Editorials - 05-06-2021

While the ferocious second wave of COVID-19 is slowly on the wane, Gujarat has recorded the highest number of mucormycosis cases in the country. Mahesh Langa reports on how a State with poor public health infrastructure and manipulated data was unprepared to tackle the surge in cases

In April, Bhavesh Desai (name changed), 56, was happily dreaming of a peaceful retired life in two years when he was suddenly assailed by two infections, one after the other. First, all food became insipid and Desai lost his sense of smell — both symptoms of COVID-19. By the time the RT-PCR test result came bearing bad news, the Class 2 government employee in Ahmedabad with two children had developed a fever and cough. With his condition worsening, Desai began searching for a hospital bed. Two days later, he found one in a private hospital where he was treated for two weeks. By the time he recovered, Desai was fatigued but relieved.

However, within a few days, Desai’s cheeks began to swell like small melons and his muscles became numb. He was referred to the Civil Hospital, where he was diagnosed with mucormycosis, commonly called the ‘black fungus’. Desai had never heard of it. He was shocked to learn that this aggressive infection could affect his eyes, nose and even brain. Desai found himself back in hospital. This time, the doctors had to remove his left eye to save his life. “I don’t know if I should feel happy that I have survived two deadly infections or sad about losing an eye. The other eye has just 70% vision,” he says.

Desai is among the 5,000 cases of mucormycosis that have been reported as of June 3 in Gujarat. Official records state that more than 250 people have died from the invasive fungal infection. With the State already grappling with a deadly COVID-19 wave, the rise in cases of ‘black fungus’ is a new cause of concern.

A surge in mucormycosis cases

Over the past few weeks, mucormycosis cases have increased across Gujarat, with Ahmedabad, Surat and Rajkot reporting very high numbers, particularly among those patients who, during prolonged hospitalisation, were administered high doses of steroids and antibiotics. Patients suffering from the fungal infection usually have a stuffy and bleeding nose, swelling of the eyes, blurred vision, and droopy eyelids.

“In Ahmedabad Civil Hospital, we have had 850 patients with mucormycosis. The ENT division has conducted 498 surgeries on patients who had the fungal infection,” says J.V. Modi, Medical Superintendent of Civil Hospital. At the time of going to print, more than 100 patients with mucormycosis were waiting in hospitals for their operations. “In Surat alone, around 100 people must have lost their eye or even their jaw bone due to the infection. It is more dangerous than COVID-19,” says a doctor from Surat’s Civil Hospital.

According to doctors, mucormycosis normally progresses slowly from the nose to the eyes and brain, but the real enemy this time is COVID-19. A host of factors can trigger mucormycosis. First is a weak immune system. The heavy use of steroids during COVID-19 treatment among diabetic patients can increase their sugar levels and create a conducive environment for the fungus to grow and thrive in the body, they say. So, a rational use of steroids and constant monitoring of sugar levels are important.

Though the State Health Department declared the fungal infection as an epidemic and created separate wards in Civil Hospitals in Ahmedabad, Surat and Rajkot, it has not made public the details of the number of cases, deaths, surgeries conducted, or people who have lost their vital organs as a consequence of the infection.

“As soon as the second wave of COVID-19 started declining in Surat, the city witnessed a sudden surge in mucormycosis cases,” says Manoj Mistry, a newspaper editor from the Diamond City, which saw thousands of COVID-19 deaths from early March to mid-May.

The government has also not fixed the treatment costs for patients of mucormycosis who are being attended to in private hospitals even though Gujarat had emerged as the State with the highest number of mucormycosis cases in India by the second week of May.

Luckily for Desai, treatment for the infection in Civil Hospital, a government hospital, did not cost him much. However, his stay at a private hospital for two weeks for COVID-19 treatment depleted his savings by half. “Despite the charges capped by the government for COVID-19 treatment in private hospitals, it’s still very high and beyond the means of any middle-class family,” he says.

Those who been treated in private hospitals for both the infections have paid huge sums for treatment. “More than COVID-19, treatment for mucormycosis is expensive because it also involves delicate surgery by specialist doctors,” a medical practitioner says. “Normal surgery will cost not less than Rs. 1 lakh in addition to expenses on medicines, hospitalisation and so on.”

To tackle the epidemic, the Gujarat government notified a State-controlled distribution policy of the anti-fungal drug Amphotericin-B, used to treat mucormycosis, for private hospitals after the issue of shortage of the drug was taken up by the Gujarat High Court that sought a response from the State government. And on May 27, an 11-member State-level task force comprising experts and doctors was formed and will play a key role in framing Gujarat’s policy on mucormycosis treatment.

