'The Health System Is in Hysteria': Israeli Doctors and Hospital Officials Warn of Major Coronavirus Fallout

As the epidemic is set to peak, physicians and senior health officials speak out on their concerns

Hilo Glazer
Shany Littman
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Doctors and hospital administrators

Dr. Guy Choshen, ER director, Ichilov Hospital, Tel Aviv

Several weeks ago, the phone rang in the office of Dr. Guy Choshen, who for eight years had been deputy director of internal medicine at Ichilov Hospital in Tel Aviv.

“The management wanted me to open a new department, for coronavirus patients,” he tells Haaretz, in an interview at the hospital. “I replied that I’d be happy to do it. We set up a unit within a few days, and we gleaned a great deal of experience from patients with a mild case of the virus.”

Not long afterward, Choshen received another call from management. The head of the emergency room was leaving, he was told, and they wanted Choshen to replace him.

“I love challenges, but I’m not an expert in emergency medicine. Trauma, surgery – that’s not my line,” he says. “I’m an internist. But someone was needed to take the team into the big battle awaiting us, and for that they called on me. I do what I’m told, I’m a soldier in the system.”

These days, Choshen works until late in the evening. When he gets home, he showers and changes his clothes before letting anyone in the family touch him. “I have three children. I eat supper with them, exchange a few words, get some sleep and go back to the hospital. What will the situation be in a week? I don’t know.”

Dr. Guy Choshen, ER director, Ichilov Hospital, Tel Aviv.
Dr. Guy Choshen, ER director, Ichilov Hospital, Tel Aviv.Credit: Tomer Appelbaum

Will you move into the hospital?

“Yes.”

You won’t be able to go home?

“No.”

How many ventilators do you have?

“We’re meant to deploy for about 180 ventilators. We’re now training teams that usually don’t deal with this kind of thing. In Italy, we saw orthopedists and ophthalmologists who suddenly became doctors in intensive care units, respirating patients. My neurosurgeon friends haven’t the faintest knowledge of how to do it. But now they are being trained.”

Ichilov was also preparing to launch a new emergency wing – four underground floors, below the cardiology department. “The hospital estimates that we will have hundreds of patients on ventilators,” Chosen says.

So at the moment you have 180 machines and a few eye doctors who know how to plug them in.

“Now do you understand why there’s been insistence on a lockdown?”

And what will happen next?

“What will be decisive here is the number of people on ventilators – that’s what could bring us to our knees. Along with the correct decision about lockdown, there were things that weren’t done and should have been done a lot sooner, and massively. I have no doubt that there was a mistake made here. The tests should have been put into fifth gear much earlier. We could have identified the lone sick person and kept him at home, and prevented a chain of thousands of additional infected people.”

Let’s go back to preparations for the peak. How do you deploy for that?

“We are a bunch of hotheads. I remember all those war movies, and series like ‘Game of Thrones,’ with scenes of face-to-face battles. That’s how I feel. We’re putting on war paint and honing our swords and waiting for battle, for the enemy to arrive in masses.”

How do you decide whom to ventilate if there are not enough machines?

“There are hospital ethics committees that deal with the question of whom to put on ventilators and who not, according to criteria. Things like this happen in routine times, too: Sometimes I ask to transfer a patient from an internal medicine department to the ICU, but the head of the ICU doesn’t agree. He says, ‘My bed is very precious in terms of resources and personnel. There is little prospect that I can help the patient you’re describing.’ Sometimes that seals the patient’s fate.”

That’s become routine in Italy and Spain.

“Yes. Their hospitals are in shock. All the working methods and knowledge collapse, as with an army fleeing the battlefield. That is why the heads of the health system here are in a state of hysteria – and rightly so. But the hysteria needs to be ours, not that of the public, because even if we are brought to our knees, only a small part of the population will be harmed.”

Prof. Doron Kopelman, head of surgery, Haemek Hospital, Afula, an initiator of the ‘doctors letter’

Prof. Doron Kopelman was one of the initiators of the so-called doctors letter of March 24 – an open letter addressed to “the nation’s leaders,” protesting the situation of the Health Ministry due to years of neglect and budget cuts – which was initially interpreted as a call to remove the ministry’s director general, Moshe Bar Siman Tov.

Kopelman wishes to put things in their correct context. “Underlying the initiative is the feeling that the present crisis blatantly manifests the health system’s improper organization, and outrageous discrimination between the center of the country and the periphery, when it comes to infrastructure, resources and personnel,” he said during a conversation at his home in Caesarea.

