If there’s a single concept that emanates some cautious optimism these days, it’s the pair of words “exit strategy.” It embodies a basic assumption that’s nice to hold onto: A horizon, a future, the day after the coronavirus.
The precise timing of when Israel will start the process of returning to normalcy is unclear, but there’s an assumption that it will happen in the coming weeks. It depends on the continued spread of the coronavirus and the level of illness in Israel. The pace of contagion in the country has stabilized to an extent that allows the health care system to maintain a reasonable routine and provide necessary care to the seriously ill, including those on ventilators.
Once decision-makers reach the conclusion that the situation is stable enough and the medical system can respond swiftly enough to a pinpointed outbreak, and then the country can gradually withdraw the emergency regulations and movement restrictions in a matter of weeks.
Experts told Haaretz that the process would be restrained. In a few weeks’ time, they envision a routine that still involves wearing masks, avoiding contact and having temperature checks at entrances to public places, even after other restrictions have been lifted.
“When we look at the countries that have come out of this and resumed living, like China, we see a basic change in the level of behavior,” says Prof. Eyal Leshem, director of Sheba Medical Center’s geographic medicine and tropical disease institute at Tel Hashomer. “This means taking your temperature everywhere. Just like how we’ve grown accustomed to having our bags searched at building and mall entrances, we’ll have to get used to having our temperature taken as well.”
Leshem believes social distancing rules will continue to be enforced. “We are speaking about a long-term social change in terms of contact among people,” he says. “We will have to get used to wearing masks and to having less contact with people outside our family.”
He believes that hospitals will start monitoring for people potentially infected with the coronavirus at their entrances as a matter of course.
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Businesses, schools and public services will likely reopen first, while leisure activities will be the last to be integrated into the new routine.
“The process of resuming a routine and coming out of isolation will work by the principle of first in, last out,” Leshem says. “The labor market will gradually resume operations based on how essential something is to the economy. In the school system, high school students who can take their matriculation exams will resume their routine first, followed by middle schools, elementary schools and finally preschools.”
Leshem says entertainment venues will be the last to resume operation, since their patrons tend to be close together and their activities are less critical to the economy. He says the same principle will hold for having citizens emerge from isolation, with at-risk groups being the last to do so.
Dr. Lion Poles, who is responsible for emergency services at Kaplan Hospital in Rehovot and member of the team handling epidemics, says that since the degree of immunity among the population is not yet known, “the process of exiting isolation can be expected to be very cautious and measured, to keep it an option to take a step back when necessary. I imagine the first will be younger employees in productive economic [jobs], which will also operate on a partial scale. Schools will only open at a later stage because releasing children is liable to create massive contagion in the schools.”
Poles estimates that older and elderly people can be expected to remain in isolation for many more months to come. He expects the elderly “to remain under curfew for several to six months’ time. Over a continuous period there will be repercussions and I anticipate that during this period and afterwards we will see signs of psychological distress in this population group, which the medical and welfare systems must prepare for now.
"In addition, because people will be half a year older, we will also see a worsening of background illnesses among older people as a result of forced neglect of diseases such as diabetes, high blood pressure, and kidney and lung disease.”
How do we resume our routine?
Resuming a normal routine will depend to a great extent on the information we gather on the virus through medical research and the medical solutions we come up with. The world scientific community has swiftly gotten involved in a lot of cooperative research. The med-tech community has also begun developing relevant systems, and advancing clinical trials with existing medications and efforts to develop a vaccine.
Prof. Haim Bitterman, scientific director of the Israel National Institute for Health Policy Research, says “there are four main variables at play when figuring out when to anticipate an end to the coronavirus crisis, for which we don’t have answers yet.”
He said the first variable is seasonality, meaning whether the virus is seasonal or to what extent it’s influenced by seasons. There are hopes that it will be seasonal, like the flu, Bitterman says, but in Australia, which has opposite seasons, the flu is still spreading. He adds that there still aren’t answers to the question of seasonality, since SARS started in December 2002 but began disappearing by July.
A vaccine is another variable. Prime Minister Benjamin Netanyahu said recently that the biological laboratory in Nes Tziona had had a significant breakthrough in the development of a vaccine, and researchers are looking forward to conducting experiments on animals. If these succeeds, then they could move on to clinical trials with human beings.
The general estimate in Israel is that it will take about a year to find an effective vaccine for the coronavirus. Developing one could restore life to normal, though this will probably happen beforehand.
“Israeli society will learn to live with the virus until there’s a vaccine,” Leshem says. “And even when there’s a vaccine, it will take time to produce nine billion of them. The Mossad can’t do everything.”
The third variable is the development of medical therapy. A vaccine, while critical, wouldn’t supply a complete answer to the virus. A broader array of medicines would help resume our routine much more quickly.
“The flu is a lethal and difficult illness but there’s medicine that can be administered that can prevent death,” Bitterman says. Once medicine is found to help to treat the virus, it will be possible to handle the coronavirus epidemic more like other illnesses, he adds.
A fourth variable is herd immunity: A natural defense that builds up when a large number of people are exposed to the illness and develop antibodies, thus helping to protect those who aren’t immunized. Researchers are looking at whether this sort of immunity can help overcome the virus.
“We still don’t know clearly if we can achieve the effect of herd immunity at all with the coronavirus,” Poles says.
More serological tests are needed to determine whether people have moved from the stage of developing initial antibodies to that of antibodies that create immunity, or protective antibodies, he says.
Poles believes that if Israel were to conduct serological exams, it would find many people have been infected asymptomatically and have moved on to having protective antibodies. Israel still isn’t carrying out serological tests, but knowing this information would affect the process of restoring life to normal.
“The moment we achieve 60 percent of the population with protective antibodies, we can say that herd immunity is working. But until we do those tests we can’t say that with confidence,” he says.
Moving lower-risk parts of the population out of isolation is also thought to hasten the development of herd immunity. “If Israel doesn't have herd immunity, I imagine we would see people falling ill after a cautious release from isolation, and that’s fine, this is a kind of illness that we need to create contagion while keeping it on a low flame. Therefore it requires a cautious and measured approach,” Poles says.