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The Coronavirus Endgame Strategy: How We Exit the Lockdown Stage

If Israel doesn't control the rate of coronavirus transmission, tens of thousands of people could get infected in the next two weeks

רן בליצר
Ran Balicer
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Workers disinfect the elevator at The Great Synagogue, Tel Aviv, March 17, 2020
Workers disinfect the elevator at The Great Synagogue, Tel Aviv, March 17, 2020Credit: Moti Milrod
רן בליצר
Ran Balicer

Israel was one of the first countries to respond well to the coronavirus. Every step adopted by the Health Ministry was considered scandalous at the time, and within a week or two became the standard in well-managed countries.

The cessation of flights to China, placing those returning from a lengthening list of countries into quarantine, “closing the skies,” including to those returning from the United States, an epidemiological investigation surrounding every patient, limiting contacts, social distancing and finally – home quarantine for everyone. All of these steps, except for the last one, were adopted in Israel long before they were in European countries. With these decisive actions, we have received the greatest possible gift in this predicament: time.

Haaretz Weekly Ep. 70Credit: Haaretz

According to estimates, Israel has gained 14 days compared to European countries and the United States. If anyone thinks this is a short period of time, you should be aware that in “epidemic time,” this means Israel has 10-15 times fewer patients than we would expect to see now.

But time slips through our fingers in such a situation; every passing day brings us closer to the point when the healthcare system is likely to be defeated by a wave of thousands of patients who require respiratory assistance and intensive care.

Even if Israel were a country with the optimal ICU infrastructure, it would collapse after a week (with several multiples of the number of patients who could be treated). And it doesn’t have the optimal ICU infrastructure – instead, we’re at the bottom of the charts in the index of ICU beds for the population.

Therefore, at this time there is only one solution: a dramatic reduction in the number of those infected, starting tomorrow, in order to halt the multiplication. Otherwise, within two weeks Israel could reach tens of thousands of people infected, and a week later 5 percent of them would fill up all the country’s ICU beds.

Such a reduction is attainable only one way: home quarantine. For every person in his home and with his nuclear family, and to have no contact, even the most minimal, with other households. There are #stayhome movements developing worldwide, which call on everyone to stay home in the name of social solidarity. That is the “prescription” for a dramatic reduction in the number of new patients, and that is the achievement that Israel must attain now. Today.

There is no room here for gambling. Is it possible that the partial quarantine which Israel has already adopted has significantly reduced contagion? Perhaps. We will know that only in two weeks from now. But if they made a mistake, every missed day will increase the number of infected at the height of epidemic (in about a month from now) by 33 percent, and is likely to be the difference between the resilience and the collapse of the hospitalization system.

Such a collapse means not only the unnecessary deaths of 5 percent of coronavirus victims, but also of patients suffering from illnesses that require acute treatment to prevent deterioration. For heart, kidney and lung diseases, in the absence of a functioning healthcare system, every complication is lethal.

A sign calling people to stay home at a beach, Tel Aviv, March 20, 2020Credit: Oded Balilty,AP

What will happen in the coming month?

The days of grace that Israel earned thanks to its decisive action are running out, and in the next two weeks we will reap the harvest of our communal behavior over the past month. It’s true that directives were issued and to some degree obeyed, but specific events may turn out to be game changers. Only 10 days ago Israel celebrated Purim. In many cities the mass events were canceled, but in Tel Aviv there was a party atmosphere and the masses were out in the streets.

If in the coming days we see a surge in deaths among young Tel Avivians, we shouldn’t be surprised. In this event, the bill arrives after a two-week delay. The same is true of the large weddings in the ultra-Orthodox community last week.

If in the next two weeks morbidity increases significantly, the burden will be felt in the hospitals, but we can reasonably assume that the scale will still be something we can tolerate, even if there is a cumulative number of 10,000 patients. From that point on, things can go one of two ways: If a decisive, comprehensive quarantine is maintained in the coming days, it is probable that in two weeks from now Israel will see a significant halt in the rate of multiplication of cases, it won’t reach tens of thousands of cases, and the healthcare system will continue to function.

