HEALTH AFFAIRS: Assuta Medical Centers chairman Shuki Shemer: There is no public health without the public.
By MAAYAN JAFFE-HOFFMAN
The coronavirus has barreled across Israel, destroying public health, the economy and social welfare, as a powerful tornado flips cars, wipes out buildings and kills.“The government has lost control of the pandemic,” admitted Prof. Shuki Shemer, chairman of the board of Assuta Medical Centers and former director-general of the Health Ministry. But he told The Jerusalem Post on the eve of Rosh Hashanah that, like a shining rainbow after the storm, he, too, believes there is still cause for optimism.According to Shemer, the country’s rapid exit from quarantine without a system in place to sever infection chains led to the first spike in infections. In these last months, weddings and the opening of schools caused a major wave of infection, including a surge in seriously ill patients.“The policy has to be one of risk management in such an uncertain situation,” Shemer advised. “You can do nothing, but it might not work out, or you can do something dramatic that might end up not being necessary. The government has to decide what the right thing to do is.”Until now, he said, there has been too much politics and populism and not enough professionalism. But as the medical and scientific world learns more about COVID-19, there are best practices being developed. He said that although the coronavirus continues to “deceive and attack us,” in the war against the pandemic, there are at least five lines of defense.The first and most basic is personal and public discipline: wearing masks, social distancing and maintaining personal hygiene.“This is not self-evident, and a small part of the public does not observe it – and it is a pity,” he said. But he acknowledged that in order to get the public to comply with these basic orders, it is necessary to develop an information system and increase public confidence. “There is no public health without the public.”The second line of defense is distancing from older people and those at high risk of developing a severe case of the virus, such as those with preexisting medical conditions.“Young people should not physically approach older people in any way,” Shemer stressed.Of the deceased in Israel so far, some 50% were residents of senior living centers, according to Shemer. The average age of those who died is around 81.The third line of defense is to prevent crowds – at home, work or in the community.“Gatherings are an unfailing source for new infections,” he explained, such as “teens who hold huge parties, demonstrations in which [protesters] do not adhere to the rules of wearing masks and social distancing. Even a small family party – the more we can avoid these things, the better.”If all these lines of defense are breached, he said, the fourth line of defense should be imposed: targeted lockdowns in neighborhoods, towns and even cities that are defined as “red.”Today, in Israel, however, we are already on the fifth line, what Shemer calls the “doomsday weapon” – a full closure.ALONGSIDE THESE lines of defense are some basic principles: First and foremost is increasing the public’s trust in the instructions given and strictly enforcing their compliance with the instructions.In addition, he said, the laboratory infrastructure needs to be strengthened and “smart isolation” of infected people and those who had contact with them needs to be done. He stressed that there is no more time to wait for a strong team of epidemiological investigators to operate and cut the chains of infection.“It is an existential issue that requires a lot of thought, planning, allocation of many resources and training – and the use of technological means and digital location as well as accumulation of knowledge – so that there is information on how to overcome the virus,” Shemer explained.“The most important thing for me, however, is that alongside every decision there is advanced planning for what will happen afterward, assuming we overcome the outbreak and reduce the morbidity so that we do not repeat the mistakes of the past,” he continued. “Controlled trial and error must exist.”Shemer said that he thinks that Israel did an exceptional job at tackling the coronavirus when it came to the country. He said closing the sky was a critical and correct decision, despite the fact that it received much criticism at home and abroad.He also praised the work of former Health Ministry director-general Moshe Bar Siman Tov and former head of public health Sigal Sadetzky, who, he said, “understood the meaning of this pandemic and presented it to the decision-makers. They deserve a lot of thanks from the public.”He also said that the current director-general, Prof. Hezi Levi, took the helm during a storm and should be credited.But Shemer acknowledged that not everything was done right.THE FIRST closure led to a sharp decline in morbidity – Israel was at the top of the countries with low morbidity and mortality – but at a heavy economic cost, “which in my estimation we still do not understand and recognize in all its meanings,” Shemer said. “The social price also requires special attention – about a million unemployed; the difficulty of supporting families who lack the most basic subsistence needs.”He said he is concerned about the escalation of physical and verbal violence among families and in society.“Loneliness, anxiety and distress are no easier to cope with than COVID-19 and will have manifestations in the future,” Shemer warned. “The strength of a country is tested in the treatment of its weak links. Certainly, increased attention is required for those with special needs and disabilities.”There are also physical health implications that have little to do with the virus. During the “first wave,” the ministry ordered hospitals to significantly reduce elective procedures and treatments, which led to the postponement of thousands of surgeries. Moreover, coronavirus anxiety prevented people from seeking medical care, causing long-term health damage. He said doctors from across the country have reported preventable deaths as a result of deferring treatments.