“This discrimination is particularly flagrant regarding the number of [hospital] beds per 1,000 people, the number of physicians and the shorter lifespan [of residents] in the north and the south – and that distortion has now surfaced even more acutely.”

How are these disparities related to the coronavirus crisis?

“They are related because they originate in the structural deficiencies. Israel has government hospitals; hospitals affiliated with the HMOs; Ichilov, which is semi-municipal; and also hospitals that are sort of freelancers, such as Shaare Zedek and Hadassah [both in Jerusalem]. Too many kinds, too many commanding officers. Now we are at a time of war, but there is no central command. It’s inconceivable for the chief of staff to allow every division commander to act according to whim.”

The division of hospitals into different types is a given that can’t be changed instantly, certainly not in the midst of a crisis like this.

“Obviously, so I expect that in wartime the entire army will operate according to uniform, operational orders. Not guidelines. Not director general’s circulars. Or-ders. Of the kind that will be executed at the same time and in the same way.”

How have we already paid a price for the absence of that uniformity?

“Above all, in the infection of medical teams. It’s been clear for weeks that this is a major problem. Whole departments have been shut down because of cases of infection. In our department, we divided the team into two groups a couple of weeks ago, so that they wouldn’t encounter each other. Why does this have to happen via sporadic initiatives from the field? And why does a guideline like that surface only after three weeks?”

How else is this felt?

“Non-urgent operations. We stopped them a few weeks ago, so as not to expose patients in a delicate medical condition to the coronavirus. Take gastric bypass surgery, for example, which is usually performed on ostensibly healthy people, but with immense risk factors. Why should I take the risk that they will need a ventilator? Sounds logical, right? So why did the Health Ministry only issue the directive to stop elective surgery [two weeks ago]?”

As the conversation continues, Kopelman loses his cool. “What really makes me boil is the private hospitals. It’s inconceivable that they should be conducting private operations while we are in the throes of battle. Why not take all the Assuta-type [i.e., private] hospitals and convert them into hospitals to deal with the coronavirus? We need those resources and those surgeons. You have time to perform an elective operation? Come to us [instead] and work to save lives. What has to happen for them to understand this? Where is the chief of staff?”

When referring to the mistakes he believes were made at the top, Kopelman distinguishes between the epidemiological and the clinical realms. “In the former, it could be that the actions of [the Health Ministry’s director of public health services, Prof. Sigal] Sadetsky and of Bar Siman Tov regarding lockdown and social distancing, are what saved us. But the other side – hospitals working at 200 percent of their capacity because of the coronavirus – has not yet had to stand the test. Those are the areas that we’re warning about and trying to correct.”

In Kopelman’s view, the failures are not occurring only in the hospitals. There is also “the scandal of the treatment being offered to prevent infection in old-age homes,” he asserts, “You have to be an experienced clinician to understand the significant difference between the incidence of illness among the elderly as opposed to that of young people.” That is what happens, he adds sarcastically, “when the chief of staff here is an economist or a rabbi” [referring to Bar Siman Tov and to Health Minister Yaakov Litzman, respectively].

Well, it wasn’t by chance that your letter was taken as a call to remove them.

“First of all, there’s no problem with removing a commander during a war. In the Yom Kippur War [former IDF Chief of Staff Haim] Bar-Lev replaced ‘Gorodish’ [head of Southern Command, Shmuel Gonen]. That was a dismissal. In large measure that’s also what was done to Maj. Gen. Udi Adam, the head of Northern Command, in the Second Lebanon War. Precedents exist. It’s not forbidden, and it’s not immoral. But that isn’t the intention in the present situation: We come not to behead Bar Siman Tov, but to help him. Our call was to place a senior professional in clinical medicine at his side.”

What will happen if he doesn’t have someone like that at his side?

“I have the feeling that despite everything, and despite what I’ve said here, we will still triumph. Thanks to the internists, the anesthesiologists, the surgeons, the nurses and the paraprofessionals – all those people who are doing their work out of a true sense of urgency and emergency. And perhaps also thanks to Bar Siman Tov and Sadetsky, with their actions at the national level.”

Prof. Raphael Walden, deputy director, Sheba Medical Center, Tel Hashomer

Casting an eye on how Israel is deploying in light of the epidemic, Prof. Raphael Walden is very concerned about the price of the general closure.

“A person who is walking in a park alone or with a partner, or is on the beach, is not infecting anyone,” he says. “It’s the same with a surfer who is ordered by the police to get out of the water. Is the surfer endangering anyone? On the contrary, he’s in total isolation.”

