The way things are looking and sounding in Israel, the coronavirus is still the muffled sound of rolling thunder, the effect of which is still relatively limited.
The worldwide crisis has turned the gaze inward, in each and every country. The solution will come ultimately through international cooperation – development of a vaccine against the virus, perhaps development of medications, transparency in reporting and coordinated policy. At the moment, however, each individual country is fighting the battle alone, unable to expect aid from abroad in the near future.
Haaretz Weekly Ep. 72
In these terms, the damage to health from the virus is not out of control here. The possible, scary crash point for the health system has been postponed. The effective decisions taken at an early stage – isolation of sick people, social distancing rules and, what is especially important, the call for elderly people to stay at home – have to some extent flattened the morbidity curve and bought a number of additional precious weeks for getting organized. The number of dead is rising steadily, but Israel has not yet encountered circumstances in which there is a deluge of especially vulnerable patients – elderly people and people with pre-existing medical issues – creating heavy pressure on the hospitals and the medical teams in a way that would prevent effective treatment.
The coronavirus in the land of Israel is apparently a bit different from its European kin. Israel has some specific advantages in dealing with the virus, such as a single major point of entry – Ben-Gurion International Airport, though it is not under sufficient supervision – and a younger population than in Europe. However, the number of cases that have been diagnosed does not reflect the real rate in the population, which, according to various estimates, could be double the reported number or more. This is connected to the number of tests performed daily, which is still low, and to the significant, if not precisely known, percentage of asymptomatic cases in the population.
The critical datum is the proportion of people on respirators among the diagnosed cases, which at the time of writing stands at about 1.3 percent. Not only are ventilators lacking – though there is currently a world-embracing effort to obtain more – but sufficient teams that know how to work them are also needed.
Prime Minister Benjamin Netanyahu is proud of his achievements. The percentage of deaths in Israel is indeed low, less then 5 percent among the diagnosed cases, as compared to 6 to 11 percent in European countries that have been badly hit, from Britain to Spain and Italy. The fear of a slide into the Italian model here in Israel at the beginning of April has not happened so far. The focus, therefore, is on putting out specific fires, first and foremost in the ultra-Orthodox towns and neighborhoods.
This week, though fatally too late, there has been evidence of the Haredi rabbis and politicians coming to their senses. Since Wednesday, the streets of the mostly ultra-Orthodox city of Bnei Brak have emptied and the army is gradually stepping into the shoes of the local authority, with the aim of giving aid. There was something symbolic in that this was happening contemporaneously with the unfortunate report that Health Minister Yaakov Litzman and his wife Hava have come down with the virus. The viral infection in Haredi locales will continue to cast a dark shadow on Israel’s fight against the coronavirus.
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On Thursday the CEO of the Maccabi HMO, Prof. Ran Saar, voiced a hair-raising estimate: The number of cases in Bnei Brak is already liable to be about 75,000, about 38 percent of the city’s population. If this estimate is anywhere close to reality, any effort the Israeli public has made during the past several weeks is about to go down the drain, because of the situation in Bnei Brak.
On Passover Eve, next week, the problem will become even worse because of the head-on clash between the caution that is required now and religious customs that are thousands of years old. In about a month’s time, the problem will repeat itself in the Muslim population surrounding the events of the holy month of Ramadan. In consultations with Netanyahu, the prevailing assumption is that the peak rate of infection is expected in May.
Decision time ahead on economy
Coping with the coronavirus is not a sprint – but rather a marathon. The fear, as Assaf Orion of the Institute for National Security Studies puts it, is this: For all that the leadership in Israel is focused on preventing deaths from the virus, it is not sufficiently balancing its decisions with the economic damage that has already been caused. “We are like a pilot who is entirely focused on the altimeter but is liable to fly straight ahead and crash the plane into a mountainside,” says Orion. “It is not possible to look only at the numbers of the dead. It is necessary to take into account the long-term economic repercussions as well.”
There will not be any relaxation of the shutdown policy by Passover. It might even become stricter before seder night, with the aim of preventing gatherings of extended families in violation of the government’s instructions to the public. Afterwards, however, the decision point will be reached: What should be done about the economy? Many economists believe that the recent restrictions, among them lowering the permitted number of workers in companies from 30 percent to 15 percent, is causing tremendous additional damage without necessarily reducing the morbidity curve.
A near-consensus is taking shape: It is necessary to have a gradual opening of the economy for people to get back to work, while continuing to protect the vulnerable populations (practically speaking, an instruction for them to remain in their homes) and constant tests with the aim of identifying outbreak flashpoints. Prof. Amnon Shashua, the founder of Mobileye, who has submitted a proposal concerning this matter to Netanyahu, calls the necessary solution “vertical closure” – releasing younger populations to go back to work, under restrictive conditions, with the aim of thawing the economy.