Throwing caution to the winds

Meanwhile, the government is also busy trying to get the pandemic under control. Gujarat has seen an avalanche of COVID-19 cases during the second wave. On March 1, 427 daily cases and one death were reported. This shot up to 2,410 daily cases and three deaths on April 1 and then 13,847 daily cases and 172 deaths on May 1. On June 1, there were 1,561 daily cases and 22 deaths.

The virus has officially killed about 6,000 people since mid-March. However, data from hospitals, crematoria and burial grounds suggest that the number of deaths is as high as 15 times the official number. According to doctors, the official data on deaths capture only those who did not have co-morbidities and died of COVID-19. “For those who had COVID-19 but also suffered from diabetes or hypertension, the cause of death is attributed to the co-morbidity,” a medical practitioner says. Leading regional language newspapers such asGujarat SamacharandSandeshhave raised questions on the government’s data by devoting increasing numbers of pages to obituaries. The State government has also not been forthcoming about casualties in homes. However, the Chief Minister has maintained that the State follows the guidelines of the Indian Council of Medical Research. During the second wave, the virus also spread to remote villages, where public health infrastructure is especially rickety in such demanding times, making the government’s work even more challenging.

The Gujarat government seemed ill-prepared for the brutality of the second wave. From December 2020, the State began to shut some of its COVID-19 care centres unlike neighbouring Maharashtra which kept them open and even began to build more such centres. Gujarat also dereserved COVID-19 beds in private and government hospitals since the pandemic appeared to be on the decline. In February, Gujarat turned its focus to elections for municipal corporations like Ahmedabad, Surat, Rajkot, Vadodara, Jamnagar and Bhavnagar, 31 district panchayats, 231 taluk panchayats, and 81 municipalities. Voting was held in two phases on February 21 and 27. In the first phase, all six municipal corporations went to vote and the results were declared on February 23. The results for the second phase of polling for panchayats and municipalities were declared on March 2.

In the run-up to the election, there was aggressive campaigning across the State. Much like in other parts of the country, caution was thrown to the winds at these gatherings. Neither the leaders nor the public observed physical distancing or wore masks despite the fact that the Chief Minister himself contracted the virus during campaigning.

“In Gujarat, the second wave was invited by the authorities and political parties which were more interested in local elections than in following COVID-19 norms. As soon as the elections ended in the State, COVID-19 cases began to surge,” says a prominent doctor and member of the State government’s COVID-19 task force. He adds that the cases had in fact started rising from the second week of February, but the authorities suppressed the data as holding elections was given more importance than public health.

“As a member of the medical fraternity, I am also partially responsible for not going public and warning government authorities as well as the public at large. As part of the IMA [Indian Medical Association], we should have expressed and communicated our apprehension about the second wave to the government,” says another leading doctor.

By the first week of March, the pandemic curve began going north in the State and by mid-March, there was an alarming rise in cases and deaths in all the major cities. By the end of the third week, COVID-19 cases began to be reported from semi-urban places and by March end, from the villages. It was when cases began rising rapidly that the government began to prepare at a feverish pace, adding beds and ramping up facilities.

“Undoubtedly, the local elections brought the virus to the villages, which had escaped its clutches during the first wave. Every village had an election meeting or a rally without any COVID-19 norms,” says the District Collector of one of the worst-affected districts.

From mid-March onwards, the State administration shut down public transport services in the cities, banned mass gatherings, restricted movements in markets and religious places, and limited participation in social events and family events. However, those measures came too late. Many say these were attempts to close the stable door after the horse had bolted.

A summer of horror

April 2021 was arguably the most cruel month in the history of contemporary Gujarat. The healthcare sector was bursting at its seams and thousands of deaths were being reported every day. The administration appeared to be struggling in dealing with the crisis.

“It’s not that the administration was not working but our all efforts were falling short because of the sheer number of cases and deaths that were taking place. We were overwhelmed. There was a shortage of hospital beds, essential medical supplies, ambulances, and even mortuary vans to take the dead to their final destination,” a senior official says. The State and its people never anticipated a second wave, he says.

According to another bureaucrat, more people may have died for want of oxygen, hospital beds or essential medicines rather than COVID-19 in April. “We could have saved thousands of lives if there was an adequate number of beds, supply of oxygen and perhaps proper pandemic management,” he says.