As Walden sees it, “a lockdown carries a steep price, including in human lives. People live in crowded apartments, where substantial psychological pressure can build up. I have no doubt that this will lead to an increase in the incidence of heart attacks and in people suffering from high blood pressure and diabetes. We saw footage of a cyclist in a park who was pursued by two police vans with a third van blocking his way, as though he were a terrorist at large in the city. That’s absurd.”

As for the hospitals’ preparedness to cope with the peak of the crisis, Walden notes that we started from a bad place. “We have a catastrophic deficit of ICU beds, from the outset. We are at the bottom of the list of OECD countries.

“The nature of medicine has changed a great deal in recent years. Today, many patients are treated by the HMOs [as outpatients], in the community. The profile of the hospitalized population is tending increasingly to serious cases: people who are more frail, with multiple, complex diseases. It is out of the question for a ventilated patient to be in an internal medicine ward where there are two nurses for 40 patients, but that’s what’s happening. The situation is grave, and the coronavirus epidemic is only aggravating it.”

How are you readying for an increase in the number of patients who will need ventilators?

“We are trying to obtain more ventilators. The health system has reached a situation where veterinarians are being asked to donate their ventilators.”

But the number of machines is not the only problem, Walden says: “Entire intensive care systems are needed, with trained medical staffs. You don’t just hook a patient up to a machine, put it on automatic pilot, and everything works out. These are patients who need supervision, ‘dynamic’ patients, who need meticulous IC in every way. This is an Achilles’ heel right now – there aren’t enough trained teams.”

He adds that “tough decisions are made every day about people whose place is in an ICU but for whom there is no room. So there’s a hybrid, an ‘intensive treatment’ unit, where sedated and ventilated patients are hospitalized. In the United States they look at us and don’t understand what kind of animal this is. But yes, it exists here, and it’s substandard.”

Walden is also disturbed by the fact that until now, testing on a more massive scale has not been done in old-age homes. “It’s unbelievable, this is folly! The elderly are begging to be tested, and that does not demand immense resources.”

Are you preparing for the possibility that you will have to decide whom to ventilate?

“No guidelines have as yet been issued – for example, that people over 80 will not be ventilated. I don’t think there will be any such proposals. You could have an 80-year-old who is vigorous and productive and active, while a 45-year-old has collapsed lungs. The effort that is invested in every such patient is considerable and continuous. It’s an extremely difficult ethical dilemma, because ventilating one person costs the lives of three other people whom you could have saved. The treatment is not a one-time act. It’s not someone who’s drowning in the sea and you jump in and save him. It involves an investment of three weeks of intensive effort, at the expense of a system that is in a state of serious congestive failure.”

Prof. Amnon Lahad, chairman, National Council for Community Health

In the view of Prof. Amnon Lahad, the number of victims who will suffer from the health system’s intense focus on the epidemic is liable to exceed the number of victims of the virus itself. Many other health issues are currently being neglected, which means fewer diagnoses and less treatment – leading to loss of life.

“It’s hard to quantify it,” he says, “but we are seeing, for example, fewer people going to hospitals for events that could lead to a stroke. That’s easily seen: If a person is suddenly paralyzed in half his body, he will go to a hospital; but if a person loses his power of speech or his field of vision for a minute or two – due to a minor embolism that comes and goes, but attests to heightened risk of a major event – those cases are now not arriving so much. People are afraid to go to the hospital, and that poses a risk.”

The case of a possible stroke is only one example, Lahad notes: “I don’t have data, but I wouldn’t be surprised if fewer people with chest pains – namely, something presaging a heart attack – come to the hospital. We have stopped doing mammography and tests for occult blood in the stool. That means there will be a rise in cancer cases, which we will see only a few months down the line.”

If I want to have a mammogram tomorrow, is it possible?

“It could be done, assuming there’s a team available, but in practice it is almost not happening. I don’t want to use the word ‘hysteria,’ but the fear is greater than the reality. We’ve not been able to work at full capacity for over two weeks. If it continues for a long period, the price in mortality will be steep.”

What about more routine tests?

“We have stopped doing cholesterol and blood pressure tests almost completely. The [HMO] clinics are operating by phone, or online. On a normal day I see about 20 patients, today there wasn’t even one. But the sick haven’t disappeared. If this crisis lasts a couple of weeks, it’s not that significant; but if it goes on for some time, it will be catastrophic. Even if 2,000 people die from the coronavirus – and I don’t make light of that – the collateral damage of the lockdown and the isolation will be more serious. And I also think the authorities are scaring us and that not so many people will die.”