“It is quite clear that delaying medical procedures like mammograms to detect breast cancer, colonoscopies to detect colon cancer, etc. could result in a serious, preventable illness,” he said.Shemer runs a network of several hospitals, including Samson Assuta Ashdod Hospital. He advised that even during the coronavirus crisis, the health system should operate as though there were no pandemic, and the care of coronavirus patients should take into account the day-to-day operations of the health system.Of course, the health system itself has been starved for decades, which makes such an endeavor more challenging. Although Shemer said he believes in the system and that, “even before the coronavirus crisis, I argued that Israel has a strong healthcare system with no danger of collapsing, [but] it was and still is lacking in budget and sufficient infrastructure.There are not enough doctors or nurses in the hospitals or health funds. He said that the constant pressure on medical personnel has led to a great deal of attrition on the part of caregivers.“They need to be strengthened with additional manpower, better working conditions and well-being,” he said.SHEMER SAID he is concerned about the winter, when the coronavirus and the flu will mix. He cautioned that there will be hundreds of thousands of patients with the flu that will require being diagnosed and differentiated from coronavirus patients.“We need to start the winter with far less than 4,000 patients a day,” Shemer stressed. “If the situation is like it is now, where coronavirus is at full strength, then the system will not be able to stand up to it.”He said this is the year for a strong communication campaign focused on ensuring that the public is vaccinated for the flu – starting with older people and young children, who tend to be super-spreaders, followed by people who are immunosuppressed.Shemer said that the country currently does not have enough flu vaccine doses – only about two-and-a-half million – and that it needs five million. “We are doing what we can – the whole world is looking for it,” Shemer said. “We are making a lot of effort.”He said that the steps the country takes to stop the spread of coronavirus could also help curtail the spread of flu. Masks, social distancing and good hygiene can also stop the spread of flu.Shemer did caution, however, that flu and coronavirus are not any more alike than flu and coronary heart disease. Although they have similar symptoms and first signs of the disease, the infected population is different. The outbreak of the disease is also different, and the coefficient of infection is greater. For example, with influenza, children are easily infected and can easily infect the adults. With coronavirus, younger children tend to get infected less and be less contagious.WILL THE current closure work? Was the decision to shut down the right thing to do?“No one knows the right answer, and everyone has their own opinion,” Shemer said. “The government needs to make the decision, and the government needs to take responsibility.”He said if the lockdown is to be successful, the public should stop gathering, enforcement must be stepped up, and fines need to be high enough.“The virus is with us and will continue to be with us for at least another year or two,” Shemer said, noting that he does not believe in first or second waves. Rather, he said that “since I cannot delineate when a wave starts and when it ends, I am one of those who believe that the disease should be looked at in a uniform sequence and that the current outbreak should be recognized as a continuation of previous ones. And unfortunately, we will have more in the coming years.”He also believes in coronavirus commissioner Prof. Ronni Gamzu’s traffic light plan – “it is a marathon plan.”He said that the government’s failure to pass the program in the beginning when there were only 30 to 40 red zones is part of what led Israel to where it is today.“It needed to happen a month ago,” he said. “It is likely that if we had started the traffic light plan, we would not have had to lock down. But that is spilled milk. A smart country needs to learn from its mistakes.”Furthermore, he said that the government needs to stop its “zigzag” policies and make decisions that are logical and based on professional opinion, while being flexible as scientists learn more about the virus.“The public is smart, not stupid,” he said. “People want to know why.”BEING AN optimist, he said that he does not believe Israel has completely failed just yet.“Each country has its own plans, the rate of closing and opening the economy in a different way. What we see today as a green country can quickly turn into a red country and vice versa,” Shemer explained. “I believe that if the right actions are taken, we will return to being a green country and even lead the top countries that have intelligently overcome the coronavirus.”He said trust is something that, if broken, can be built again – and he encouraged the government to work with Gamzu to build it. In exchange, he said, the public also has to work with the health professionals by keeping the directives.“If we don’t want to, we will not get infected,” he said, “we just have to follow the guidelines.”And, Shemer added, for every challenge there is an opportunity. Coronavirus is an opportunity for Israel to develop advanced technologies that will make life easier and incorporate distance work, learning and medicine into our lives.“The hospital infrastructure will be strengthened because of coronavirus, and home treatments will increase,” he said. “From every crisis, new opportunities must be developed. I am optimistic about Israel’s ability to emerge from this crisis better than many countries in the world.”