstoy. “Let the Arabs think about their own interests. I don’t think we should make concessions just because things are bad for them, because concessions won’t give us a balanced peace.”
In the 1996 elections, almost two-thirds of the new immigrants supported Netanyahu, who defeated Labor’s Shimon Peres by 30,000 votes, less than 1 percentage point. Sharansky’s Israel
B’aliyah party, which garnered about half the Russian vote, became a vital part of Netanyahu’s ruling coalition.
The Russians’ rightward slant has confounded many Israelis on the left who welcomed the immigrants’ arrival. For decades, left-leaning, secular Ashkenazi Jews dominated the Israeli political, academic and media establishments. In recent years, Likud and other parties on the right have come into power by harnessing the support of two other key constituencies — Sephardic Jews, who are the long-time have-nots of Israeli society, and the ultra-Orthodox.
So when the massive immigration of Soviet Jews began in 1989, members of the old elites assumed that the new arrivals would boost their sagging fortunes. “The Russian political pattern is surprising, given their mostly European, Ashkenazi background,” says Hanoch Smith, a leading Israeli pollster. “It was assumed that they would be like the previous Jews who came out of that part of the world, so the left thought, ‘Oh, boy, more supporters for us!’ But decades of communism has had an enormous impact on their thinking.”
Political analysts and Russian immigrants themselves point to a variety of psychological and sociological factors that nudge the Russians toward the right. Many former Soviet citizens, aware of the Israeli left’s embrace of socialist political and economic concepts in decades past, react with visceral distaste to the very language used by Labor and its allies. Critics of the left, notes Alexander Yakobson, a lecturer in history at Hebrew University in Jerusalem, exploit that revulsion by routinely referring to Labor’s leaders as “socialists” rather than “social democrats.”
“Soviet communism is really a perversion of one important tradition of the Western left, so it discredited all of the terms the Israeli left uses, like ‘peace,’ ‘progress,’ and even ‘left,’” says Yakobson, whose family emigrated to Israel from Russia in 1973. “The left here is still paying a price for that.”
The vibrant and increasingly assertive Russian presence is one of the most striking features of modern day Israel. It is difficult to stroll down the streets of Tel Aviv or Jerusalem or a host of other cities and towns without hearing the rhythmic cadences of Russian speech. Dozens of national and local Russian newspapers compete on newsstands with the Hebrew-language press. More subtle indicators also attest to the change: Vodka consumption in Israel has risen by 50 percent this decade, and medical clinics advertise circumcision services for adult Russians, the vast majority of whom did not observe Jewish rituals in the Soviet Union.
Today, it is possible for immigrants to live entirely within the Russian community and never have to learn Hebrew. On Aliat Hanoar Street, the center of a Russian neighborhood in the seaside city of Ashkelon, delicatessens post signs touting non-kosher staples of the old Soviet diet like svinina (pork) and kalbasa (sausage). A nearby bulletin board features Russian-language announcements for a travel club, gatherings for former citizens of Belarus, rock guitar lessons and a Russian magazine.
Some on the left believe Labor and its allies have done a poor job of reaching out to this new block of voters, and have boggled the job of explaining to Russians that territorial compromise could lead to greater national security for Israel.
Many Labor activists dismiss predictions of doom, noting that a majority of the Russians supported the party in 1992, when it ousted the Likud from power. But political analysts attribute that early success not to any great love for Labor but to pervasive discontent over the Likud government’s clumsy handling of the huge wave of immigration that began in 1989. At that time, the newcomers found themselves living in substandard housing and working far below their educational level. Unemployment among the immigrants rose well into the double-digits, and stories abounded of Russian doctors collecting garbage, lawyers cleaning hotel rooms and engineers pumping gas.
Today, while some Russians, especially newer immigrants, are still struggling, many have risen rapidly through the ranks of Israeli society and take palpable pride in their achievements. More than three-quarters of Russian immigrant families own their own apartments. Russians now account for almost a third of the licensed doctors in Israel. The Gesher Theater, founded in 1991 by immigrants, has attained national and international renown.
“They had high status (in the former Soviet Union) as engineers, teachers, doctors, and here they found themselves at the bottom of the professional ladder, not knowing the language,” says Leonid Belotzerkovsky, publisher of the Russian-language newspaper Novosti Nedeli (News of the Week), who himself emigrated from St. Petersburg in 1988. “They have moved up surprisingly quickly. I wouldn’t imagine that immigrants from any other country would have attained that in less than ten years.”