A senior staff member at Civil Hospital describes the situation as being “completely chaotic”. “There were long queues of patients waiting to be admitted, there were 80-90 ambulances carrying patients for admission outside hospitals... At least 100 people must have died just waiting to be admitted,” he says.

The administration was forced by the Gujarat High Court, which took suo moto cognisance of the situation, to swing into action. It was only after the High Court’s intervention that the Health Department started conducting RT-PCR tests at all the district headquarters. Before that, there were no laboratory facilities to even conduct tests in half of the 33 districts of the State.

There also appeared to be no mechanism in place for oxygen procurement and supply in the initial stages of the second wave. After the situation became dire in April, the government appointed two bureaucrats as nodal officers for oxygen supply.

Though the State government has denied that deaths were caused due to the lack of oxygen, Mistry says patients have died without oxygen in several hospitals. Local media reported dozens of deaths in the north Gujarat and Saurashtra regions due to shortage of oxygen in hospitals in remote districts.

“The Centre had allotted 1,000 tonnes of oxygen to the State based on the number of cases and patients, while our requirement was around 1,350 tonnes. Why was Gujarat given less oxygen than required, you may ask. That is because it fudged cases and projected low figures,” says a top bureaucrat and core group member who was involved in pandemic management.

The IMA in Ahmedabad and Surat even warned that there would be a law and order situation in the cities if oxygen supply was not ramped up in hospitals.

The neglect of public health

Gujarat’s health infrastructure struggled to cope during the health emergency despite the fact that the State saw a lower number of daily cases compared to neighbouring Maharashtra or even southern States like Karnataka and Tamil Nadu. The official number of daily cases never crossed 20,000 in Gujarat compared to Maharashtra where daily cases touched 70,000 and Karnataka where they touched 50,000.

“Yet the situation seemed worse in Gujarat. All the figures from daily case numbers to daily tests to cases of hospitalisation and deaths were lower than the actual count. That made our job more difficult because the numbers were kept artificially low, but in reality, there were no beds available anywhere in the city,” says the CEO of a top hospital in Ahmedabad.

There are huge numbers of vacancies in healthcare centres. There are almost 8,000 vacancies of medical and paramedical staff in the panchayat-run primary and community health centres in districts and municipal-run health centres in the cities, for instance.

“When the High Court asked the State government whether all the districts have HRCT (High Resolution Computed Tomography) machines to conduct CT scans since in certain cases the virus is not detected in RT-PCR tests, 15 out of 33 districts had no CT scan machines in government-run hospitals and health centres,”wrote Congress spokesperson Manish Doshi to the Chief Minister.

In the last two decades, while the private health sector has grown visibly in cities like Ahmedabad, Rajkot, Surat and Vadodara, public healthcare has not seen concomitant growth. “The State will have to now promote public health infrastructure and manpower. The pandemic has shown that it cannot rely on the private sector to compensate for public health,” a senior bureaucrat says. He says the State should follow the examples of Kerala or Tamil Nadu while investing in public health.

In 2017, the Comptroller and Auditor General of India pointed out in its audit report the poor healthcare conditions in districts and rural areas. It said that in some hospitals, patients were being forced to sleep on the floor in rural health centres as there were no beds available. The condition of rural and district hospitals and health centres does not seem to have improved since. Total spending on health remains below 4% of the Budget.

“In my district, in the main Civil Hospital, there were almost 700 patients with only a dozen medical staff including two doctors, a few nurses and paramedics to attend to them. This was the situation in April when the pandemic was at its peak,” says a District Collector from the Saurashtra region. “If we don’t draw proper lessons now and improve our healthcare, the next wave could be even more fatal,” he says.

The National Biodiversity Mission can help mend the dysfunctional relationship between humanity and nature

On this World Environment Day (June 5), with the novel coronavirus pandemic raging across our vast country, we must reflect on the ways to rebuild our relationship with nature. India’s vast and rich biodiversity gives the nation a unique identity, of which we can be proud. The varied ecosystems across land, rivers, and oceans, feed our people, enhance public health security, and shield us from environmental disasters. Our biodiversity also serves as a perpetual source of spiritual enrichment, intimately linked to our physical and mental well-being.

Staggering value of forests

And while the precise economic value of all ecosystem services provided by biodiversity may not be known, estimates suggest our forests alone may yield services worth more than a trillion rupees per year. Imagine how much greater this value will be with grasslands, wetlands, freshwater, and marine added.

Sadly, today, we face not only one of the worst public health crises but also worldwide declines in biodiversity. Globally, we have lost 7% intact forests since 2000, and recent assessments indicate that over a million species might be lost forever during the next several decades. Our country is not an exception to these trends.

