The cabinet is expected this week to discuss implementing the next stages of Israel’s exit strategy from the coronavirus crisis. On Sunday, after a great deal of confusion and endless questions raised by parents, the preschools resumed partial operation after being closed for nearly two months.
The continued relaxation of restrictions will be accompanied by the monitoring of the infection statistics. As of now, three weeks after the easing began and 12 days after Independence Day, which saw a relatively large number of family gatherings, the numbers are still pretty low and will allow the plan to continue. Some ministers believe that given the difficult state of the economy, it’s possible to take greater risks in the health realm and reduce restrictions more quickly.
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One of the problems with the process is that there still isn’t a fixed team of authorized experts that, as far as the government is concerned, will have the last word on the recommendations. This vacuum is being filled by a series of competing teams, most of them voluntary, that are providing often-conflicting proposals.
For some strange reason, many of the experts leading these teams are physicists, not epidemiologists. Thus, one extreme scenario presented by the teams of physicists from the Hebrew University toward the end of March, which predicted 10,000 deaths in Israel, resonated strongly and for a short time was accepted as a kind of compass by Prime Minister Benjamin Netanyahu and senior Health Ministry officials. Meanwhile, the team of experts advising the National Security Council, whose presentation was published in Haaretz last week, had in early April set a tough prerequisite of only 10 new cases a day for gradually lifting the closure. Other advisers, some of whom met with Netanyahu while others were adopted by the treasury, were preaching a “herd immunity” approach that could have caused thousands of Israeli deaths.
Prof. Dov Schwartz, the former chief scientist of the Atomic Energy Commission, is a member of another team, made up also of doctors, epidemiologists and economists, along with some other physicists.
“The many advisory teams, which were assembled ad hoc, included excellent scientists in their fields, but some had no previous experience in the field of epidemiology,” said Schwartz. “Every government ministry made sure to equip itself with its own experts, who were chosen primarily due to their publications in their original research fields and because their positions dovetailed with the ministry’s agenda. The forecasts were mistaken and proved far off from what actually occurred.”
In keeping with the most threatening scenario, extreme restrictions were imposed until there was an almost total lockdown by the end of March. Now, when the closure is being lifted and Israel as of now has suffered 248 deaths and more than 16,000 cases of COVID-19, far below the gloomy predictions, the argument over whether those tough steps were justified is intensifying. The dispute is being worsened by the enormous economic damage done and the state’s slow response in assisting the self-employed and the unemployed.
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Channel 12 reported Friday that Netanyahu, in early April, had told Likud members that if reports from South Korea about recovered coronavirus victims becoming re-infected proved true, “it could mean the end of humanity.” Those reports from Seoul have since been refuted.
The forecasts regarding the spread of the infection raise question marks regarding the exit strategy as well. In mid-April the team of experts advising the NSC, headed by Prof. Eli Waxman, adjusted the infection rate that would allow continued easing of the restrictions from 10 new cases a day to 100. That was the guideline adopted by the cabinet, with one mitigating condition – that those new cases don’t come from previously known hotspots (people coming from abroad, old-age homes or communities with widespread outbreaks).
Two other conditions were also approved: New infections occur at a rate that would double in 10 days or more, and that the number of seriously ill, most of whom need ventilating, doesn’t exceed 250.
How did the number jump from 10 to 100 new cases a day? That happened because it was understood that the lower standard would be difficult to reach and could end up being an unnecessary barrier to loosening the restrictions. According to Schwartz, the daily rate of new cases is less important in and of itself, since it doesn’t reflect the true number of infected (some of whom are asymptomatic and as a result don’t even seek to be tested).
The critical statistic is the number of patients who will need ventilating – and that’s a number that can be pretty accurately derived based on the daily increase of cases. The coronavirus data in Israel to date show that between 3 percent and 4 percent of confirmed cases will end up in serious condition, and most of those will need ventilating within a few days. On average, patients with serious cases of COVID-19 begin to deteriorate rapidly around 10 days after contracting the virus.
At the start of the crisis, Israel had some 1,500 available ventilators. That number has risen since, but the real bottleneck relates to the teams that operate them. A patient hooked up to a ventilator requires continuous care. As of now, there are fewer than 1,000 teams available to deal with such patients. As winter approaches and a new flu season begins, that number will drop because there will be flu patients whose condition will also require ventilation.
Training a new team takes a pretty long time, so it’s not possible to increase the number of teams immediately. According to Schwartz, treating ventilated coronavirus patients is even more complicated, because the team must wear heavy personal protection equipment, which means a shift of coronavirus treatment lasts only three hours, rather than six. This means that twice as many teams are needed. Schwartz says that as of now there are only 500 to 700 available teams.
A patient who needs ventilating is hooked up to the machine an average of 15 days. In Israel to date, around half the ventilated patients survive (in some Western countries, the death rate among the ventilated reaches 80 percent). The forecast regarding the number of ventilated patients is dependent on two other factors: The number of seriously ill patients on the first day the infection rate starts increasing and the daily multiplication rate.
According to Schwartz, “The calculation is simple. If, say, the initial rate of a new outbreak is 10 seriously ill patients a day, half of them die and each patient is in intensive care for 15 days, we will end up with 75 patients in the unit after 10 days. And that’s if the daily growth coefficient is exactly 1, meaning there is no increase in the number of seriously ill patients per day.
“But if there is a doubling of the number of seriously ill patients every 10 days, meaning a growth coefficient of 1.07, the situation we had here a month ago, after those same 10 days we will end up with 150 seriously ill patients, most of them ventilated, in the coronavirus intensive care unit,” he continues. “This gives us a security coefficient of four in comparison to the number of intensive care teams that can treat COVID-19. On the other hand, if the rate of daily growth rises to 1.15, the situation we were in a month-and-a-half ago, in 10 days we will get to 300 seriously ill patients, nearly half the maximum number of people the wards can handle.”
This, Schwartz says, is the upper line that cannot be crossed. He brings an analogy from his original field of research. “In an atomic reactor, where there is also a chain reaction that causes a similar exponential explosion, without a security factor of at least 2, the reactor cannot be operated.”
It’s been Israel’s luck, says Schwartz, that its health system didn’t reach an extreme situation. The largest number of ventilated patients at any one time has been 137, in the first half of April. The number as of Sunday was 65. But the virus has caused a serious economic and social crisis in Israel and there’s no way of knowing if there will be a second wave down the line.
“What should be done now is to set up a sort of second Agranat Committee, which will examine in depth the conclusions to be drawn from the current crisis,” says Schwartz. “My concern is that in contrast to defense incidents, which are inscribed on human consciousness in general and on the Israeli public in particular – when it comes to plagues, things are forgotten quickly. No one will learn the lessons without a central and permanent national agency that will collect all the knowledge that has accumulated and deal with preparing for emergency events like plagues. Such an agency must include experts from a variety of fields and be prepared for the next possible scenarios.”