The Health Ministry’s public and political line of credit for extending the coronavirus lockdown has run out. The upcoming exit from the lockdown is no longer a matter of when, but of how.
The modest drop in the number of confirmed COVID-19 cases and critically ill patients after many weeks, even if it continues, is pushing the ministry, the professionals and the decision-makers toward an exit point rife with peril and little room to maneuver. The ministry will be forced to build a gradual, precise strategy with a large component of uncertainty, which is likely to put lives at risk.
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The effort to get every available drop of vaccine into people’s arms by the exit point could have a positive effect; every day that passes widens the circle of those getting the second dose. But even if a significant percentage of those who are 60 and above are optimally protected by next week, it’s doubtful this will outweigh the expected increase in the number of new cases of the British strain once the lockdown is lifted, along with the number of seriously ill. It’s hard to expect that this time, there will be any grace period after the exit to plan the next steps.
On the other side of the equation is a worn-out, frustrated public that is carrying a burden of ongoing health care, social and financial damage, which is manifesting itself in a lack of trust and an increased flouting of the lockdown regulations and the rules of social distancing.
The strict, uncompromising stance that the Health Ministry and its minister Yuli Edelstein have taken with regard to maintaining the lockdown has the professional support of the director of public health services, Dr. Sharon Alroy-Preis, and the coronavirus chief Prof. Nahman Ash. But there are other voices in the ministry and its professional affiliates that have less stringent opinions, who point to the Immense damage the lockdown is causing. They voice their opinions in closed forums, but their positions don’t make it into the decisive discussions in Edelstein’s office or the forums headed by Prime Minister Benjamin Netanyahu.
“The problem is that the ones promoting the policy of the ministry are primarily the doomsayers, including the mathematicians and modelers that present hardline models,” said a ministry source. “Not everyone believes them. The working assumption these models are based on is that everyone will get infected. But it’s not clear that that’s true. That keeps the ministry fixed in place and doesn’t allow it to move forward.”
Sources in the health care system say that lately, other voices are being heard in the experts committee and on the pandemic task force. They are coming from those who understand that the current situation cannot continue and that other solutions must be found.
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“Poverty and education impact public health and we can no longer ignore this,” the Health Ministry source said. “And that’s even before the wider effects on the economy. It comes up in meetings and discussions of the task force but it stops there. It doesn’t get to the discussions by the decision-makers, this isn’t presented to the minister or the prime minster. I don’t think that at the end of this week most of the experts will back a decision to extend the lockdown another week. They also understand that it’s too much.”
Still hovering in the background is the pressure on the hospitals and the number of seriously ill patients. The first signs that the number of sick people is dropping and the ever-growing number of those vaccinated among the risk groups could lead to an even further improvement. But even with the current high numbers, there are sources in the health system who argue that over the past year Israel has become more prepared and more experienced, and would be able to manage high morbidity rates as the price of ending the lockdown.
“There is a better testing and investigation mechanism in place,” said a senior health official. “Regarding the hospitals, if at first we spoke of a limit of 800 seriously ill patients, the hospitals have been managing for a while with 1,200 seriously ill patients, and they are still not close to insufficiency. It could be that we could live with this so we can open the economy, understanding that the vaccination process will lower the numbers.”
In addition to the internal discussions within the ministry and the health system, the ministry is under all sorts of pressures, from politicians in the midst of an election campaign to people with commercial and financial interests.
A way out
Exit options are already being discussed on the theoretical level, but there are no objectives and no strategy as of yet.
“One of the main problems is that there are no discussions about substance. They talk for hours about whether the lockdown will start on Thursday or Sunday, but there’s never any discussion about where Israel wants to go, and what price it’s willing to pay to achieve that goal,” said a Health Ministry source.
Sources in the health care system say the more conservative forces, including the politicians, prefer to deal as little as possible with risk management, especially during an election campaign, where taking a risk could have political consequences. “In fact, there are a variety of alternatives for exiting the lockdown, more gradual or less, broader or less so. Each comes with different levels of risk,” said a health care official.
Health care sources say that the lockdown exit will naturally include the opening of schools and commerce, though it isn’t clear yet in what format. Some say that unlike after the second lockdown, when the Health Ministry’s measured, orderly plan was brutally trampled on by the politicians within the first week, this time the ministry will only plan the first stage, and work on the subsequent ones in accordance with developments in the field (and the pressures that will be brought to bear by the politicians with an election looming).
From an epidemiological perspective, the medical and science communities can’t see any exit being managed smoothly. Israeli caution and solidarity, which have repeatedly failed to hold up over the past year, aren’t expected to surprise anyone this time, even if there’s an intense information campaign. That’s why the public and media discourse is focusing on the price.
“If in the past there was a reality in which you knew you always had the option of imposing a three-week lockdown, and the R [the average number of people a sick individual infects] would drop to 0.65 and the infections would drop from 9,000 to 2,000 [per day] and the numbers would continue to drop from the power of inertia, which would give you leeway for a few weeks forward to manage [the exit] more cautiously and observe your own recommendations for a safe exit – that’s over,” Prof. Ran Balicer, the head of innovation at Clalit Health Services, told the “Kalman-Lieberman” program on Kan public broadcasting.
Balicer said there were two main reasons for this. The first is the British variant, which is far more infectious and apparently makes people sicker. “When we make decisions on a daily basis, we are taking more risks with the new strain,” he said. “But even on a state level, when we entered the lockdown we got to an R of [only] 0.95 during the lockdown, and all we are doing is maintaining the status quo. If you exit the lockdown, you’ve just gone back to where you were and the morbidity continues to rise.”
Balicer noted that the breakdown of public discipline has also contributed to the high infection rate. “We are seeing upticks in the graphs in all communities. The problem is not just weddings in the ultra-Orthodox community. The rise we’re are seeing in the past three weeks is in the general community, which means that these people are coming into contact with one another.”
Balicer and other experts therefore believe there is no exit scenario that is free of dramatic risks or that does not rely on the public’s goodwill.
“One alternative is a super-responsible opening,” Balicer said. “The minute you allow more contacts at work, you must make sure to reduce contacts anywhere else – no visiting friends or any unnecessary encounters. As for the mass violations we’ve seen, there must be enforcement, a social and political way to turn these into unacceptable. Under that situation we can maintain a new routine and very slowly open the economy as much as possible.” This past year, however, makes many people doubtful there would be such a sharp change in public behavior.
But there’s another alternative, he said, which looks very much like just giving up. “Everyone will act as he sees fits and we will pay the price as a society,” he said. “The price for society will be very, very painful. Because every addition of seriously ill in the hospitals’ current state of sufficiency is being translated into deaths, and this is disproportionate, and not just among older people.”