Climate change and the ongoing pandemic will put additional stresses on our natural ecosystems even though it is becoming clear that repairing our dysfunctional relationship with nature is one of the ways to mitigate climate change and curtail future outbreaks of infectious diseases that can bring unimaginable misery. Thus, preserving biodiversity is directly relevant to the social, economic, and environmental well-being of our people. We must rethink and reimagine the concept of One Health for all living organisms, including the invisible biota in soils that sustain our agricultural systems.

Investments in the field

Fortunately, our government is considering major investments in biodiversity science to meet societal needs. In 2018, the Prime Minister’s Science, Technology and Innovation Advisory Council (PM-STIAC) in consultation with the Ministry of Environment, Forest, and Climate Change and other Ministries approved an ambitious National Mission on Biodiversity and Human Well-Being (NMBHWB). A Bengaluru-based Biodiversity Collaborative is working with the National Biodiversity Authority to hold consultations and prepare road maps of the Mission that will be steered by a core of the country’s leading biodiversity science and conservation organisations, from public, academic, and civil society sectors.

The Mission will strengthen the science of restoring, conserving, and sustainably utilising India’s natural heritage; embed biodiversity as a key consideration in all developmental programmes, particularly in agriculture, ecosystem services, health, bio-economy, and climate change mitigation; establish a citizen and policy-oriented biodiversity information system; and enhance capacity across all sectors for the realisation of India’s national biodiversity targets and United Nations Sustainable Development Goals (UN SDGs).

Furthermore, the Mission will allow India (home to nearly 8% of global biodiversity on just 2.3% of global land area, and containing sections of four of the 36 global biodiversity hotspots) to emerge as a leader in demonstrating linkage between conservation of natural assets and societal well-being.

An important framework

The ongoing spread of COVID-19 places this Mission among the most significant national initiatives. The pandemic has exposed the dysfunctional relationship between humanity and nature, and we must urgently address the issues it has laid bare: the emergence of infectious diseases; lack of food and nutritional security; rural unemployment; and climate change, with all its stresses on nature, rural landscapes, and public health. In response to these critical and interrelated issues, the Mission offers a holistic framework, integrated approaches, and widespread societal participation.

The Mission’s comprehensive efforts will empower India to restore, and even increase, our natural assets by millions of crores of rupees. Mitigation programmes will lessen the impacts of climate change and other natural disasters, such as pandemics and floods. We can rejuvenate agricultural production systems and increase rural incomes from biodiversity-based agriculture while also creating millions of green jobs in restoration and nature tourism. Restoration activities across India’s degraded lands, which amount to almost a third of our land area, alone could generate several million jobs.

The Mission will help India meet its commitments under the new framework for the Convention on Biological Diversity (CBD), and UN SDGs related to pressing social issues including poverty alleviation, justice and equity, and protection of life. It will generate a strong national community committed to sustaining biodiversity, promoting social cohesion and uniting the public behind an important goal.

Mission programmes will offer nature-based solutions to numerous environmental challenges, including degradation of rivers, forests, and soils, and ongoing threats from climate change, with the goal of creating climate-resilient communities. Scientific inputs, especially related to geospatial informatics and policy, can guide the development of strategies for conservation and ecosystem management.

Equally important, the Mission’s “One Health” programme, integrating human health with animal, plant, soil and environmental health, has both the preventive potential to curtail future pandemics along with the interventional capability for unexpected public health challenges. Additional programmes, directed at food and nutritional security, will in turn also influence public health outcomes.

Need for a cadre

The planned Mission recognises that we need a strong and extensive cadre of human resources required to meet the enormous and complex environmental challenges of the 21st century. This will require training professionals of the highest calibre in sustainability and biodiversity science, along with an investment in civil society outreach. The gains of environmental change will be upheld and carried forward by the cultural change from environmental education for millions of students, from kindergarten to postgraduate levels.

Finally, biodiversity is everywhere, and we interact with biodiversity all the time in our daily lives. Public engagement, whether it is in the policymaking arena, or in exploration, restoration and conservation of biodiversity, is a critical component of the planned Mission.

Today, on the heels of theInternational Day for Biological Diversity celebrated last month, nothing could be more important than to renew our pledge to nurture all life on earth.

