Some Israelis are clinging to the hope that after Passover we’ll get back to normal life, to something fairly similar to how things were before the crisis hit. This is not the case, and this must be made very plain.
Even after some of the coronavirus restrictions are lifted, large gatherings will not be permitted, physical distance will have to be maintained, online orders and deliveries will still be preferable and we’ll continue to wear masks. The “exit strategy” from lockdown is not a one-time event featuring a swift return to the fondly remembered past, but a series of trial and error measures of two to three weeks in duration that will eventually lead to a routine that differs significantly from the one we knew for most of our lives. It will last for many months, at least.
Businesses will also have to adapt to the new reality of distancing, out of necessity (and as an opportunity). Activity that combines long-distance ordering and delivery will have to become the main source of income for traditional, small businesses too, particularly during weeks when there is a rise in the incidence of illness and a tightening of the lockdown. Such a transformation does not happen quickly, but is essential. This will require a national effort, incentives and government aid to support businesses and encourage them to change their paradigm as long as they are capable of doing so. The time to start the process is now, as months of ups and downs await us amid the coronavirus routine.
In previous articles, I wrote of the reasonable conditions for activating an exit strategy, of which there are two – the first is a safety margin for averting disaster, and the second is a ready and effective epidemiological alternative for coping with a large number of patients in the absence of a lockdown. As we examine each of these conditions to see whether the time is right for an exit from the lockdown, we’ll also see why, even if both these conditions are not fully met, for reasons of proportionality and risk-management, we will very likely have to take the first steps towards easing the lockdown after Passover.
We are about to begin the first experiment of the exit strategy. This is a continual process of risk management, managing medical and economic risks.
Let’s begin with the first condition – a safety margin for averting disaster. For this purpose, we must guarantee that there are enough available beds in the system to absorb four to five “doublings” of the number of seriously ill patients (that could happen within three weeks) and obtain a good indication that at the time of the exit from the lockdown another significant exponential increase in the infection rate does not occur. Fortunately, the number of seriously ill patients is currently stabilizing at around 100-200, a number that is widely agreed to be within a safety margin to ensure that the health system would not collapse in the wake of a cautious and calculated easing of restrictions.
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But is the outbreak in Israel currently trending downward, or increasing linearly or exponentially? Unfortunately, it is impossible to answer this question with certainty, because of the “masking effect.” By just observing the numerical totals of patients we are essentially flattening a complex, multilayered picture and only seeing its projection, like a shadow on the wall.
The curve of seriously ill patients is rightly considered the most credible data from which it is possible to assess the outbreak of the disease. But the heightened isolation of the elderly population could creates an exponential decline in the appearance of seriously ill patients from this group, and mask a continued exponential rise in the incidence of serious illness among younger populations, of which a significant percentage is also vulnerable. And there is another masking effect, when a declining outbreak in the general population due to social distancing masks an exponential increase in the infection rate among populations that do not carefully adhere to the rules, and then this higher infection rate naturally spills over to the rest of the population.
Unlike the curve of seriously ill patients, daily observation of the curve of the infected (“all patients”) does not provide any insight on which to base any plans at this time. The number of new patients will depend largely on two factors that frequently vary from day to day – the amount of tests that are performed, and the population that is tested (the indication for testing). The daily fluctuation in the rate of positive tests depends above all on the fluctuation in the number of daily tests, as is reflected in the percentage of positive tests that has remained constant with the increases and decreases in the number of tests conducted.
As for the indications, we can explain the distortion by way of an example. If we compare a day on which many tests are carried out on people returning from abroad from a country where there is an outbreak, with a day in which hundreds of asymptomatic patients without a specific indication are surveyed, we’ll see a large difference in the number of positives – regardless of the trend of the outbreak in the general population.
To be able to glean useful insights from the tests, the list of those tested must be analyzed according to the date of the onset of symptoms (if any) and the indication for testing. But such information is still not available, based on information provided by the Health Ministry. Therefore at this stage, drawing conclusions about the disease’s spread rate from the total number of infected people tested each day is not at all informative for the purpose of determining the exit strategy or its timing.
