Israel Hits the Brakes Too Late in Its Second Round Against Coronavirus

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The coronavirus ward in Ichilov Hospital in Tel Aviv, in March 2020
The coronavirus ward in Ichilov Hospital, in Tel Aviv, Israel, in March. The organizations involved in the response to the outbreak have to work with a Tower of Babel of information systems.Credit: Ohad Zwigenberg
רן בליצר
Ran Balicer

Every Israeli driver who has attended a periodic defensive driving course is familiar with the concept “braking distance.” A driver traveling at a speed of 140 kph. (87 mph.) will run over a pedestrian who is 100 meters (328 feet) in front of him – even if he brakes at the very first moment he sees him. The lesson is obvious: Don’t even reach such a speed, and if you do so by mistake – hit the brakes hard before you actually see the pedestrian starting to step onto the road, since by then it will already be too late.

When it comes to a solution to the coronavirus, for weeks we have been seeing the illness spread in Israel at one of the fastest rates in the world. The percentage of those who test positive, which is the most stable and important indicator, has increased gradually within a month from less than 1 percent to 5 percent. And that was despite a constant rise in the number of people tested, something which is actually supposed to reduce the percentage of positive results.

In this situation we can assume that hundreds and perhaps even thousands of Israelis are being infected every day without being detected, and that they are continuing to infect others and to create an accelerating process.

Epidemiological studies show that the reopening of events halls to 250 participants was one step too far. Such “normal” conduct will be reasonable once again only in a situation where the incidence of disease stabilizes and becomes moderate, and an efficient health system nips every chain of infection in the bud. But a situation that is just the opposite is a recipe for exacerbating an uncontrollable infection rate, which is in fact what has happened.

Yet, up until the past week – although we do understand the direct and delayed connection between contagion and serious illness – the country’s decision makers (justifiably) hesitated to hit the brakes and hurt the economy. At present, however, when we are already seeing a significant and predictable uptick in the number of seriously ill individuals, we are dangerously approaching the so-called braking distance and tough decisions are in order.

Tel Aviv this week. Every family should make sure to keep away from gatherings at its own initiative. Credit: Ofer Vaknin

The real bottleneck: the staff

Despite rumors about the “domestication” of the virus and its becoming less lethal, apparently even now about 2 percent of those who contract it become seriously ill, after a gap of two weeks. In the past three days we have seen, every day, an average of 10 additional seriously ill patients – which corresponds to the 500 infected people that were detected on a daily basis, two weeks beforehand.

“We’re far from insufficiency,” some people will claim. “There are thousands of ventilators available in the health care system.” It’s true that there are thousands of available ventilators at present. But as opposed to the prevailing belief, it is not the ventilators that cause the bottleneck in treatment: It’s the manpower shortage.

In light of the large number of skilled staff required to treat each coronavirus patient (especially in the pre-ventilator stage and in the effort to prevent deterioration to the point of invasive artificial respiration), and the disturbing rise in the number of health care workers who are themselves ill or in isolation – we can reasonably estimate that even a few hundred seriously ill patients would significantly challenge the capacity of the health care system, and could lead to a decline in the quality of care each patient receives.

This would result in a higher mortality rate – not only among patients who are seriously ill from the coronavirus, but also due to cardiac diseases and pulmonary illness, and among post-surgical patients. In my opinion, that is the real definition of the system’s point of insufficiency, rather than the number of ventilators that are ready for use.

The fact that hundreds of those infected will become seriously ill in the coming three weeks was already a given when they were infected in the past three weeks, and we are unable to change that. But we can still influence the rate of illness in August during the narrow window still open to us during the next two weeks.

I would claim that in the famous graph that has been with us since March, we have passed point 2 and are approaching point 3.

Scenarios for coming out of lockdown

A hesitant response

We can guess why certain parts of the population are still not acknowledging the danger they face, and instead of returning to the coronavirus “routine” and accepting the inconvenience involved in using masks and maintaining social distance, are opting to return to a normal routine and to ignore the directives.

When dealing with a public that longs for an optimistic scenario, the media have created a growing platform for unfounded explanations (“The Israeli summer will eliminate the coronavirus,” “The virus has turned into a tame kitten,” “A polynomial analysis proves that there won’t be another increase in the rate of illness”) and are disseminating extreme theories and myths that allow people to dismiss the serious risk of illness. I’m the first to acknowledge the importance of skepticism and critical thinking, but it seems that optimism to the point of blindness has become the bon ton and risk management was overlooked.

But the main problem now is that the public has learned from personal experience that decisions on restricting movement and business activities are not accompanied by a promise of financial security for those who are being harmed, as was done in other countries. The need to choose between public health and earning a living has made it tempting for many Israelis whose livelihood has suffered, and for the public representatives who speak on their behalf, to believe in the optimistic scenario.

A drive-though coronavirus testing compound in Jerusalem.Credit: אמיל סלמן

And if that is the choice, it is understandable that there is a natural tendency to postpone the decision until the very last moment, when the crowding in the intensive care units becomes a palpable reality, before adopting any steps that restrict commerce and burden the economy further. Perhaps we really can wait a little longer? A few more weeks? Maybe the incidence of disease will be halted on its own. Maybe it will turn out that the increase in the incidence of disease is no longer connected to the increase in seriously ill patients?

