Publications

the system-wide campaign to battle the corona crisis in israel. the spread of the coronavirus is a national security crisis for israel that demands a multidisciplinary strategy to confront the crisis. it requires the appointment of a campaign operator to govern public health measures, secure economic and societal strength, and prepare for the various consequences of the epidemic. as part of the strategic process, we recommend a core idea that is based on a phased approach to the crisis. stage 1, the current stage, involves a lockdown in order to control the rate of morbidity and buy time so that the health system can meet the needs of an increased number of infected people, mostly those in need of respiratory care, and improve the understanding of how to confront the spread of the virus. stage 2 comprises a gradual and controlled relaxation of the lockdown, which means living with the virus while allowing revitalization of the economy but controlling morbidity rates, through ongoing quarantine of groups and areas at risk, and allowing groups less at risk a return to a more normal fabric of life. in order to effect a sound transition between stages, it is necessary to increase significantly the number of respirators, undertake massive and rapid large scale testing, and employ advanced tools to locate carriers of the virus. stage 3, which will occur in tandem with the other stages, must focus on formulating an exit strategy from the crisis, which takes into account the need to adjust to life with the virus and prepare for the possibility of a renewed outbreak. the spread of the coronavirus has created a multi-dimensional crisis in israel. internally, the epidemic is endangering public health, undermining economic and social resilience, challenging effective governance, and even providing cover for processes that could potentially harm democratic values. externally circle, israel is at risk from the spread of the epidemic in its regional environment and in the global system. this article does not refer to political contexts and considerations, though they clearly play a part, inter alia because the coronavirus emerged in israel in the period between an election campaign and the formation of a government. israel’s handling of the coronavirus outbreak has so far been characterized by an attempt to find a balance between three leading elements: at the top of the pyramid is prime minister benjamin netanyahu, who is seen as the final and sometimes the only arbiter, usually on the basis of work by the national security council (nsc), with no oversight by the government or the knesset. at the base of the pyramid are two entities with evident tension between them – the ministry of health, which is striving to limit the scope of the infection at (almost) any price, and therefore has urged extensive enforced social distancing, with possible lockdowns and even a full civilian lockdown. opposite it is the ministry of finance, which is trying to limit the damage to the israeli economy caused by the halt of business and production and the broad restrictions on going to work, at a time when the severe negative repercussions of the pandemic on the global economy are clear. until now, the approach urged by the ministry of health has taken precedence over economic considerations, with the overall aim of flattening the curve of infection and keeping to a rate of new infections that doubles every five days instead of every two days. the aim is to avoid overwhelming the health system to the point of paralysis ꟷ and in particular where it would not be able to provide artificial respiration measures and other resources to the most seriously ill. the director general of the ministry of health, moshe bar-siman tov, clarified that flattening the curve and slowing the rate of infection would allow the system to gain time in order to build up medical reserves and study the disease. he stated that in any case it would be “a long story.”. what is the desired end state? apart from immediate steps, the extended duration of the pandemic and its damage to the health system and the economy means that the crisis must be handled in a campaign-like fashion. a campaign against the pandemic and its consequences requires looking at it from the end state to the beginning, in other words, from the desired reality after the crisis. the features of the end state should be as follows: minimal damage to the economy and rapid recovery; a stable rule of law and preservation of democratic governance; a limited number of dead; a health system that continues to function, while implementing the lessons learned and preparing for the next outbreak, which may well occur in the autumn; a stable security situation; maintenance of public trust in the state system; demonstration of social resilience. in addition, israel should strive to be seen as a “light unto the nations” – a model for coping with a pandemic, and in the development of a medical and technological response. at the same time, israel should utilize new opportunities wisely that will arise in the global market following the crisis. from this framework it is possible to derive specific objectives and examine a range of options in order to choose the best option. on this basis the stages of handling the crisis can be defined, indicating junctions where decisions must be made after examining the possible need for changes in direction. thus, the end state is the compass for examining the effectiveness of the chosen objectives. objectives in handling the crisis. maintaining national performance, including: national security; economic continuity that will facilitate a speedy recovery; societal stamina; and trust in the government system. protecting the lives and health of the public, while improving the ability of the health system to provide effective treatment for patients, and reducing the number of severe cases and deaths from the epidemic and other causes; at the same time, there must be preparations