The flattening of the coronavirus infection-and-fatalities curve in Israel, and most of all the stabilization in the number of patients requiring a respirator, has sped up discussions in the past few days on an exit strategy from the crisis. Even though it is clear that this will be a long process, and a number of restrictions are expected to continue for many months, it seems that the media, as well as the public, is now less busy with counting the number of dead and those on respirators, and is more interested in the question of how can the economy be put back to work.
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The change does not only come from the pandemic data. Most Israelis have been stuck at home for over a month and leave for only a few short breaks. The elderly are besieged and isolated, families with young children are busy trying to somehow pass the time, and for families that were already on the edge – because of poverty or a violent atmosphere in the home – the crisis has exacerbated an already bad situation.
For many, it is an insufferable mental burden. Moreover, for quite a few people – the newly unemployed, self-employed and even those with salaries whose jobs are in question – the crisis is accompanied by immediate financial fears.
These circumstances highlight claims that minimize the severity of the health risk. The coronavirus is marked as someone else’s problem: The elderly (the average age of those who have died from COVID-19 as of the beginning of the week was 81), Haredim (whose communities and neighborhoods had the highest infection rates), or the Arabs (in East Jerusalem and surroundings the signs of an outbreak in coming days have been multiplying).
The fear of the virus is being replaced by a certain degree of complacency. It is no accident that police are reporting a drop in civilians following the coronavirus instructions after the first day of the Passover holiday. It is a natural result, not just of the erosion in willingness because of the time that has passed, but also of the infuriating double standard that our elected officials demonstrated on seder night.
All this is the background for the great number of calls for rapid easing of the restrictions on the economy. In the background is developing a sort of viral doubt, in the spirit of what Prof. Michael Levitt said here a month or so ago. Is the coronavirus killing the elderly, or is it a background factor, with the disease only slightly accelerating the unavoidable result of the prior medical complications? Is the reduction in the rate of infection the result of the determined steps taken by the Israeli government a month ago, or is this simply how the virus has been behaving all over the world: first hitting like a tidal wave and after a few weeks receding?
For now, new online heroes are being born, people who are undermining the foundations of strict order dictated from above. Prof. Isaac Ben Israel, chairman of the Israel Space Agency, claimed in an article he published that the peak of the spread of the virus in Israel is behind us, and it is possible within a few days to end the closure policy and replace it with a “policy of moderate social distancing.” Psychiatrist Prof. Yoram Yovell wrote that Israel has fallen into a dangerous state of “tunnel vision,” wallowing in the number of dead and failing to see the enormous economic and psychological damage that the closure is causing.
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A series of reports were released over the past few days with competing – and sometimes contradictory – recommendations on how to exit the crisis and at what pace. All collections of experts presented their own schedule and backed it up with confident assertions. But there is only one thing that most of the groups have in common: the small number of epidemiologists they have, and the even smaller minority of women on their teams.
The multiplication of reports is the continuation of the strange dissonance exploited by Prime Minister Benjamin Netanyahu to manage the crisis: Between centralization to chaos. These competing proposals allow Netanyahu to continue to maneuver, without announcing his decisions. A policy of divide and conquer. On Monday, Haaretz reported on the more binding plan of the National Security Council, which is under the prime minister’s direct authority. The NSC plan also talks about returning people to work under a great number of restrictions, still excluding civil aviation and tourism during the summer and with a fear of a renewed virus outbreak in the fall. In the meantime, they are buying more time for the health system: Buying and manufacturing more protective equipment and ventilators, which will keep the system away from its point of collapse in the case of a flood of new patients.
Testing is the Achilles’ heel
But most of the exit plans do not mention the real Achilles’ heel of the government’s handling of the coronavirus crisis: The small number of tests and the cumbersome, inefficient process of interpreting their results – in spite of the Health Ministry’s frequent promises to fix these faults.