Lahad also notes the damage stemming from the surge in the number of unemployed – a situation that will also take a psychological toll.

“Studies show that when we approach 10 percent unemployment, a rise in the general mortality rate occurs. According to European data, the mortality rate increases by 0.4 percent for every 1 percent increase in the unemployment rate above 10 percent.

“So, 20 percent unemployment will add another 4 percent to mortality. That’s 1,600 people more a year. I can’t state on the certificate that a person died of unemployment, but that could actually be the cause. And I’m not just talking about suicides, but also about incidence of sickness.”

Given what is happening in Italy, don’t you think the decision about social distancing is justified?

“No one is wise enough to know. You need to check the direction the curves are taking. Israel [its population] is much younger than Italy. The question is what safety precautions you take. And that has a price in health, too, not only regarding the economy. Social distancing is needed, and it’s a good thing the theaters were closed, and maybe even the schools. But to paralyze the economy is a different story.”

So, what is your opinion about how the crisis has been managed so far?

“I think the prime minister is getting advice from a narrow range of people. There are wonderful people involved, but there isn’t even one who has look into the eyes of patients lately. And that’s a problem.”

Dr. Kobi Arad, ER director, Yoseftal Medical Center, Eilat
Dr. Kobi Arad, ER director, Yoseftal Medical Center, Eilat.Credit: Udi Portal

Dr. Kobi Arad, ER director, Yoseftal Medical Center, Eilat

“If there’s a periphery in Israel, then I am the ‘mother’ of all the peripheries,” says Dr. Kobi Arad, of his hospital in the southern resort city.

“We are working furiously treading water to keep our heads above the surface. That’s the essence of our activity here, amid the sense of a grave lack of resources and technologies, and because of the inherent difficulty of recruiting people [to work here]. The usual situation is one of everything on the edge. And if you extrapolate from that to the whole health system in Israel, that’s how it works. Everyone can cope with a capacity of 130 percent, but for us it’s routine. We are at the bottom of the ladder.”

What will happen if the coronavirus strikes Eilat in a massive way?

“When you work in a system with no room for deviation at all, you’re used to functioning regularly in a state of congestive failure. But now, with the coronavirus, we are having to carry out a huge geometric leap. Sheba [Medical Center], for example, has a huge number of ventilating machines, elective services and clinics, so they’ve shifted masses of personnel to the essential places. We have nowhere to draw on, so I am recruiting from any place I can, but not on a scale that will provide a response to an extreme scenario.

“As it happens, we’re covered when it comes to ventilators. Because of our remoteness, and the need to be ready for a multiple victim [i.e., terror] event, we have hard-core equipment in the storerooms that can provide a specific response. But that machine is not the only variable here. Every ventilated person constitutes a whole system of monitoring, physicians, nurses, ICU. Anyone who just counts ventilators doesn’t grasp the complexity of the problem.”

Arad believes that also from a national perspective, the excessive focus on available ventilators is diverting attention from treating other vulnerable individuals. He is referring, in part, to the guideline to cease elective surgery at government hospitals.

“That is an epidemiological disaster foretold,” he says. “The only thing that was excluded from that blanket directive is oncological operations; but between saving lives and cosmetic procedures there is an infinite list of orthopedic operations, joint replacements, intravitreal injections to save eyesight. None of these will happen. People will go blind, will deteriorate, will be in mortal danger. This will have long-term consequences that I’m not sure anyone in the country is weighing.”

What particularly upsets Arad, he adds, is “that a whole country is in a state of emergency, but elective medicine continues to take place in private channels, like at Assuta. Those sort of personnel are not being shifted from the private sphere to the public one, which is simply not logical.”

Tell us a little about what’s happening now on the ground.

“What’s happening in practice is that the hospitals are thumbing their noses at the instructions from above, or are doing things before the instructions arrive. The issue of the tests, for example. When someone arrives at the hospital with symptoms including fever and a cough, it’s inconceivable that the physician cannot administer the test for the coronavirus without authorization from the Health Ministry, in order to get a correct clinical picture. It’s unprecedented.”

Has that happened to you?

“Of course, but I’m one of the nose-thumbers, because not to administer a test like that has ramifications. A sick person could shut down an entire department. After all, there’s a dire shortage of N95 face masks. I keep them in a safe and hand them out sparingly, per person, per shift. They’re a rare resource.”

