- Israel is the second country in a CNBC series on how the world is fighting Covid-19.
- The country has done a good job in its first phase of the pandemic. But recently it has seen a resurgence of cases.
- It could have done better with contact tracing and a more phased reopening.
CNBC is looking at how countries around the world have tackled Covid-19. By talking to a wide range of experts, as well as everyday citizens, we're taking stock of what's gone well — and what hasn't. So far, there have been more than 10 million cases worldwide of Covid-19 and more than 500,000 people have died. The United States has reported more than 3 million cases and more than 130,000 deaths, the most of any country. Israel, the second country in our series, has confirmed more than 33,000 cases and more than 300 deaths.
"The first wave"
Many of experts have separated Israel's response into two buckets: February to May, and May to now. Some are calling it the first and second wave of the virus.
By mid-April, the country of 8.8 million was ready to declare that it had succeeded in the fight against Covid-19, and had begun reopening schools, bars and restaurants. Prime Minister Benjamin Netanyahu noted in press conferences at the time that the country had done an admirable job "in safeguarding life and blocking the outbreak of the pandemic" with its aggressive response. The mood in Israel was highly optimistic.
But that wasn't the end of the story. The country is now seeing a fiftyfold increase in new cases and is starting to shut down pubs, pools and gyms once again. The government is now wondering whether Israel reopened too soon.
Still, a lot went right in Israel in the first phase of the pandemic that other countries can learn from. One of the major reasons that Israel was largely able to fend off Covid-19 over the spring and early summer, they say, is that politicians deferred to public health experts to formulate a plan — and they stuck to it. There were early lockdowns across the country, and a decision to bar all flights from China in late January.
"A month ago, I remember jokingly saying to a friend in another country 'warm regards from the other side of the curve," said Yonatan Adiri, founder and CEO of Healthy.io, an Israel-based health-tech company. "But it didn't last."
Israel's health system provides universal coverage to citizens and permanent residents. And Israelis choose from four competing nonprofit health insurers that provide a benefits package. The country also collects medical information in a centralized manner, and the four insurers use the same technology. That made it easier for Israel's public health officials to conduct bio-surveillance and contact those at risk than it was in some other countries, like the U.S., where medical information is scattered across health systems.
"We created a predictive model for those likely to suffer from the virus and in early March, we sent SMS messages and followed up with personal phone calls from physicians to everyone at risk for the higher tier of Covid-19 complications," said Dr. Ran Balicer, a public health physician and director of health policy planning at Clalit, the largest of the HMOs. "We told them that if they felt ill, they should call us and we would sort them out through telemedicine and home care as best we could."
Balicer said that his company also sent daily questionnaires to members to collect responses about symptoms, which helped them create a "geographic early warning sign." This kind of information is also relevant to help public health departments direct more testing and other resources where it's needed most. When it comes to bio-informatics and data science, most of the experts agreed that Israel is among the best in the world.
Culture of experimentation
Israel is often referred to as a "start-up nation" for a reason. The country is known for its entrepreneurial ethos, and that same culture of experimentation has shone through during the Covid-19 crisis, experts say.
"This is the start-up nation so it's a lot of trial and error," said Dr. Yair Schindel, a managing partner for the Israeli health and life sciences venture fund aMoon and a member of the health ministry task force on the virus.
"We are trying things on a weekly basis," he said. "And figuring out a way to live with this virus without shutting down the economy completely."
Schindel said that the government is recommending that people in certain regions quarantine — "sometimes it's a city, sometimes a neighborhood" — and there's also a theory about using "capsules" to separate people into groups that can more closely congregate together at work and at schools. As it faces rising numbers of Covid-19 cases, he notes that there's been a willingness to try out various strategies to keep cases under control and curb rising levels of unemployment.
Schindel said that 100,000 citizens are taking a serological test, which is a blood test that looks for signs of a previous Covid-19 infection, to help officials better understand how the virus has spread across the population.