While the number of daily tests is still below 10,000, preparations for a lower rate of the spread of the infection are not based on reliable enough information – as opposed to the number of patients on ventilators, which is an unequivocal statistic, and whose stability is encouraging.
Last week the Health Ministry was asked the average time for interpreting the test results. The answer provided to Haaretz was a day or two. The report from the Gertner Institute – the Health Ministry’s research institute for epidemiology and health policy –which was released this week, presents a different picture. The institute, which enjoys full access to the ministry’s data – a privilege that independent researchers have been begging for to no avail – estimates that 10 or 11 days pass between the time a person is infected with the coronavirus and when they are diagnosed with the virus. Almost half this time is wasted because of the complications in resolving the test results and returning an answer.
According to the Gertner report, the coronavirus testing system manages to find only 20 percent of the chain of contagion in time. In other words: Until the government reaches the people who came into contact with the original patient, the horses have not only escaped from the barn a long time earlier, but have circled it three times and moved on to the nearby pasture, already having infected all the succeeding links in the chain of infection.
All the exit scenarios are built on a steep reduction in the daily number of new infections – and on keeping it at a low daily level of 10, or at most a few dozen, depending on the report. As a result, it is necessary to dramatically improve the efficiency of the entire process. A team in the Defense Ministry defined a target of 12 to 16 hours for the completion of the entire coronavirus testing process. IDF Chief of Staff Lt. Gen. Aviv Kochavi listed the handling of the tests as one of the eight areas the IDF can take on. It may be that this should be considered.
In the meantime, one valuable change has taken place. At the beginning of the week, the authority to order a test was transferred to family doctors and pediatricians in the HMO clinics. Until now, the doctor had to send those who wanted to be tested to the Magen David Adom ambulance service, and the carrying out of the test was dependent on the judgment of Magen David Adom medical staff – according to the symptoms and the workload of each station. From now on, the decision has been shifted to the HMO’s doctors. This is supposed to reduce the load on Magen David Adom, and in some cases to enable quicker testing through the health services’ own labs.
Whom do these experts speak for?
In June 2017, a team of experts from the Health Ministry released “the health system preparedness plan for a flu pandemic.” This is a comprehensive, detailed document of 164 pages, and the scenarios it outlines are rich in similarities to our present situation, even if the coronavirus in its 2019 version is different in a number of aspects from the seasonal flu – and it certainly is not just a “flu with better PR.”
The members of the team, including Prof. Ran Balicer, who is also a member of a group dealing with pandemics today, outlines a “reference scenario” with a number of stages. At level four of the disease’s spread, which is much more severe than the coronavirus today, 150,000 people would be hospitalized and 30,000 would have died, with a fatality rate of under 2 percent of those infected. This is the most serious but reasonable scenario, according to which the reference scenario was established. The team recommended that from the moment Israel declares preparations for the pandemic that has already broken out around the globe, the responsibility for managing the crisis be handed over to the “crisis management team” of the Defense Ministry.
This is a controversial step, which of course has not been taken as of yet. The IDF requested on Monday to clarify, in light of earlier reports, that Kochavi is not asking to transfer all the responsibility for the crisis to the military, but rather that he mapped out eight areas which the IDF can focus on and help out. For now, looking in at the health system from the outside raises a large number of questions. These are not just problems concerning the lack of funds or day-to-day management, even if it involves the handling of an unknown and unprecedented crisis in its scope. The Health Ministry still has a clear problem with managing the data – even though the entire picture is being built with the help of the IDF’s intelligence branch – and in reporting to the public transparently.
It’s hard to shake off the impression, which is supported by conversations with many doctors, that the heads of the healthcare system operate much like a closed guild. Nor is the status of the senior medical professors who comment on the crisis on the TV channels entirely clear. Are they independent experts, spokespeople without uniforms (in this case, smocks) for the healthcare system, or advisers who participate in the prime minister’s closed meetings with the ministry leadership?