But if the quarantine is only partially maintained, as we are seeing at present, the probability is that we will see a continued deterioration, we will cross the threshold of the healthcare system’s capacity – and then, death rates will increase sharply for many weeks. At that point the government will impose a quarantine that is more extreme than any we have known until now, without a clear expiration date.

In the optimistic scenario, under a full closure, the country will reach the end of April without crossing the healthcare system’s capacity threshold, and perhaps even see a trend toward stopping the morbidity, with a decline in the number of new cases diagnosed every day. It all depends on us, and on the rate of deaths during the last week of March.

The key question: What is the “exit strategy”?

When we start a process as destructive to the economy as a full closure, there must be a clear exit strategy, with an array of possible scenarios depending on events. Any step must be aimed at reaching a clear endgame that presages a new, long-term routine. It is hard to predict at present, but because I tried in early February and again in early March to describe in detail the anticipated and desirable future, I will try to suggest once more where we may be heading.

Let’s start with the endgame, in other words the new status quo, which will make it possible to lift the closure significantly. In such a situation, which is similar to the present routine in South Korea, there is contagion but at a controlled rate, which maintains a “safe distance” from the point of incapacitating the health care system. In other words, the most important thing in any case is to calculate a number of weeks ahead and understand whether we are getting dangerously close to a scale of morbidity that leads to the collapse of the healthcare system, and to tighten or ease the steps accordingly.

Several complementary elements would make this possible: highly disciplined and cautious behavior of the population, with no exceptions, including an effort to prevent contagion inside our homes; a broad testing system that makes it possible to quarantine every patient immediately (full quarantine, preferably outside the family unit), along with all his contacts; “morbidity intelligence” for an immediate early warning about every divergence from the balance and a return to a system-wide spread of the virus – an intelligence system based on a large number of tests and independent reports, massive reinforcement of the healthcare system and maximum protection of its employees, and prolonged self-quarantine of the population vulnerable to complications, i.e. older people and those who suffer from a chronic illness.

The final step – isolation of the older and medically vulnerable population – is especially important, and will continue for a longer time than all the other steps. A system for the psychological and physical support of these populations throughout the crisis should also be established.

This new routine can go into effect gradually only when there is a dip in the morbidity curve which indicates that the doubling in the number of patients every three days has come to an end.

We can assume that a partial implementation of these recommendations is not sufficient for achieving that hoped-for change, and that we must adopt stricter steps even now, like in the countries where there was a system-wide spread and it stopped almost all at once. In any case, many countries such as France, New Zealand and others have done this in recent days as a preventive step, instead of adopting it at the crisis stage, like Italy and Spain.

If the government doesn’t take decisive steps, we are likely to get the worst of both worlds: a prolonged, partial closure and a blow to the economy, a risk of the collapse of the healthcare system, and two weeks later a total closure that will last for months. It’s like the Jewish parable about the indecisive man who ate the stinking fish and was also beaten and expelled from the city.

U.S. President Donald Trump explained Monday that governments must not take a step in which the cure is worse than the disease, referring to the economic consequences of the closure. It’s a good comparison. In cancer, too, the number of cells is continually doubling. If you don’t have chemotherapy in the very early stages of the disease, the stages in which the cure really is worse than the disease, a person finds himself taking the same cure when his body is collapsing under the burden of the secondary growths, and then the chemotherapy is less beneficial, it takes a long time, and the suffering is much greater. Here too, preventive medicine is preferable to treatment.

If we can halt the rate of multiplying deaths within three weeks, we can start a gradual exit from the closure, until we reach the new status quo. We won’t return to the routine of two months ago, but life will return slowly but surely under a new routine. And who knows – maybe the summer will bring a significant easing of the disease, and we will join the countries that succeeded in avoiding disaster.

Whatever the case, the coming days are crucial, and I hope that the we will make correct, determined decisions – as individuals and as a nation.

Prof. Ran Balicer is a public health physician, manager, researcher and serves as Founding Director of the Clalit Research Institute, and as Director of Health Policy Planning for Clalit - Israel's largest healthcare organization. On Twitter: @RanBalicer

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