Coronavirus: Will Israel’s healthcare system survive?
HEALTH AFFAIRS: Until the country gets a handle on the virus, Israelis can expect repeating waves for as long as one to three years.
By MAAYAN JAFFE-HOFFMANMAGEN DAVID ADOM workers, wearing protective clothing, bring a patient to the coronavirus unit at Sheba Medical Center in Ramat Gan(photo credit: FLASH90)
Like the 1960s hit by Barry McGuire, Israel is on the “eve of destruction,” where no one can be saved if the healthcare system is in a grave.“The system is deteriorating to a point that it will no longer be salvageable, and then it cannot save sick individuals,” Prof. Dan Ben-David, president and founder of the Shoresh Institution for Socioeconomic Research and a Tel Aviv University economist, told The Jerusalem Post. “Look what happened in other countries, what’s happening in a bunch of states in the United States now. Fast-forward to flu season in Israel and imagine it happening here. We could be Arizona. We could be Italy.“The health system is woefully inadequate for what is coming our way,” he continued. “Someone has to wake up.”On Thursday, the Health Ministry reported that Israel had one of the highest numbers of new diagnoses since the start of the pandemic. With around 28,000 people screened the same day, the infection rate surged over 6%. Public health officials say to contain the disease, that rate should be under 1%.“If this growth continues, then we will be in danger,” warned Eli Waxman, former chairman of the National Security Council’s expert advisers committee on the coronavirus outbreak. “We must make sure that every few days the numbers are going down; otherwise, we will have to take more serious measures.”According to Waxman, the health system can accommodate between 500 and 1,000 ICU patients, and Israel is rapidly climbing in that direction, with more than 200 people in serious condition on Thursday.Just ask Nadav Katz of the Hebrew University of Jerusalem’s Racah Institute of Physics, who explained that in recent weeks the benchmark of moderate and severe patients has been going up, putting patient care at risk. He told the Post that when doctors and nurses are stretched too thin, patient care is downgraded, and more people die.“When you are about half of the capacity, that is already starting to be too late,” Katz said. “By the time people respond and by how the dynamics of the virus play out, it is going to overshoot. It is not as if you can flip a switch and people stop becoming infected or getting seriously ill.”The government’s decision to roll out a series of harsh new restrictions could push off the breakdown a few more weeks, Waxman said, but until the country gets a handle on the virus, Israelis can expect repeating waves – going back to normal activity, the pandemic spreading again, reimplementing social distancing – for as long as one to three years.ENTER FLU season. People are coughing, they have colds, and doctors cannot differentiate between who has COVID-19 and who has a bad cold. Patients check into the hospital and get tested, but the results take more than a day and up to several days, as they do now, because nothing has really changed.“The system will be inundated with people who are sick, not necessarily with COVID. Without the ability to distinguish between them, they are taking up the space of someone who needs space in the hospital. That person’s condition deteriorates. People are not treated in time,” Ben-David described. “Extrapolate onward and understand the magnitude. I do not want to even think about what it could look like. We are heading toward a disaster.”Dr. Yael Haviv Hadid, who runs Sheba Medical Center’s coronavirus intensive care unit, agrees. She said that she has heard from her colleagues that this year the flu will “not be an easy flu” and “we can handle it only if we are prepared.”But she also said that every winter “we have the same kind of problem”: overcrowded facilities and patients severely sick with the flu being treated in the corridor. The system cannot take more than that, she said.“I am not sure everyone will be able to be admitted to the hospital at that point,” Zeev Feldman, chairman of the Organization of the State Employed Physicians of Israel and deputy president of the Israeli Medical Association, told the Post. “I think there will be chaos.”“There is a moral issue,” he continued. “The Finance Ministry promised hundreds of positions for physicians so we can absorb and train them, and we received nothing. They promised hundreds of more slots for nurses – nada is being delivered.“If anyone has the impression that hospitals are getting ready and gearing up to treat Israeli citizens in the winter, he should wake up from this illusion, because with all the hundreds of millions of shekels the government spends, it has not committed to cover the deficits of the hospitals nor given us the means to prepare for the winter. The people cannot believe what the government says,” he concluded.THE COUNTRY has a history of neglecting its health system since the 1970s, and the situation has grown increasingly acute since that time. Ben-David reminded the Post that 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, he 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.“We are even bad compared to ourselves,” Ben-David said. “Israel’s mortality rate doubled over the past two decades.”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. In other words, in nearly every hospital, there is a shortage in the number of nurses compared to the number of beds.On Wednesday, the National Association of Nurses said it will go on strike on Monday if the Finance and Health ministries do not find a way to support the public health system.“The Association of Nurses hereby announces that as of July 20, 2020, it will launch an emergency strike,” chairwoman Ilana Cohen wrote in a letter to the directors of the health funds and the Health Ministry. She said the strike is “out of national responsibility and in order to stop the collapse of the nursing system and save lives.”She said that “the Finance Ministry is not doing enough to put human life and public health at the top of its priorities, and therefore, unfortunately, we have no choice but to take organizational measures before having to deal with immoral and inhumane decisions.“We nurses have decided to take action and take all legal measures at our disposal to prevent injury and loss of life, to stop the deterioration [of the health system] at the hands of coronavirus and to prevent the expected ‘Yom Kippur’ of the public health system.”WITH SO many people infected with coronavirus, patients are infecting the nurses or sending them into isolation, only exacerbating the situation. As of Thursday, there were 2,866 medical personnel in isolation, including 837 nurses.The numbers sit on the back of a report this week by the Hebrew website Ynet that the Defense Ministry reports significant deficiencies in personal protective equipment for medical staff, including masks, medical robes and plastic protective screens.Only 14% of expected N95 medical masks have arrived in Israel, the report showed, and only 27.5% of medical robes.