Decision-making in national security crises (and the coronavirus is a national security crisis even if not a single shot has been fired) is a cold business, not for the weak of heart. It is possible that down the road there will be a need to take greater, calculated risks. If this were a war, in which the entire Israeli economy was under threat and so badly affected, presumably the government would take far greater risks with the aim of removing the threat.
A document written this week for the National Security Council examines five alternative exit strategies, marking a target date for a change in the policy – April 19, the first day after the end of the intermediate days of Passover. The alternatives draw up competing models: gradual lifting of the restrictions (“the way we went in is the way we go out”); release according to work shifts (in which the working population is divided in two); alternating release (four days at work followed by 10 days of lockdown); release by age (dividing the population into three groups); and conducting a “breathing lockdown,” in which renewed lockdown is imposed in areas where outbreaks of the disease are identified.
The document, which was written at the Ministry of Intelligence Services, recommends a mixture of elements from the various models. The way things are looking now, the final decision is a long way off.
In the discussions held this week, the pressure from the Health Ministry continued, with the backing of the National Security Council and implied support from Netanyahu, in favor of continuing the lockdown and even tightening it. However, the Bank of Israel pushed for considerable easing of the lockdown, while adopting surveillance methods that appear to have been invented by George Orwell, on the grounds that they have been tried successfully in East Asia.
The element lacking in the policy, more than a month after the first case was identified in Israel, still has to do with testing. In the consultations this week there was talk of increasing the daily number of tests to 10,000 by Thursday of the week ending and to 30,000 next week. It is not clear that the state will stick to the timetable it has set. However, there are various conceptual breakthroughs that could enable a rapid climb to an even larger number, perhaps in April. The intention is to give first priority to testing three populations: people who have apparently been exposed to the virus, with an emphasis on vulnerable populations; essential workers who are liable to spread the infection in the course of their work; and people doing essential work in the health system and the economy.
However, all this is just plans on paper. At the moment it appears that getting the test results is still slow and there is a lack of a great deal of knowledge that would help formulate a correct policy. Along with increasing the number of what are called polymerase chain reaction tests, which identify sick people, the country is not yet preparing for serological tests to identify people who have already been ill, have not shown any symptoms and have developed a certain amount of immunity to the virus. This is a critical element in decisions about coming out of the lockdown, but it has yet to be organized and an extensive system for administering such tests to this end is not yet in place.
Centralization vs. chaos at the top
As of Thursday, Netanyahu entered into isolation for the second time this week, this time for six days, because of Litzman’s illness. Isolation has also been imposed on a number of the top people in the health system and the defense system. This is a hitch that could have been avoided, had meeting physically at a single site been replaced by consultations at a distance.
Participants in the discussions continue to report two contradictory tendencies: centralization and chaos. The decisions are finalized between the prime minister, the director general of the Health Ministry and the head of the National Security Council, while most of the cabinet ministers have no real influence on them. All around, the organizational pandemonium is huge. There is not yet anything reminiscent of orderly, planned work in dealing with a crisis. The daily agenda for the government is very far from the way, for example, the Israel Defense Forces conducts a war.
The focus on the number of the dead, about which Orion commented, raises the suspicion that with the aim of maintaining the relative achievement, the economy will be damaged even further. In the background is the figure of Netanyahu himself. A considerable part of the public does has no trust in his considerations and motives. On Wednesday evening, prior to another dramatic nighttime appearance and the declaration of new restrictions on movement, came the incredible report about the negotiations with Kahol Lavan: The sides are discussing the establishment of an official residence for the deputy prime minister in addition to the prime minister’s residence on Balfour Street in Jerusalem. In a country where the number of unemployed has crossed the 1 million mark, this is a demonstration of sheer obtuseness.
In the meantime, about two weeks have gone by since Netanyahu called on Benny Gantz to carry his end of the stretcher of unity in the name of the war on the coronavirus. The disagreements between the sides on the divvying up of ministerial portfolios indicate that the sense of urgency was not entirely authentic. Apparently, there is a close relationship between the decisions that are landing on the public in the fight against the virus and Netanyahu’s considerations in his efforts to create an atmosphere that suits his needs in the negotiations.
The deliberations of the Knesset Special Committee on Dealing with the Coronavirus headed by MK Ofer Shelah of Yesh Atid complete the picture of government leaks. From the committee meetings, the weakness of the Health Ministry, the inaptitude of the minister who heads it and the flawed functioning of other government ministries are evident. The National Emergency Management Authority at the Defense Ministry is hardly in the picture. The crisis is revealing that the agency has barely planned for any health problem that isn’t connected to war and the firing of missiles at the home front. Since in a war on the home front the burden on the hospitals would be tremendous, the question arises as to whether in such a case Israel would fail because of that same weak link.
