A post-pandemic prescription for the Knesset to heal Israel from COVID

HEALTH AFFAIRS: These are the doctors' orders to the country's newly elected officials for ensuring that Israel continues surfacing from coronavirus and becomes healthy again.

A MAGEN DAVID ADOM medical worker tests people for coronavirus at a mobile site in Jerusalem. (photo credit: OLIVIER FITOUSSI/FLASH90)
A MAGEN DAVID ADOM medical worker tests people for coronavirus at a mobile site in Jerusalem.
(photo credit: OLIVIER FITOUSSI/FLASH90)
Prime Minister Benjamin Netanyahu claimed during his election campaign that the coronavirus pandemic would be over for Israel “within a few weeks.” And while the country remains ill with election deadlock, Israel seems to have broken through the COVID-19 crisis and to be surfacing healthier on the other side.
It is unclear whether anyone will be able to form a stable government. While the public waits for President Reuven Rivlin’s decision about who will be charged with putting together a coalition, health officials are putting together their list of priorities for the next administration.
The Jerusalem Post spoke with four top doctors and scientists: Prof. Gabriel Barbash, former director-general of the Health Ministry and director of the Weizmann Institute of Science’s Bench-to-Bedside Project; Prof. Cyrille Cohen, a member of the advisory committee for clinical trials on SARS-CoV-2 vaccines at the ministry and head of the laboratory of tumor immunology and immunotherapy at Bar-Ilan University; Dr. Talya Miron-Shatz, founding director of the Center for Medical Decision Making at Ono Academic College; and Prof. Zeev Rotstein, director-general of Hadassah Medical Center.
They offered the next Knesset and government their three most important recommendations for ensuring that Israel continues surfacing from the pandemic and becomes healthy again.
Keep an eye on the airport
Ben-Gurion Airport is the weakest link in the coronavirus chain, according to the health experts, because it is through this portal that vaccine-resistant mutations could enter Israel and even potentially unravel its mass vaccination success story.
“I am concerned that at some point, we will see some variants that are more resistant to the vaccines,” Cohen said. “It does not mean that the vaccine will become ineffective, but it could become less effective, and then the good numbers we are achieving won’t last.”
In the first wave, people entering Israel from the US led to 70% of the country’s coronavirus cases. Ahead of the third wave, travelers brought in the British mutation, which spreads at least 30% faster than the original Wuhan virus strain and therefore slowed the effectiveness of Israel’s vaccination campaign.
In addition, travelers have brought in the Brazilian mutation, a New York mutation, and the South African mutation – the latter two of which render Pfizer vaccines less effective.
Cohen recommended that people returning or traveling to Israel continue to be screened for the virus within 72 hours of boarding their flight. On arrival, travelers should be screened again with a PCR swab test. Any positive tests should undergo genetic sequencing to tell health officials more about the specific strain of the virus that the person had been infected with.
“It is not enough just to know if someone has the virus,” Barbash said. “We need to know what strain of the virus to be able to catch potentially dangerous variants before they spread.”
Moreover, if people do test positive, the state must improve its ability to effectively enforce quarantine. The ministry had reported in the past that as many as two-thirds or more of arrivals did not go to hotels and failed to properly quarantine at home.
A Japanese study published earlier this month in the Journal of Travel Medicine showed that the country had seen a sharp increase in the number of coronavirus disease cases detected among travelers and returnees at airport quarantine stations, despite the pandemic subsiding in parts of many countries.
“A nasopharyngeal specimen was collected from travelers and returnees arriving in Japan, and quantitative reverse transcription polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 was performed in four airport quarantine stations,” the study explained, noting that 782 cases of infected people out of 168,061 tested were discovered at these stations between March and September 2020.
The samples were genetically sequenced and revealed that people, as expected, carried a variety of strains. As such, the study’s authors recommended formulating “an efficient strategy of testing and real-time genome sequencing” to support a quarantine protocol while infection chains and variants are being investigated.
Israelis will want to travel and already some countries have announced they will welcome vaccinated citizens who carry with them an official vaccination certificate. Earlier this week, Greece announced that it is removing its tourist cap – formerly 10,000 travelers could visit the country per week – and Cyprus said it will welcome Israeli travelers without quarantine beginning April 1.
Israel will also soon want to allow vaccinated visitors from abroad, but first the country must have a system in place to validate travelers’ vaccination certificates.
Cohen said that alongside testing and sequencing, Israel must reinvest in its contract tracing capabilities.
In August, the Israel Defense Forces was formally charged with cutting the chains of infection for the country, and established a contact tracing unit, recruiting conscripted soldiers and reservists to operate it.
The unit quickly became overwhelmed, as the country saw more than 8,000 new cases per day – an unmanageable number for even the best epidemiological trackers.
But Cohen said that contact tracing is the key to controlling variants, and therefore maintaining a strong “test-trace-isolate” system – especially for those arriving from abroad – must be a priority for the next government.
Finally, any new government should prioritize vaccinating Palestinians because they also travel in and out of Israel, just through a series of land crossings, Barbash said.
“If they are not vaccinated, then there will be mutations that come in just like from the airport,” he stressed.