It’s that bad?

“We hold video calls with colleagues in China, and they use N95 masks routinely. The fact is that among the 40,000 medical personnel in Wuhan, there was not even one case of infection, other than the ones at the very start when they didn’t know what they were up against.”

For his part, Arad is astonished that the Mossad was enlisted to obtain medical equipment. “If it weren’t sad, it would be funny – that at the last moment they send our security services to snatch up equipment at the expense of other countries.”

But he does have praise for the Health Ministry’s conduct, early in the outbreak: “In January, when the coronavirus was an event that was happening only in China and nearby countries, the Health Ministry initiated a series of meetings of professionals. They need to be complimented for that.

“There was a conference in Jerusalem, in which Prof. Sadetsky and Dr. Vered Ezra [head of the medical management unit in the Ministry of Health] presented scenarios according to which we would see sporadic cases of the virus in Israel, brought in by people coming from abroad. That forecast set the policy. They spoke of a procedure for testing a patient in the ER – a process that takes 45 minutes. I got up and said that it’s not a task that’s appropriate for ER. An argument started, and then someone said, ‘We see the numbers, they’re not so big, you will be able to handle it.’ Anyone who says something like that, well, you see how far removed they are from day-to-day medical practice.”

You’re angry.

“You have to understand, Sigal Sadetsky is a highly esteemed woman, of real caliber in her field, but patients are not her area of expertise. I would imagine that it’s been very many years since she saw a patient face to face. That’s one example of many of the absence of clinical insight at the apex of the system.”

Yoli Gat, director of an old-age home in Herzliya, and a member of the executive committee of the Israel Gerontological Society

“On the cruise ship Diamond Princess it emerged that quarantine does not prevent infection,” says Yoli Gat, who for the past 30 years has held a variety of management positions at both public and private assisted-living institutions. “To this day, it’s not clear where the infection came from, but the source was probably with one of the crew that prepared and served the food.”

It’s self-evident to Gat that the lessons of the “coronavirus ship” should have been applied immediately to assisted-living centers, old-age homes and nursing facilities in Israel. She notes that quarantining of the elderly population, however strict it may be, does not take into account the direct, ongoing and necessary contact of the population at these institutions with the staff there.

“The infection that is now occurring in protective housing facilities shows that we didn’t have to wait for the appearance of the coronavirus,” she says. “At the very least, it’s essential to test the staff that serves residents of these homes. Not when symptoms appear, but now, at this point in time. Because if a young member of the staff is a carrier of the virus, he will likely overcome it, but for the elderly person he’s caring for, it will be too late.”

There have been increasing reports of cases of infection in old-age homes – on the backdrop of the Health Ministry’s refusal to conduct comprehensive tests on residents and staff alike, unless they report symptoms. About two weeks ago there was at last a shift in policy, when a Health Ministry team issued a directive to do as much testing as possible among caregivers who come into contact with an elderly population, even if they haven’t developed symptoms.

The symbol of the failure, at the time, was the Nofim Tower assisted- living facility in Jerusalem, where the Health Ministry agreed to test all the occupants after three cases of coronavirus deaths.

“Even there it took three weeks of shouting before anything was done,” Gat says. “There were cases of infection in other facilities, but that didn’t induce the Health Ministry to change course.”

Maybe because there aren’t enough test kits.

“It’s true we’re talking about tens of thousands of staff, but their location is known, it’s easy to get to them – what could be simpler? Everyone who comes into contact with an elderly population must be tested. Doing a pilot with random people who come to a supermarket is logical, but to neglect those who work with the high-risk population?

“This a recurring ritual,” Gat continues. “First come the shouts and the catastrophes, and then the Health Ministry gets its act together.” Before the new recommendation was issued, she says, “Prof. Sadetsky actually came up with a guideline extending the testing possibilities at old-age homes, for both staff and residents, but then added a qualification: ‘For those who display symptoms.’ So what was the point?”

According to Gat, “When guidelines are finally handed down, they are of a type that can’t be implemented, and after we explain that to them, the authorities send a correction. For example, at midday [on March 29] the Health Ministry issued a directive barring the employment of staff who also hold jobs elsewhere. Obviously, that is unrealistic. Nurses always work in at least two places, not to mention the multidisciplinary teams in nursing units, people who work for a few hours in a number of departments. A directive like totally rules out the possibility that they will be able to reach and work in every place.”

What is the alternative?