Early this week the CEO of Tel Aviv’s Ichilov Hospital, Prof. Ronni Gamzu, was interviewed on TV, and showered praise on the functioning of the Health Ministry in the crisis. Later on it was reported that the ministry had appointed Gamzu to head a special team that will be in charge of treatment in senior citizens’ residences. Never mind that this team is being appointed only a month after the deadly events in the Migdal Nofim assisted living residence in Jerusalem, which since then have been duplicated in dozens of similar institutions throughout the country. Isn’t Gamzu busy enough running a major hospital during a pandemic? Where does he have the free time to head such an important team as a secondary job?
The heads of the healthcare system still have someone to learn from, of course. In reports to the media and posts on social media, the prime minister is disseminating self-congratulation. On Saturday night his bureau boasted, in an official message, that “Thanks to the efforts of Netanyahu and the discussions he conducted with heads of state, barriers were removed and this morning three huge shipments landed from three countries, which include 2.4 million chloroquine tablets.”
The style of this message was not customary in Western democracies, at least before the Trump era. And without downplaying the benefit that ensues from the prime minister’s connections, this specific drug, which U.S. President Donald Trump also spoke of in glowing terms, is controversial among doctors and its effectiveness has yet to be proven.
Meanwhile, Netanyahu is publicizing a report claiming that Israel is the safest country in the world in terms of the coronavirus. The percentage of fatalities here really is exceptionally low, still less than 1 percent of the number of verified patients – but as Prof. Isaac Ben-Israel has written, the source of the complimentary “study” is a small Russian-owned venture capital fund located in Hong Kong. “The mother of fake news,” according to Ben-Israel, who twice received the Israel Defense Award. Somehow, the entire issue creates a longing for the satirical Saudi blogger, whose absence is felt in the present crisis.
But don’t worry, the world is slowly but surely returning to the known and familiar. The daily sprays of sewage from the Twitter account of Israel’s crown prince has already resumed, as though we weren’t talking only two weeks ago about a national emergency government for the battle against the coronavirus, in whose context everyone was going to “help to carry the stretcher.”
Here is a reasonable guess: If the crisis between Likud and Kahol Lavan continues, it’s only a matter of time until Kahol Lavan chairman Benny Gantz is slandered as a rapist, an adulterer, and someone whose sanity is in doubt. The chorus of trolls will mobilize for the mission with love, as always.
The technology news
A team of researchers from the Technion - Israel Institute of Technology, Rambam Medical Center and Intel Corporation last week prepared a “hot map” designed to help with early detection of hotspots in the spread of the virus in Israel, as well as detect low-risk areas, where it will be possible to ease the lockdown earlier. At a very early stage the system developed by the team identified the anticipated outbreaks in Bnei Brak, Elad and Jerusalem, when there were only 13 to 22 cases in those cities. Last week the team warned of an anticipated outbreak in two Arab communities, Jisr al-Zarqa and Umm al-Fahm, which has also turned out to be correct.
A member of the team, Dr. Oren Caspi, a cardiologist at Rambam and a researcher at the Technion, told Haaretz that the system they developed can help decision makers before the implementation of exit strategies, for instance by pointing up the need to conduct different policies in different regions, depending on how fast the virus is spreading there. “These are tools that will make it possible to impose lockdowns selectively, enable the economy to survive, and make the information available to people regarding their areas of residence,” he said. To a certain degree the system is similar to the early-warning rocket alert regions mapped by the Israel Defense Force's Home Front Command.
The system was first developed as a tracking tool designed to coordinate data from Israel and the rest of the world, and to examine the connection between climate measurements and the rate of the disease’s spread. On this issue, Dr. Caspi, to his regret, has no good news in advance of summer.
“There still isn’t enough data. And in any case, we didn’t find a sufficiently strong correlation between a decline in the rate of the spread of the virus and a rise in temperature,” he said. “On the other hand, there is a certain correlation with precipitation: When there’s more rain, the virus spreads more quickly.”