Kamal Bawa is President of the Bengaluru-based Ashoka Trust for Research in Ecology and the Environment (ATREE), and currently leads the Biodiversity Collaborative. The views expressed are personal

There are no second chances and nations must use COP26 to address the enormous threat of climate change

This is an incredibly difficult time for the world. The world is facing two momentous challenges: COVID-19 and climate change. Both need us to come together globally to find a way forward. World Environment Day (June 5) is an important moment to take stock on climate change.

When I was in India earlier this year — my first visit to Asia in my new role — I saw first-hand India’s ambitious work on renewable energy, and held vital discussions with government leaders, including Prime Minister Narendra Modi, businesses and civil society. I was inspired by the resolve I saw.

India’s response

India has a strong record on tackling climate change, including impressive domestic targets to have 450GW of renewable energy by 2030, and establishing the International Solar Alliance and the Coalition for Disaster Resilient Infrastructure (CDRI). India played a critical role in delivering the landmark Paris Agreement and we are working just as closely with India in the run-up to COP26, the 26th UN Climate Change Conference of the Parties, to be hosted by the United Kingdom in Glasgow from November 1-12, 2021. Last month, Mr. Modi and the U.K.’s Prime Minister Boris Johnson committed through the 2030 UK-India Roadmap to work closely together on the best ways to drive the green growth agenda. They reaffirmed their personal commitment to work together for an ambitious outcome in November and sustained action beyond.

When the U.K. welcomes the countries of the world to Glasgow in five months’ time, it will be a moment to get the world on track to address the enormous threat of climate change and build a cleaner, brighter future for everyone.

In 2015, the world signed the Paris Agreement, to limit global temperature rises to well below 2°C, aiming for 1.5°C, because the science tells us that would avoid the worst effects of climate change.

Emissions have to be cut

In terms of limiting warming, every fraction of a degree makes a difference. An average global temperature rise of 2°C, compared to 1.5°C, would see hundreds of millions more people affected. The Climate Action Tracker estimates that countries’ current emissions reduction targets have us on course for average temperature rises of 2.4°C. To limit warming to 1.5°C, we must halve global emissions by 2030. So this is the decisive decade.

This is what makes this year’s COP so critical, and as hosts of COP26, the U.K. is pressing for urgent action around four key goals.

First, to keep 1.5°C within reach, globally, we need to reach net zero by the middle of this century. To achieve this we will need to take strong action over the next decade. In the U.K. we have found that setting ambitious short-term targets backed up by a net zero target has given a clear signal that the future is low carbon. India will reach its own decisions, but I firmly believe India has an opportunity to show that a different development path is possible. An opportunity to be at the forefront of a new global green transition with all the benefits of jobs and cleaner air that brings. India has already proved it has the innovation and political will to do this. India has quadrupled wind and solar capacity in the last decade.

Our second goal is to protect people and nature from the worst effects of climate change. Even as the world has been dealing with the novel coronavirus pandemic, the dangers of global warming have continued to become more evident.

Having been born in India and having spent time as the U.K.’s Secretary of State for International Development, I am committed that this COP will deliver for the communities most vulnerable to climate change. The two cyclones, Tauktae and Yaas, that hit India last month, show that we must act on the very real need for flood defences, warning systems and other vital efforts to minimise, avert and address the loss and damage caused by climate change. India’s CDRI, which the U.K. is proud to partner on, is already a great initiative towards this.

Funding promise

Our third goal is for developed countries to deliver the $100 billion they promised annually to support developing countries. The U.K. is pushing for all developed countries to increase their climate finance commitments ahead of COP26, to deliver the right flow of finance and technology to meet the needs of countries such as India in their transition. This is a personal priority for me, one that I am committing to work tirelessly to deliver — we need all developed countries to step up, as it is a matter of trust.

Working as a team

Fourth, we must work together to deliver on these goals. That includes building consensus among governments for an ambitious, balanced and inclusive outcome — so that the negotiations in Glasgow are a success. As well as bringing businesses and civil society on board behind our COP26 goals, and building up international collaboration in critical sectors.

We must act now, to launch a concerted effort to reduce emissions throughout the next decade. And use the COVID-19 recovery to reimagine our economies, building a better future.

I call on all countries to step up efforts on these goals, because COP26 is our last chance for keeping hopes of limiting global warming to 1.5°C alive, and our best chance of building a brighter future; a future of green jobs and cleaner air.

This is our moment. There are no second chances. Let us seize it together.