Politics touches on everything and for the most part corrupts. When Litzman recovers, in the hope that Netanyahu will make the obvious move and replace him with a different minister in the next government, there will be a place for examining his dealings in the Health Ministry, which have included massive aid to rabbis and influential people identified with him. Even this week, when the Defense Ministry was asked to prepare glatt kosher guest houses to take in coronavirus patients who must urgently be removed from Bnei Brak, suspicion arose that he was recommending his cronies. At the ministry they asked for an explicit instruction from the National Security Council, for cover.
In this drama, which is the most complex if not the most difficult crisis Israel has ever faced, the IDF is still looking on with interest and a bit from the outside. Defense Minister Naftali Bennett is immersed entirely in the pandemic – and is succeeding in infuriating Netanyahu and the top Health Ministry people by pushing original ideas and constant invasion of areas that are not his to invade. Still, time after time Bennett is exposing how cumbersome and convoluted the system is. That was the case on Wednesday, after Amalia Duek’s report on Channel 12 about the neglect at Ben-Gurion International Airport, which let thousands of returnees from abroad arrive in the country without obliging them to go into isolation. This misstep quickly escalated into scathing exchanges of accusations between Netanyahu and Bennett.
The army is gradually entering the picture, by means of the Home Front Command, the Technological and Logistics Directorate and Military Intelligence, but it is far from being in a leadership position. Considering that it is the only organization in the country capable of operating a tremendous logistics system, along with the extensive manpower available to it (which, being young, is also less exposed to harm from the virus), the army’s part is still relatively limited. Presumably its role will expand as things get knottier.
In the background, tensions, battles for authority and credit envy are developing not only between Netanyahu and Bennett but also among the various security organizations. The media are filling up with excited reports about the joint defense establishment war room operating at Tel Hashomer (Sheba Medical Center). But in actuality, not even a definite chain of command has been established there. The IDF is directly subordinated to the defense minister while the Mossad is directly subordinated to the prime minister. Who makes the final decision? It is not clear, and perhaps that is just the way Netanyahu prefers it to be.
Also within the Israeli Defense Forces, disorder prevails. Every day soldiers are sending journalists photos from their units, in which the crowding and blatant ignoring of the social distancing strictures are obvious. At inductions, in training and in course graduations, there is constant, confused indecision about allowing soldiers to go home. Female soldiers who were inducted this week reported to the Induction Center, spent time together there in crowded conditions and the next day were sent home until after seder night. In courses and units soldiers are receiving orders about home furloughs that are revoked when it is discovered that another person has been infected, after which another ban on exiting the base is imposed, again and again. This is not a format that will hold up forever. The IDF is not the Russian army, in which soldiers get home leave once a year.
Challenge of old-age homes
Along with ultra-Orthodox locales, the most sensitive nodes for infection by the virus are in the assisted living facilities and nursing homes. Thus far, fatal outbreaks have been reported at Migdal Nofim in Jerusalem and Mishan in Be’er Sheva. At other nursing homes too, and in the geriatric department at the Meir Medical Center in Kfar Saba, many cases have been reported. The elderly are the most vulnerable population, but unlike elderly people who live on their own, at the residential facilities it is difficult for them to isolate themselves from the outside world. Contact with staffers, who are sometimes infected with the disease without knowing that they are sick, ignites fires that are hard to extinguish afterwards.
Two weeks after its stubborn, unexplained refusal, the Health Ministry somewhat softened its stance and began to approve more comprehensive and extensive testing at assisted living centers, even of elderly people who were asymptomatic. Prof. (Emeritus) Hillel Bercovier of Hebrew University Faculty of Medicine, who has spent years researching epidemics, says the state has to impose far stricter rules with regard to the employees in assisted living centers, until the epidemic is overcome.
“There is no alternative,” he says, “to imposing strict rules for workers in these places because otherwise the outbreaks will only get worse. We have to create sterile separation: Workers are to be divided into two shifts of several weeks each, such that before they start a shift they will spend a preparation period in isolation in order to reduce the chance of being infected with the virus when they are outside. They also have to take upon themselves restrictions when they are on days off. The state must find a way to help the families of these workers.
“In addition, they must have frequent coronavirus tests. The elderly have already gone into isolation under instructions from the government and they are not seeing their families. But if we aren’t protecting the first circle around them, the workers at the residential centers, the contagion will spread and harm the most vulnerable people,” says Bercovier. When asked whether these restrictions are perhaps too stringent, he replies: “It’s saving lives. I don’t see any other option.”