This column is very frustrating to write. I thought and hoped we’d be in a very different place by now. I read a column that I wrote in April, at the end of the first wave of the pandemic, where I outlined the systems that had to be established immediately to avoid a renewed outbreak of the coronavirus and avoid the need for another lockdown.
Three of them will become operational for the first time only this week: the Alon center of the Israel Defense Forces Home Front Command for epidemiological tracing to break the chain of COVID-19 infection (to be fully operative only at the end of October); a set of quality measures of the outbreak control infrastructure; and the geographic “traffic light” scheme, to be implemented this week.
If we insist on finding a silver lining, in retrospect it might turn out that we benefit from the second wave: that is, if it had not occurred and we had continued to bask in our success in dealing with the first wave – we would end up exposed to a winter wave that would devastate us. On a less positive note, it should be said that these systems are going into action on the buzzer. Recent case count shows a problematic nationwide rise among all sectors, which has given us the dubious title of first place per capita in new infections worldwide.
Interpretation of last week's data should be qualified by noting that some of the dramatic increase (from 2,000 to 3,000 new confirmed cases per day) can be attributed to increased testing among the ultra-Orthodox population. This is in fact a positive side effect of a well-organized, proactive process of discovering new cases. In addition, the young age of these newly infected individuals should not lead to a dramatic flow of seriously ill patients into hospitals in the short term.
But another factor in this recent increase, among all population groups, can be attributed to disregard for national directives that ban large gatherings, expected to bring about a painful uptick in new severe cases and an accumulation of seriously ill patients in hospitals.
The problem of the status quo
Many people believe that the Israeli economy is wide open, more than most Western countries. Various indicators show that the economy is slowly recovering, but it’s clear that the economic situation is on the edge of an abyss. Why not go on maintaining the status quo and seeing where things lead?
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But like the frog that slowly grows used to boiling water in the old fable – we are now living “at peace” with a situation in which 10 to 20 percent of the daily death rate in Israel is due to the coronavirus. We bid farewell to 100 people a week, some of them young and relatively healthy, with most of the deaths avoidable.
Things are not good, but they could be worse. We should show caution and not embrace theories that are still unproven about a threshold of population immunity to which we will arrive at any moment, due to past exposure to similar viruses, or a threshold of herd immunity that’s lower than any we have known in another disease. These are attractive theories but they are not sufficiently grounded and increase public confusion. It’s tempting to rely on them, but they have repeatedly turned out to be unreliable.
Academics trying their hand for the first time at interpreting epidemiological data in the framework of the current crisis can always come back next month with a new explanation after the previous one did not hold up to the test of reality. Decision makers, however, don’t have the privilege of taking wild gambles.
The approach mistakenly called the “Swedish model” of not disrupting the spread of the disease can easily turn into the “New York model,” certainly in the winter. No country in the world has truly managed to fence in the older and vulnerable population. In no country has the disease stopped suddenly of its own accord without intervention – but, an uncontrolled spread that has brought magnificent health care systems to their knees? This we have certainly seen. They also thought it wouldn’t happen to them, and apparently they too had a scientist who said confidently that there wouldn’t be more than 10 dead.
Winter is on the way and if the disease spreads more, Israel’s health care system will no longer be able to keep the coronavirus death rate (CFR) at a level that is one of the lowest in the world, and we’ll all cry out “do something!” But then the impact of the change will be slow, the decline in serious illness seriously delayed and the toll heavy. Therefore, there is no alternative: We must act now to reduce the spread of the disease.
The prisoner’s dilemma
Indeed, many people support various steps to prevent infection, but under one condition: that the activities they love not be curtailed. Culture, prayer, restaurants, weddings, going out with friends – everyone wants to draw the line one inch beyond the limit. In this context it sometimes seems that Israel has only two modes: When the threat is imminent, everyone rallies round the flag, seeking the common good, altruism until victory. Otherwise? Nobody wants to be a sucker. This is classic behavioral economics theory – reaching a “Nash equilibrium” vis-a-vis different communities, in which we are dragged toward and become fixated on the worst choice of all, instead of seeking a balance in which everyone takes responsibility, sacrifices a little and thus achieves the maximum aggregate, collective good.
It must be said that the problem here is not about one community or another. The increase is seen throughout the country. We’ve reached a situation where less than 20 percent of the country’s population lives in a “green” locale. Restaurants are crowded in the evening with young people without masks, in numbers that exceed what’s permissible. Conduct at events halls and weddings is scandalous in all parts of society. Pictures of mass mask-less gatherings in closed spaces over the past few days – in hotels, at Mount Meron, at private events – are disturbing and frustrating, and tear social cohesion apart.
At this point, locales where almost half the country’s population lives have been designated “red” or “orange.” Local control centers have been established to help the red-designated communities deal with the situation and, make no mistake, the efforts invested there are great and coping with the crisis is complex and very difficult for these residents. Not because the people there are less disciplined, as some like to say, but first of all because the basic conditions there are crowded and intertwined in ways people in Tel Aviv cannot fathom.