“We must have this equipment; without it, medical staff would be at real risk of infection,” the head of the emergency department at Shamir Medical Center, Dr. Daniel Trotsky, told Ynet.“We are collapsing,” Cohen said in a previous letter to Finance Minister Israel Katz. “The system is broken down – period.”The health fund labs are stretched to their limits, too. Lab workers warned that unless the daily tests are lowered – at a time when they must continue to be increased – they would have to begin throwing out tests without processing them.“The Health Ministry has only put a Band-Aid on the coronavirus,” charged Esther Admon, chairwoman of the Israel Association of Biochemists, Microbiologists and Laboratory Workers, earlier this week at a Knesset coronavirus committee session. “In winter, the entire population will not be able to receive laboratory services. Everything will collapse.”She said that some lab workers are retiring now because they are unable to cope with the load. Others are moving to private clinics. And they cannot hire students, because when they learn that the hourly wage is around NIS 30 an hour, they do not want to come to work.THE HOSPITALS, too, are buckling under the pressure. Feldman accused the government of “immorality” with respect to its attitude toward the finances of the public health system.“Back in March, [the government] ordered us to stop elective procedures, it told us to build new ICU units and we did that,” Feldman explained. But hospitals are reimbursed for selling “services” to the health funds. When they do not, there is no income.Moreover, the cost of the ICU beds was high. Feldman estimates that small hospitals each have around NIS 85 million in debt, and larger ones closer to NIS 220m. Multiply that by the number of hospitals, and the debt is close to NIS 2 billion – not including the deficits of the health funds, which he said are also likely exorbitant.“At this point, instead of reimbursing the hospitals and reassuring them that those expenses and loss of income will be covered by the government, the Finance Ministry is silent, and the hospital directors are trying to deal with the corona crisis at the same time as they are struggling to pay salaries.”Hadassah Medical Center head Zeev Rotstein said his hospital alone is hundreds of millions of shekels behind due to the crisis, including from the government not legislating the needed budget law for more than a year, which would have reviewed and increased the hospital’s reimbursement income. Without a government and Knesset, no calculation was made, and the previous budget was left in place.“The previous law means giving away more than NIS 500m. to the health funds. It is an average discount of almost 30% from the first shekel,” Rotstein told the Post. “We don’t have a profit of 30%, meaning every procedure we do puts us more in deficit.Last month, Rotstein found he could not pay salaries, or buy medicines and products that were needed to treat patients. In the final hour, the government came through with a NIS 30m. transfer. Another payment is expected mid-August. But Rotstein does not know how long the government will agree to send the funds.“This needs to be fixed before winter and even more so before next year,” he contended. “How do they want us to operate in 2021? We cannot plan accordingly, and we feel completely lost.”IT DID not have to be this way. Israel is a small country that can control its borders. Its people are used to living in crises and managing wars. So what went wrong?According to Ben-David, the “coronavirus emergency government.”“There is a gap between reality and the la-la land the government lives in. It’s just a tragedy,” he said.Under this new government’s authority is, of course, the Health Ministry, which has proven itself ill-equipped to manage such a large-scale crisis.Waxman and Ben-David recommended back in April, and still maintain, that the way to solve the crisis is to put in place a centralized authority that would be run by an IDF commander under the direction of the ministry. The authority would effectively spearhead a crisis control center and be responsible for the management of real-time data, logistics, procurement, testing and epidemiological investigations. It would manage the health funds, the hospitals, the police, the Home Front Command, the Shin Bet and any other body that plays a role in fighting the pandemic.Now, Waxman said, Israel has only one tool in this war: social distancing, which “is the same tool we used in the Middle Ages. We can use other tools to fight the pandemic, and Israel has the capabilities to do it.”On Thursday, the Health Ministry announced that it had appointed IDF Maj.-Gen. Amir Abuafia to head such an authority. However, even if such an authority is ultimately established, it is unlikely it will be able to leverage its best assets, because the ministry is unwilling to relinquish control.Just this week, Health Minister Yuli Edelstein said on video, “I have been hearing in recent days a question that just makes me smirk: ‘Who is in charge? Who is running the event?’ I want to tell you in the simplest and clearest way: I am responsible for this event, I have the authority, and I take all the responsibility.”“The fact that we don’t have such a single authority to manage all these bodies is the root of the problem,” Waxman told the Post. “By the Health Ministry not moving the management to an authority that can handle the crisis, it is putting our health at risk.”Feldman expressed similar sentiments, accusing the government of a dangerous level of populism.“Every ministry is pulling toward its own direction, trying to override the recommendations of the Health Ministry,” he contended. “Every political figure is trying to gain some popularity, some exemptions for his or her constituency. This is not the way we will win the war against coronavirus.”Waxman cautioned that if the Knesset continues to debate whether gyms and pools should be open rather than supporting a move that will build Israel’s capacity to test, trace and isolate, “we will have serious problems.“If we build the capacity to test 20,000 people a day and efficiently cut off the infection chains within 48 hours, we can handle this,” Waxman said. “If we do not meet this capacity, we will not be able to handle it. We must stop the infection chain not only to maintain the healthcare system, but for the economy. If we do not do this, the economy will suffer much more.”Can the public help?Haviv Hadid said, the Health Ministry’s policies notwithstanding, “the health system cannot handle the challenge without the support of the public.“The public has to take responsibility for what is happening here,” she charged. “The public needs to be careful. Follow the rules. Wear a mask. Get vaccinated for the flu. Just because you say it is nothing, that does not mean it will be nothing. We will pay a very heavy price.”“I call upon our leaders to wake up, to see the situation and leave all their political considerations behind them,” Feldman said. “Recruit all of the state agencies that can help to fight together against this pandemic. Something like this occurs only once in 100 years – we need to survive it.”
