The past few weeks have shown just how fast the coronavirus can get out of control if you stop paying attention to it, even briefly.
In mid-April, when the economy was still largely shut down, there was a turnaround in the incidence of infection. The number of people recovering exceeded the number of new patients, and the latter figure was around 300 per day and dropping. The number of patients needing ventilators, which stood at 114 on April 20, was also falling.
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A few days later, most hospitals closed their coronavirus wards due to lack of patients. And in May, Israel began exiting lockdown.
The public, the political leadership and the healthcare system were all optimistic, sometimes to the point of apathy. Israel looked like one of the most successful countries in coping with the coronavirus.
The lockdown imposed in March exacted an enormous personal and economic price from Israelis. Over a million people were unemployed, and many industries shut down completely.
But Israelis were told this had to be done to “flatten the curve,” prevent the healthcare system from collapsing and buy time to get organized. And they cooperated.
Over the past few days, however, the number of new patients has soared and the number of severely ill patients has risen steadily. In hindsight, several factors over the past two months contributed to this sharp deterioration.
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Not breaking the chain of infection
An effective system of breaking the chain of infection is one of two essential tools for avoiding lockdowns amid the coronavirus (the other is public compliance with social distancing and mask-wearing rules). Such a system enables outbreaks to be contained quickly and keeps them from spreading.
An effective system involves several elements – identifying patients, contact tracing, quarantines and testing. But Israel’s system remains ineffective.
Very few nurses have been assigned to do contact tracing, and they aren’t well coordinated. Last week, the Health Ministry’s director of public health services, Prof. Siegal Sadetzki, and Director General Hezi Levy demanded funding to hire another 200 nurses, administrative workers and doctors.
Moreover, the newly created contact tracing center hasn’t yet received the necessary authority. Consequently, it takes six days or more to trace a patient’s contacts, far from the goal of 24 to 48 hours.
Some people are never even informed that they had contact with an infected person. Others are told to quarantine, but must wait a long time to be tested, or to get the results.
Reopening schools too quickly
In mid-May, Prime Minister Benjamin Netanyahu announced that schools would reopen fully for all grades, scrapping the previous system in which teachers and students studied in small groups to limit their exposure to the virus. Days later, due to a heat wave, Health Minister Yuli Edelstein scrapped the rule that students must wear masks – thereby undermining a lengthy effort by the ministry to convince Israelis that mask-wearing was important.
Other countries that reopened schools did so gradually and restricted classes to small groups. But Israel’s decision to reopen schools fully helped spark a new coronavirus outbreak.
The Gymnasia Rehavia high school in Jerusalem was the first to record new cases; within a few weeks, hundreds of schools had closed due to the virus. These school outbreaks also helped the virus spread elsewhere.
Testing only after a week
From the beginning, the small number of daily coronavirus tests and the strict criteria for being tested have been criticized. With great effort, the Health Ministry finally managed to increase the number of daily tests, which is now approaching 25,000.
Rapid testing is essential to break the chain of infection. But until very recently, the ministry said people in quarantine should be tested only four to seven days after having contact with a confirmed patient.
Only on May 31 did Edelstein say that even people with no symptoms should be tested if they were quarantined for contact with a patient, and only one June 22 did Sadetzki order the health maintenance organizations to test people within 48 hours of their being quarantined.
Thus until then, many carriers, some of them asymptomatic, were spreading the virus for a long time before they were identified. The same is true for all the people with whom they had contact.
A widespread outbreak
Over the past two weeks, the coronavirus has becoming increasingly widespread; the outbreak is no longer confined to certain localities. Thus the plan for local containment has collapsed.
Until a week ago, the Health Ministry clung to a strategy of declaring places with outbreaks “red zones” based on various criteria (the rate of the increase in incidence of the disease, movement in and out of the town in question and within it, residents’ compliance with orders and the strength of the local government). But because the outbreak has spread so widely over the last week, containing it by isolating “red zones” is no longer possible. That’s also why the ministry has retreated from its demand to reinstate lockdowns in dozens of communities.
Public trust at a nadir
After five months and a heavy economic toll, the public is exhausted, confused, frightened and impoverished. The fact that the first wave ended so differently from both the nightmare scenarios predicted and the situation in certain other countries caused a significant erosion of the public’s faith in the government and its view of how dangerous the virus is.
These have led to declining willingness to comply with the behavioral rules necessitated by the virus. And this has been exacerbated by numerous incidents in which senior public officials, including the president and the prime minister, failed to set a personal example of obeying the rules.
The increased enforcement of mask-wearing, social distancing and quarantine rules is also still seriously flawed. During a recent discussion in the Knesset’s Foreign Affairs and Defense Committee, Health Ministry officials said that only about a quarter of the people who are supposed to be quarantined are actually doing so.
Lack of information and transparency
To grasp the situation and make intelligent decisions, it’s essential to collect and analyze massive amounts of data in real time. Information makes it possible to understand how the virus behaves, its incidence, the rate of infection and where it is striking the hardest. Moreover, sharing this information and making it accessible is very important for explaining the situation to the public and enlisting its cooperation.
But five months after the crisis began, critical information is still lacking. Some information has never been amassed; other information exists but was never shared with relevant government agencies, the health-care system and the public. Basic questions like what proportion of patients are asymptomatic or how long it takes to trace most of a patient’s contacts haven’t been answered.
For example, the Finance Ministry is supposed to manage the economic aspects of the crisis, but it isn’t getting information from the Health Ministry. Consequently, it has no idea what the risk different sectors of the economy pose in spreading the virus or which sectors have successfully implemented a set of rules for operating safely.
Even the health system lacks enough information to compile more than a very basic picture of the situation. And the Health Ministry doesn’t have any centralized body capable of producing essential information quickly.
Israel’s management of the coronavirus crisis has been extremely centralized, in both the Health Ministry and the cabinet as a whole. In a national health crisis like a pandemic, decisions obviously need to be made with input from professionals such as scientists and doctors. But unlike in a security crisis, sharing information widely among such professionals and involving professional associations in decisions is essential to formulate a good policy.
From the earliest stages of the crisis, however, Israel’s decision making has been influenced by only a handful of professionals. The Health Ministry’s position has been determined largely by two key figures – Moshe Bar Siman Tov, who was its director general until recently, and Sadetzki, the head of its public health services department.
Many professional associations are furious that they can’t even get a foot in the door to influence decision making. For instance, many believed from the start that more widespread testing was essential and that a contact-tracing organization must be set up swiftly. But nobody listened to them – not in the Health Ministry, and frequently, not around the cabinet table, either.
It recent weeks, the extent to which the crisis has been managed on a personal and often unprofessional basis has become clear. The decision makers aren’t even insisting on getting basic information before making their decisions.
Moreover, those decisions are being formulated by a single agency – the Health Ministry – whose functioning has been criticized throughout the crisis. This has led some advisory groups to demand that management of the crisis be removed from the ministry’s hands and transferred to the Defense Ministry and the army.
Lack of manpower
The coronavirus crisis has laid bare years of neglect in the public health system, including its diagnostic laboratories. The Health Ministry is now trying to quickly train hundreds of students to work as contact tracers in its regional offices. And the country’s 37 diagnostic labs have relied for months on student volunteers to augment their manpower.