Moreover, anyone who asserts that the exponential increase in infection has ceased and that the rates are stable is dreaming. I agree this is a reasonable estimate, and I hope that it is correct, but a more worrying explanation for these graphs is also possible. The exit from the lockdown will thus apparently be initiated without the most up to date and credible information about the rate of the disease’s spread.
Containing the virus
In the absence of a total lockdown, alternatives must be found to allow for a significant reduction in the spread of the disease from person to person within the family unit, from one family unit to another and from region to region. Some of the tools that make this possible were already employed at various stages of the outbreak.
The single most important requirement is an efficient system for rapidly identifying carriers and isolating them (preferably outside the family unit) and their contacts. All eyes are on the count of tests being carried out each day, but it will be much more important to ensure that test results can be quickly obtained and that the circle of the carrier’s contacts can be quickly closed. Without rapid identification and isolation, the rate of infection will not be stopped; instead it can be expected to worsen as soon as the lockdown is eased. To date we have not been able to demonstrate a sufficient national capability in this regard. A concentrated national effort is required to properly cope with hundreds of new carriers a day, and there is no time to lose.
The second element required to contain the rate of infection is the ability to differentially impose a lockdown on specific areas based on objective measurements of the disease’s spread. For this we need effective epidemiological “intelligence” via testing of symptomatic carriers in every part of the country and a skilled, centralized capacity for explaining and enforcing the health directives.
The third element that requires a managed national effort is the overall response for the vulnerable populations that are in voluntary isolation. Everyone is aware that a rapid and determined response is needed to deal with any suspicion of an outbreak in an old age home, including a continuous process of testing in all old age homes.
However, a coordinated national response is also needed for the elderly and other at-risk people who reside in the general community and a new “social contract” for supporting them while they are in isolation – physical, emotional and social support. A body should quickly be established to integrate the planning, economic and logistical aspects of this critical element for the populations that reside in the community.
Time to get moving
So, the two prerequisites for exiting the lockdown have yet to be fully met, and a series of urgent national efforts would be necessary to fulfill these conditions. Yet, I believe that right after Passover, an initial, moderate first step should be taken to exit the lockdown. A prolonged lockdown and lack of hope bear heavy costs, including the risk of its increasing potential to damage the economic, and public health. Poverty, emotional stress, domestic violence, postponement of vital medical treatment – all have growing and cumulative effects on public health.
Given the low and stable number of seriously ill patients, I believe we should begin with an initial step of trial and error, one we should execute cautiously and gradually while monitoring the situation as closely as possible, in case of error. Lifting too many restrictions at once may will bring temporary relief and cheers from the public and the economists, but could lead to a spike in infection and death rates that would require a tighter and longer lockdown that would in turn deal a mortal blow to the economy and public health. This is certainly a “very narrow bridge” that lies before us but we have to begin to cross it.
What about schools?
Children are thought to be the main transmitters of respiratory illnesses among families, and halting school has proven in the past to be a key tool in preventing the spread of disease on an epidemic scale. A significant percentage of adults have preexisting conditions that place them at risk for complications, and these people live within “regular” family units and are therefore exposed to infection by children returning home all at once from their various educational frameworks where they infect one another.
Voluntary isolation of the elderly population is not enough to keep the health system from being overwhelmed in the event of widespread and sudden exposure of numerous households to infection. The economic impact and the stress placed on families due to the suspension of school is clear and profound, and therefore creative and cautious solutions need to be planned such as study in small groups, integration of online studies, and implemented gradually.
We are about to take the first step of the exit strategy. It will involve a continual process of risk management – of trying to find the golden mean while navigating a winding path with an economic abyss on one side and a medical one on the other. Despite the fog of war, we must begin the journey to building a new routine in the presence of the coronavirus, and hope we are able to find a proportionate and cautious balance while facing this once-in-a-century event. I hope and believe that together we will get through the next stage of this national and global challenge.
Professor Balicer is Founding Director of the Clalit Research Institute and Director of Health Policy Planning at Clalit