“There are tasks that everyone can perform. Feeding people, kitchen services. The state could recruit students, soldiers, National Service volunteers, and allocate them to every old-age home, assisted housing units or nursing departments, based on the number of occupants. They would first be tested to ascertain that they are negative for carrying the virus, and from that point on they are seconded to an institution and sleep there. At the moment I am in a situation where I allow people to enter without knowing where they were 10 minutes earlier.”

Are you and others initiating solutions independently?

“Well I, for example, took two apartments here, furnished them and allocated them to caregivers, and told them: ‘From today you work here, sleep here and don’t go home.’ It’s a very small staff, and naturally they start to get tired, but that way infection is prevented.”

Dr. Omri Shental, an internist and director of the hospitalization department, Sabar Health

Dr. Omri Shental, of the Sabar Health company, which provides home hospitalization services, is managing to take an optimistic view of the situation. “We have an opportunity here to carry out correct management of resources and to foment social change,” he says, adding that his basic assumption concerning the epidemic is that it particularly strikes the elderly, many of whom will require ventilation.

“The deterioration from the coronavirus takes the form of double pneumonia and respiratory failure,” Shental says. In that situation, very often, artificial respiration is required.

“However, in contrast to such classic diseases as influenza or pneumonia, where improvement is visible after two-three days and the patient can start to be taken gradually off the ventilator – with the coronavirus, the lung infection is very serious and the improvement isn’t evident for two-three weeks.”

The question is then, he says, “what the anticipated benefit is for the patient. When someone is connected to a ventilator for such a lengthy period, the prognosis is that even if he recovers, he will be in a very deteriorated state physically, mentally and functionally. And with people of 80-plus, the assumption is that at the end of the ventilation period they will remain with major lung damage. Moreover, we don’t have proof that artificial respiration in patients like these saves lives. What we do know is that it causes considerable suffering.”

What’s the alternative? Not even to try?

“The basic principle is to ask people in a high-risk group what they would want to happen if they are infected by the coronavirus and develop complications. You tell the patient: ‘You are over 80, the ventilation is likely to be prolonged, there’s a high probability that you won’t survive, and if you do survive, you will likely come out of it a wreck. What do you want to do?’ The patient should have the option to choose.”

For his personal welfare, or in order to help the system?

“Both. In the war against the coronavirus, the concep of the system in Israel, and worldwide, is that we must not lose a single soldier. Accordingly, we buy ventilators, clear out hospital wards and erect tents. We mobilize everything possible to fight it. That is a mistaken conception.”

Explain.

“At the end of the day, a large proportion of the patients with serious cases of the coronavirus are elderly people who are fundamentally ill. On a normal day, two months ago, if a person like that had arrived in the hospital with a serious case of pneumonia, he or his family would have been sat down for a conversation, the situation would be explained and they would be asked whether they want ventilation.

“On a normal day, patients like that don’t even enter intensive care, they are transferred to the internal medicine ward. But today, if an 80-year-old with multiple illnesses who has deteriorated because of the coronavirus arrives, he will be ventilated and the physicians will fight for him.”

And in the meantime they will possibly lose others.

“Correct, because if a patient like that occupies a ventilator for three weeks, then at some stage, as happened in Italy, there are no more ventilators available.”

What about the possibility of disconnecting a person from a ventilator?

“That is done abroad; in Israel it’s forbidden to disconnect a person from the ventilator. We live in a country with a dominant foundation in Jewish religious law, and doing that would stir such harsh opposition that there’s no point acting on that front.

“But there are many things that can be done, so I focus on having a conversation beforehand. Even if only 10 percent of the 80-plus patients say in advance that they don’t want to be connected to a ventilator if their situation deteriorates, that will have a tremendous effect. To order one machine from China costs something like $90,000. Add to that their operation and the costs in personnel, you reach astronomical amounts.

“The moment the patient, the family and the medical team become aware that another option exists, it becomes possible to exploit the resources more correctly and also to prevent wholesale abuse of the elderly.”

• • •

The Ministry of Health stated in response that it “was ahead of the whole world with its recommendations. Beginning with travel recommendations and advisories, closing the skies and giving the hospitals and the HMOs time to deploy. From the start of the event, the Health Ministry has been focusing on two central tracks: preventing the spread of the disease and the deployment of the health system for a high incidence of illness.

“The deployment is being carried out in a centralized mode, together with all those involved and those on the front line. The professionals, clinicians, epidemiologists and others are the best in their fields and are devoting themselves wholly to the task. We will continue to lead with determination the national effort in the war against the epidemic together with those on the front lines and the entire public.”

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