The rough transition into Israeli society has left some scars among Russian immigrants, and threatens to weaken Netanyahu’s governing coalition. In a recent open letter to former Clinton advisor James Carville, who working as a campaign consultant for Barak, political columnist Ze’ev Chafets advised him to woo Russians away from Netanyahu by exploiting the tensions between Russians and other Likud coalition supporters
“The real damage … will come when you drive a wedge through the Likud’s two biggest ethnic blocs, the Moroccans (one of the largest Sephardi communities) and the Russians,” he wrote in The Jerusalem Report, a widely read English-language biweekly. “The Moroccans resent the hell out of being climbed over by the immigrants, while the Russians are visibly contemptuous of what they see as the Moroccans’ bongo-drum kultura and lousy SATs.”
Many of the immigrants still grumble that their new country does not fully accept them. Overwhelmingly secular, they fear the power that the Orthodox wield in such vital areas as marriage, divorce and religious conversion. In recent weeks, both Barak and Sharansky have stepped up their criticism of Netanyahu’s Orthodox supporters. Though they are the spouses and children of Jews, about one-third of the recent Russian arrivals are not considered Jews under Jewish law, which recognizes only those with Jewish mothers as Jews. Since Orthodox rabbis do not perform mixed marriages, and Israel does not permit civil marriage within its borders, non-Jewish Israeli citizens must go abroad to marry. The state does recognize civil marriages performed elsewhere. Conversion to Judaism is possible, but only under strict Orthodox guidelines.
Divorce can be even more complicated, since Israel does not recognize civil divorces obtained by Jewish couples elsewhere. Many divorced women arriving from the former Soviet Union have been dismayed to find out that they are still married under Israeli law. To receive Orthodox divorces, they must frequently locate and obtain permission from husbands who have not themselves emigrated and with whom they have not had contact for years.
There is also long-simmering tension between the Russians and the Sephardi. The Sephardi, who on average are poorer and more traditional than their Ashkenazi cousins, complain that the Russians have received special treatment in jobs and housing. Many Russians, in return, disparage them as uneducated riff-raff.
The tensions between the two groups gained widespread attention last fall, when an Israeli Moroccan killed a Russian immigrant soldier at a cafe in Ashkelon. Published reports alleged that the Moroccan berated the soldier and his friends for speaking Russian loudly. The murder took place a few days before municipal elections, and anger over the incident helped propel more than 100 representatives of Sharansky’s party to victory in local city councils.
“The murder was a shock, a huge shock,” says Galina Krochek, who emigrated in 1991 from Tashkent, the capital of the former Soviet republic of Uzbekistan.
“We knew that there was hate between the groups, but that it went so far as that was astonishing,” adds her husband Artur, who himself remembers being criticized by co-workers for speaking Russian instead of Hebrew. Still, all these issues seem to be second-tier political concerns for Russian immigrants as they prepare to go to the polls.
Artur and Galina, both in their mid-30s, are two of about a dozen cousins of mine who have moved to Israel from Tashkent. The result of my highly unscientific poll of my relatives conforms to the trend among the Russians. At a recent birthday celebration, over a table laden with vodka and Russian specialties such as marinated tomatoes and cabbage, I was informed more than once that “we are a family on the right.”
Of nine adult relatives present, seven indicated that they will vote for Netanyahu. The other two may cast their lot with Yitzhak Mordechai, a former Likudnik who is the candidate of the new Center Party that is seeking to draw supporters from both the left and right. None favor Labor’s Barak. In the political party vote, most will support either Sharansky’s party or Our Home Israel, a rival Russian party established by longtime Netanyahu crony Avigdor Lieberman.
My relatives, like other Russians to whom I spoke, explain their position by citing Israel’s security needs, and are also put off by what they perceive as similarities between the Labor party and communism. “We’re too small a country to make mistakes,” says Artur. “And Labor is a socialist party. We’ve seen how that worked in the Soviet Union.”
Equality, brotherhood — we grew up with slogans like that,” adds
Galina. “None of them are true.”
They acknowledge that they are concerned about the tight relationship between the Likud and the ultra-Orthodox parties. Galina is not Jewish, which means that their teenage son is also not considered Jewish. Unless he converts, he will not be allowed to get married in Israel, even though he must serve in the army like other citizens. But my cousins point out — accurately — that in the past Labor, like Likud, has included the Orthodox in its ruling coalitions. Anyway, they say, the security issue trumps all others.