Invest in public health
The coronavirus pandemic highlighted Israel’s decades-long deficient investment in its public health and hospital systems. Now, it is time for the government to invest in rebuilding and reforming them, the experts said.
According to Prof. Dan Ben-David, president of the Shoresh Institution for Socioeconomic Research and an economist at Tel Aviv University, Israel has been neglecting its health system since the 1970s, and the situation has grown increasingly acute since that time.
Israel entered the coronavirus crisis with the highest hospital occupancy rate of any Organization for Economic Cooperation and Development country.
In the area of healthcare staff, Israel benefited greatly in the 1990s from the influx of doctors from the former Soviet Union. But the country did not invest in new ones, so Israel’s physicians are getting old, Ben-David said. In terms of the number of physicians per capita, Israel is roughly close to the OECD average, but has 10 times more physicians over the age of 75.
Israel went into this epidemic with by far the highest number of people dying from infectious disease per capita in the developed world – 73% more than the No. 2 country, Greece.
Even worse, Israel has one of the worst nurse-to-population ratios, with five nurses per 1,000 people – a figure that is significantly lower than the OECD average of 8.8.
“Our doctors and nurses are excellent, but we don’t have enough,” Cohen said.
In December, Prof. Dror Mevorach, who headed one of the COVID-19 wards at Hadassah, penned an opinion piece for Ynet in which he explained that payments from the health funds never fully cover a hospital’s operating costs.
“This impossible budgetary cycle has led to Israel’s health expenditure gradually declining to just 7.3% of the country’s GDP – significantly lower than European countries such as France and Germany,” he wrote. “It has also led to a steady deterioration of the healthcare infrastructure, while simultaneously fostering its dependence on what is essentially government largesse.”
During the crisis, Israel’s hospitals were forced to shut down units and redirect care to accommodate a growing number of COVID-19 patients.
More than 6,000 Israelis died from the virus during the course of the coronavirus pandemic. But, in addition, there were many people who died of other ailments because they did not seek help. This was partly because of fears that they would contract coronavirus at the hospital or doctor’s office. However, according to Rotstein, care was also limited in some situations, as hospitals and health funds were forced to cut back on providing routine screenings and elective surgeries.
In the first wave, the government specifically asked hospitals to cease providing elective care. But in many cases, the line between urgent and nonurgent can be drawn only in retrospect, according to an article in The New England Journal of Medicine.
“A lot of procedures deemed ‘elective’ are not necessarily elective,” Brian Kolski, director of the structural heart disease program at St. Joseph Hospital in Orange County, California, told the journal.
“We did fine in comparison to other countries, but we could have done better,” Cohen said.
“It is unbelievable to have 26-hour shifts [for medical staff]; to have to wait several months to get an appointment with a specialist; to not have enough capacity in our intensive care units, [so] that people have to sleep in the hospital corridors or cafeteria. This is like a third world country, and it should not be happening in Israel,” he added.
Cohen said that it is time for Israel to reevaluate the place of the healthcare system among the country’s national priorities, charging that if the country can invest in submarines and F-35 warplanes, it should be able to improve the health system, because “at the end of the day, health is life.”
Rotstein said that historically Knesset members opted for top portfolios, such as Defense or Finance. But he hopes that after COVID, elected officials have learned that the Health Ministry is important, too.
“Until now, no one transferred support for the health system into seats in the parliament,” Rotstein said. “I think we are at a turning point.”
Rebuild trust
The coronavirus pandemic drastically decreased trust in the government and the majority of its institutions.
The 2020 Israel Democracy Index revealed that the country was at the lowest point in a decade in trust in all public institutions and government officials.
Some 57% of Jewish Israelis said that trust between the public and the government was harmed between March and June 2020. By October 2020, 90% felt that trust had diminished.
“Trust lies at the core of everything,” said Miron-Shatz. “The airport was closed and then it opened. It may have been a practical thing, but it also created a lot of mistrust.”
Miron-Shatz said that COVID demonstrated how much people rely on the government and how “quickly government can control our lives – it was radical.”
Trust in government has been tied to compliance with public health policies in multiple studies, she said.
To help improve trust, she said, the government needs to empower professional authorities to manage professional matters. 
Miron-Shatz said that not all people will bounce back from a year of COVID-19 quickly after having their resilience eroded by taking care of small children, being sick, domestic disputes or occupational uncertainty.
“We are still afraid, somewhat withdrawn,” she said, calling on the next Knesset to invest in improving the country’s mental and emotional health.
Finally, Rotstein said that wounds between segments of society would also need to heal.
IDI’s index found that 88% of Jewish citizens felt trust between haredim (ultra-Orthodox) and non-haredi Jews was harmed by the pandemic. Additionally, 38% believed trust was harmed between Jews and Arabs.
Israeli society has seen “so much hatred” during the course of the pandemic: Jews against Muslims, ultra-Orthodox Jews against secular Jews, rich against poor, Rotstein said.
“People blamed everyone else for the pandemic,” Rotstein said. “To heal Israeli society is an important message and, for this government – if there will be one – the most important task.”