The ‘braking distance’

None of those possibilities can be totally rejected, and we must acknowledge the uncertainty, but we also have to understand the principle of the “braking distance.” For all the reasons presented above, a large proportion of experts believe that the critical time for intervention, for the “final braking point,” is right before us. And the problem is that it is coming at a time when we don’t have enough effective tools to halt the spread of the illness.

A great deal has already been written about the delay in setting up the proper testing and investigation system, but I would like to draw attention to the information system as well. Unfortunately, too many months after the outbreak of the pandemic the nation lacks high-quality information about the 20,000 people tested each day – who was tested because of symptoms and who in their absence, who was tested due to exposure to a person who tested positive for the disease and who for other reasons.

Tel Aviv residents out on the streets without masks, in June. Perhaps thousands of Israelis are being infected every day without being detected, and are continuing to infect others. Credit: Eyal Toueg

At the same time, some of the tools for documentation and the computerized systems of the epidemiological nurses look as though they date back to the 1990s, and the various organizations involved in the response to the outbreak (the Health Ministry, Education Ministry, municipalities and so on) have to work with a Tower of Babel of information systems.

The “Startup Nation,” with the help of the finest elite units, has been unable for almost half a year to construct a system that gathers complete and reliable information on the most crucial issues, and now we once again have to plan policy with an egregious shortage of data.

Where did most of the infections occur? How many of those cases could be attributed to restaurants and how many to being on the beach? How many symptomatic individuals tested positive each week in the past month? What proportion of asymptomatic individuals developed a serious form of the disease? Important questions have been asked for months, and there are still no answers. This is not something that’s predestined; it’s possible and imperative to change the situation. It won’t happen in a day or a week, but it could happen before the winter.

So what do we do now?

The continued restriction on gatherings of over 20 people in closed spaces of every type is an obvious step. Even if the government doesn’t make a decision on this, every family should make sure to keep away from gatherings at its own initiative. Organizations and companies that can function via remote work or in capsules should adopt these methods whenever possible, at their own initiative, until everything blows over.

Members of at-risk populations who reside in a community must be particularly careful at this time, as at the height of the lockdown. In order to assist with individual risk management, the Clalit Research Institute has improved its risk model for serious illness, and recommends certain rules of conduct for every group, in order to reduce the dangers. The recommendations vary in accordance with the type of activity and the individual’s risk level vis-a-vis serious illness, in light of his preexisting health condition. The recommendations can be found on the Clalit Health Services website.

We must teach those around us the basic rules and we must insist on them: Masks are not enough to prevent infection – we must maintain our distance from others and wear the mask properly, especially when conversing in a closed space. These rules must be observed even more carefully by managers and leaders, in order to serve as a role model, at work and on their own time.

We must remind young people of the importance of mutual responsibility: Even if you yourselves feel that you are immune to the illness, every one of you has a grandparent, a relative or an acquaintance in an at-risk group, and it is your duty to observe the rules of caution in order not to become infected and not to endanger them. One of every seven adults aged 60 or over whom you infect will suffer from a serious, life-threatening illness as a result. Even if you yourself do not feel ill, you could still definitely be carriers: Behave responsibly, don’t become infected and don’t infect others – and don’t regret it after the fact.

A waiter wearing a face mask is serving a man at a cafe in Jerusalem, June 2020.Credit: Emil Salman

Remember too that there is a cumulative body of evidence showing that even young patients and those who are not defined as seriously ill, suffer from complications and from an ongoing disruption of their quality of life for quite a long period of time; some even require rehabilitation.

All the information available is still partial and requires long-term follow-up, but please – be careful. This is not the flu.

Still room for optimism

We have to hope that the dramatic rise in the incidence of illness and the warnings being sounded in the media have already convinced many people who until now have not done so, to behave responsibly and cautiously. As a result, the infection rates will decrease, perhaps already in the coming week, and the number of seriously ill patients will stop rising.

Whether or not that happens, while managing the present stage of the crisis we must insist on seeing within the coming three weeks the final stages in the development of an information system, a testing system and a system for investigating and finding contacts, using technological tools and first-class professionals. A set of indices showing the quality of the activity of each system should be frequently publicized for decision makers and the public, in order to improve them constantly. That is the only way we will be able to conduct a normal routine in the presence of the coronavirus, without an outbreak with every reopening of the economy.

Dealing with the coronavirus is a marathon, not a sprint. We can arrive at the next wave, the winter wave, prepared, trained and organized with an orderly, step-by-step plan and with a genuine intention to work according to it. If that happens, the sharp rise in the rate of illness in June 2020 may be remembered as our greatest good fortune, with divisions being trained and emergency storage facilities being replenished a moment before the real war breaks out.

Ran Balicer is a professor of public health and chief innovation officer at Clalit Health Services and a member of the national Epidemic Management Team.

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