The level of personal discipline and community involvement needed in Bnei Brak or Rahat to prevent the spread of the disease is much greater than that demanded of Herzliya or Nahariya. With the same behavior and same level of taking responsibility, there will be more infections in Bnei Brak than in other cities.
Before pointing a blaming finger, we must understand that the map of challenges is a differential one, not only the map of infection.
If in any case we’ll get to tight restrictions, why not now?
The question I’ve been hearing every day from the “hawkish” parties of the coronavirus struggle is: So why not declare a lockdown now and be done with it? Why wait? Why not “get it over with”? Politically and in terms of enforcement, this is a much easier option than geographically differential restrictions. Perhaps if we really hit the pandemic hard, we’ll reduce infection in no time to 100 cases per day, then we’ll have a wide-open economy with security margins for when winter comes?
The answer is, unfortunately, no. First, per one of the proposals raised by the coronavirus cabinet: a short (10-day) lockdown. A brief lockdown will bring about 1-2 rounds of infections in the extended family, and might even increase them (look what happened to infection rates in yeshiva capsules, two to three weeks after the group lockdown?). And after 10 days, will we permit these people who were in lockdown to cross over into life-as-usual in the “green” zone? Most scientists I spoke to think that a short lockdown is the worst of all possible worlds.
It’s important to remember that even tight, nationwide restrictions won’t ensure the complete, desired results. One likely scenario: We’ll go into restraint mode for a few weeks’ time during the upcoming holidays – without full-fledged lockdown; there will be no commerce, no leisure time activities, and people will be allowed to freely hold (fewer) family and social meetings. Infection will decline, but slowly.
Three weeks later, we’ll have brought the new infection rate down to 1,000 a day. And then – how long will that go on? We go back to the “traffic light” system and risk losing control again? A possible decline to 1,000 new infections a day looks like a significant achievement that’s worth the effort, but we’ve already seen that within a mere 10 days, from July 5, the number of new infections rose from about 800 to about 1,800. The achievement, born of suffering, could disappear in the blink of an eye if there is no effective apparatus to maintain it outside the red zones.
And so, in my opinion, severe nationwide restrictions should only be imposed when three essential conditions are met:
The health care system will clearly be on the verge of saturation: We have been “walking on the edge” for a month or more now. But it seems that this fragile stability is about to break down and the models are predicting an increase. Let’s hope that it will be gradual and controllable, because if the number of cases of severe illness rises suddenly, we may not be able to stop in time before we saturate the ICUs. And winter is approaching.
When it has been proven that efforts to avoid a lockdown have failed to create enough of a decline in new cases, as winter’s challenges loom: So far a combined system of “traffic lights,” command centers and increased enforcement of restrictions has not been implemented. We can’t know whether the restrictions inherent in such a system are sufficient to create a declining trend, but the risk is that we won’t know very soon: The plan was approved late, is being implemented only now, and its results will be felt only in two weeks. Absent a dramatic change in people’s behavior, the system might/will not bring about the desired decline. But there is a narrow window of hope.
Nationwide epidemiological tracing systems for breaking the chain of infection have been built, tried, measured and found ready to prevent a renewed rise in infections: In this context it must be said that these mechanisms are not yet ready, and are likely to be ready only at the end of October. This last condition is the main reason that even people who may see severe restraints or lockdown as necessary will continue to prefer to delay them, even if they seem (almost) inevitable. Every day that passes brings us close to a reasonable exit strategy. Every day that passes increases the chance of encountering an exit system that is capable of meeting the challenges.
Finally, we must not embark on such drastic measures without a complementary economic move that will ensure a stable economic basis and avoid irreversible damage to businesses and individuals. Without clear financial backing there is no hope of achieving public support for the move.
The bottom line
First, we must not get to winter without a significant decline in the rate of infection. We hit the brakes too late and all indications are unfortunately toward an uptick in that rate.
Secondly, the impact of the “traffic light” system will be felt for the first time only around Rosh Hashanah. Even before that, if we don’t see a significant decrease in infections, more painful restrictions will probably be imposed on all communities and in all cities to reduce the risks.
In this context, the choice of imposing severe nationwide restrictions during the High Holy Days will be less damaging to the economy than the alternative, at a later phase. But then, it will be a risk because the Alon center for epidemiological tracing will not have been completed. If this is the decision, let’s hope that all the systems that are up and running by the time the limitations are lifted, will be enough to keep infections low while opening up the economy.
Finally, despite the understandable frustration, in my opinion right now we must focus discourse not on accusations but rather on solutions, a shared fate and the need to deal with all parts of society collectively in light of the serious challenges we are facing.
If all of us, as a society (including our elected representatives) and as individuals, remember that in this event the name of the game is mutual dependence, setting a personal example and not pointing a blaming finger at one group or another – maybe we will still be able to recalibrate our route.
Prof. Ran Balicer is Chief Innovation Officer at Israel’s Clalit Health Services, and chairman of the National COVID-19 Expert Panel.