Alok Sharma is COP26 President

India betters score in the latest SDG Index, but methodological tinkering is cause for concern

India’s push in the right direction in achieving Sustainable Development Goals (SDGs) related to clean energy, urban development and health has helped it improve its overall SDG score from 60 in 2019 to 66 in 2021, according to NITI Aayog’s SDG India Index 2020-21. Besides SDGs on eradication of poverty and hunger, measures related to the availability of affordable, clean energy in particular, showed improvements across several States and Union Territories. The campaign to improve the access of households to electricity and clean cooking fuel has been shown to be an important factor. While this is cause for cheer, the Index reveals that there has been a major decline in the areas of industry, innovation and infrastructure besides decent work and economic growth, again made worse by the lockdowns imposed by the governments seeking to tackle the COVID-19 pandemic. But the stark differences between the southern and western States on the one hand and the north-central and eastern States on the other in their performance on the SDGs, point to persisting socio-economic and governance disparities. These, if left unaddressed, will exacerbate federal challenges and outcomes, as seen in the public health challenges during the second wave across some of the worse-off States.

Notwithstanding the improvement in key indicators, the Index has curiously made some methodological changes that render comparisons on some SDGs over previous years moot. The SDG on inequality shows an improvement over 2019, but the indicators used to measure the score have changed. The 2020-21 Index drops several economic indicators and gives greater weightage to social equality indicators such as representation of women and people from marginalised communities in legislatures and local governance institutions, and crimes against SC/ST communities. By dropping the well-recognised Gini coefficient measure and the growth rate for household expenditure per capita among 40% of rural and urban populations (instead, only the percentage of population in the lowest two wealth quintiles is used), the SDG score on inequality seems to have missed out on capturing the impact of the pandemic on wealth inequality. This could be a significant miss as a UN assessment of the impact of COVID-19 had said that the South Asian region may see rising inequality. Methodological issues on measuring other SDGs have been flagged before, but the lack of adequate measurement of economic inequality seems to be a glaring miss. Like in the first wave, the second wave, with more fatalities, has had similar outcomes on livelihoods and jobs. While the better score for India in its endeavour to achieve SDGs will bring some cheer, governments must work on addressing pressing issues such as increased inequality and economic despair.

Israel gets new coalition, but it is unlikely to survive long with its ideological contradictions

In Israel’s fractious political landscape, Benjamin Netanyahu has been known as the master of survival. In power since 2009, he has seen allies come and go, protégés turning out to be rivals, and elections happening in the shortest intervals. But he hardly missed an opportunity to turn crisis into political gain, which allowed him to become the longest serving Prime Minister, overtaking David Ben-Gurion. However, this may be ending. A coalition of eight parties, under the leadership of Opposition politician Yair Lapid, could oust Mr. Netanyahu from power and form a ‘change’ government. In this, Mr. Lapid, who leads the centrist Yesh Atid party, has joined hands with the right-wing Yamina of Naftali Bennett, and other parties ranging from pro-settlers to left-wing and Arab parties. According to the coalition agreements, Mr. Bennett, who was part of the far-right Jewish Home before founding Yamina, would be the PM for two years followed by Mr. Lapid. Mr. Lapid says his coalition has the support of 61 Members of the Knesset (MKs) — a razor-thin majority in the 120-member Parliament. Messrs. Lapid and Bennet are now pushing for a quick vote in the Knesset, while Mr. Netanyahu is putting pressure on the right-wing MKs of the coalition to vote against the government.

Even if the coalition does sail through the Knesset vote, it might, with its conflicting ideological views, remain fractious and feeble. But that does not diminish the importance of the political changes that are under way. The country has seen four elections in the last two years, with no party winning a majority on its own in any. Last year, Mr. Netanyahu formed a short-lived unity government with the Opposition leader, Benny Gantz. Mr. Gantz, leader of the centrist Blue and White, is now with Mr. Lapid. It is Mr. Netanyahu’s repeated and failed attempts to form a stable right-wing government that have led the anti-Netanyahu parties from across the spectrum to come together. Also, this is the first time in Israel’s history that an Arab-majority party has signed a government coalition agreement. Till last year, Arab parties were considered untouchables by the mainstream Jewish parties. But now, the United Arab List (Ra’am), which has 4 MKs, has officially joined the coalition, breaking a political separation wall. If voted out of power, Mr. Netanyahu will have to fight a corruption trial and possible leadership challenges within the Likud without the shield of premiership. When the Gaza fighting broke out on May 10, coupled with riots in Israeli cities, many thought it would help him politically. But the Gaza fighting appears to have weakened his position among his right-wing allies, who alleged that his government surrendered to Hamas by agreeing to the ceasefire. Mr. Netanyahu is now caught between unhappy right-wing allies and a united opposition.