This will help Israel figure out how to manage the next phase of the pandemic and determine if it has sufficient capacity within the health care system to treat an influx of Covid-19 cases. Still, there are many unknowns, including whether a positive result for Covid-19 confers immunity down the line when the person recovers.
Victim of its own early success?
When the economy shut down at the start of the pandemic, many business owners suffered. One of them was Matthew Krieger, who runs a public relations firm called GKPR. Despite taking a hit, Krieger supported the measures to restrict access to public spaces because he felt that it was more important that the country take steps to save lives.
But he notes that some of his fellow residents now feel the response was too harsh, because there were so few cases of Covid-19 — until recently.
"It was an aggressive response, but it was the right response," said Krieger, who notes that he's been disappointed to see such a rapid reopening of the economy — and subsequent outbreak. Now, he said, he's nervous to go out in public and especially into large crowds. He feels that the public health measures should have been more thoughtfully rolled back to keep people safe.
Israel was early to adopt contact tracing, a method to inform people who may have been in close contact with a Covid-19 carrier, to self-isolate. But the system has had its kinks. In recent weeks, thousands of Israelis got alerts on their cellphones that they must quarantine after an exposure. But as NPR reports, many people who received the message were at home, rather than in a place they could have bumped into someone with the virus. Needless to say, health officials got flooded with confused phone calls.
Now, the country is evaluating whether it needs to hire more people to conduct the epidemiological investigations.
There have also been privacy concerns with the country's approach to contact tracing. The Shin Bet security agency was given emergency powers in March to trace Covid-19 cases using the phone locations of those infected. But Israel's Supreme Court expressed concerns in late April that this kind of move could lead to a "slippery slope" of using "extraordinary and harmful tools against citizens." Experts across public health largely believe that digital contact tracing, which involves using smartphones, is yet to be proven as a method to contain viruses. So for now, many civil rights groups are wondering whether the trade-off to citizens' privacy was worth it.
In recent weeks, Israel has seen a reemergence of the virus — and experts have a range of theories for that.
One factor, according to Adiri, is politics. When the pandemic hit, Israel was dealing with the fallout of inconclusive elections that resulted in no majority in the country's parliament, making it impossible for a government to be formed. After a third election on May 17, the country finally appointed Benjamin Netanyahu and Benny Gantz to share power, with Netanyahu serving as prime minister for 18 months, then followed by Gantz. The two rivals announced they would set aside their differences to help the country through the Covid-19 crisis, but critics note that the government has swelled with new appointees at a time of record unemployment.
"This time around, we have a government in place so the civil servants and public health experts now have to interact with a lot of political incentives around them," said Adiri.
Other experts suggest the country reopened too quickly, and did not heed the advice of public health experts. One top official, Siegal Sadetzki, resigned earlier this month in response, and posted a multipage letter on Facebook explaining her reasons. Many believe, including Sadetzki, that Israel moved too quickly from a total lockdown to removing restrictions, without a carefully constructed plan of phases.
Now the country has moved to reimpose some of the restrictions that were lifted in May, but it may be too late, some experts believe. The country is now reporting around 1,100 daily infections, nearly double the peak in the spring.
"The tough part in the initial crisis we did really well," said Adiri. "But the routine part when it comes to managing it and living with it, we're still not there."
Everyone agreed, however, that it's too soon to determine how Israel is managing this current outbreak and whether it will rise to the challenge. "It's difficult to talk about the events right now because they are still underway," said Balicer. "I think the jury is still out, but overall I'd say that there has been a good amount of solidarity and all segments of society have come together to fight this."
We asked every expert we spoke to for their score out of 10 (1 is the extremely poor and 10 is ideal). It's an extremely subjective measurement, but the average across all of them is 7.5. Most of the experts would give a far higher score when considering the response from February to May. But the recent outbreak, in their opinion, suggests some flaws with the response.
"I would have given us a 10 out of 10, but the way we are responding now is more like a 5," said Adiri. "So overall, it's somewhere in the middle."