for a further outbreak. finding the balance between health needs and economic needs, in order to limit the direct and indirect economic damage of the crisis. attaining a high degree of readiness to deal with negative consequences – security, health, and humanitarian – from the surrounding region; at the same time, striving to find opportunities to shape a regional environment that is more stable and comfortable for israel. approaches to dealing with the virus. flattening the curve: the aim is to slow down the rate of infection and the number of deaths, while enabling the health system to continue functioning, with enough beds and respiratory equipment to treat the seriously ill. the method is to effect social distancing and impose a general lockdown, even banning people from leaving home. this option relies on the assumptions that it is possible to gain time until a treatment and/or vaccine can be found to reduce the risks. the cost of this option is very high in terms of economic damage to the country – estimates range from 50 to 90 billion shekels if this situation continues for over two months, and the crisis could continue for longer. while the number of deaths may be relatively low, there is a danger of a renewed outbreak when the restrictions are lifted. lockdown only for groups at risk: certain population groups and badly affected areas will remain under lockdown, while the rest of the country can return to normal life. in other words, there will be a more relaxed, dynamic lockdown whose parameters and scope will change constantly based on the map of affected areas. in this way it will be possible to jumpstart the economy and return to a relative routine. this option will be viable after the curve is flattened, when there is greater ability to perform large scale testing of the public to locate and quarantine infected people and their contacts, while imposing a total lockdown on particularly affected areas. it relies on a large increase in the number of respirators and an improvement in the supply of medical treatment. however, this option could lead to an increase in the number of deaths. however, there is still the chance of a renewed outbreak of the epidemic. the sooner the economy moves from a total lockdown to a more relaxed lockdown (no more than a month), the more the economic cost of this option will be lower. 2. increasing collective immunity: maintaining a normal routine to avoid economic and social collapse, based on an assumption that many will be infected, but most of them will recover and then will have natural immunity, at least for some months. this will limit and even stop the cycle of infection. at the same time, it is necessary to continue quarantining groups that are most at risk. supporters of this option rely on the assumption that once some 60 percent of the population is infected, the epidemic will stop, and a second outbreak will be avoided (re-infection is very rare). however, the implementation of this option requires a health system that is prepared to deal with a far larger number of patients than at present. with this option, damage to the economy is limited and the rate of unemployment declines, but the number of deaths, although expected to be lower in any second outbreak, will be very high in the first outbreak. the main investment will be required to improve the ability of the health system to treat tens of thousands of patients (perhaps more). the main problems with this option are the ability of a leadership to take a decision that will mean large numbers of deaths, plus the difficulty of turning back the clock and retreating from this decision, and then implementing the lockdown options. 3. stages: adopting the options of flattening the curve and imposing and lifting a lockdown as stages in confronting the epidemic. the criteria for transitioning between stages must be defined in advance, making full use of the ability to reduce damage to public health and the economy at each stage. interim objectives are: (i) reducing the number of infected people so as not to exceed the respirator capacities; (ii) building rapid mass testing capability to reduce infection through early identification of carriers, releasing vaccinated and non-infected people back to work and learning about how the virus spreads as a basis for deciding on selective easing of the lockdown; (iii) controlling the number of infections to allow proper medical treatment, until immunity/medication can be achieved; (iv) the longer the crisis continues, the greater the importance of keeping the economy moving and returning to life and work in the presence of the virus. 4. opportunities: this is not an option, since it does not exist independently, but looks toward the day after the pandemic. the idea is to allocate resources to identify and realize economic, technological, and regional opportunities that emerge during and in light of the crisis. (opportunities include: supporting start-ups, organizing national service for crisis situations; building readiness to deal with epidemics and natural disasters; conquering a share of the global market, mainly in technologies for stopping the spread of epidemics and for remote working; and more.) the corona crisis could serve as a lever, if israel is able to position itself as a positive model for coping with this particular crisis and crises in general. managing the campaign in conditions of uncertainty. this depends on the parameters needed for making decisions, the choice of options, assessment of the circumstances for transitioning from stage to stage, and the criteria for changing the strategy:. learning during the crisis: at this stage, the picture is only partial and the rate of infections presented to the public reflects the previous two weeks. the infection ratio is not clear. the ministry of health infection model must be examined and weighed against alternative models. what is the target number for new infections per day to ensure that israel does not reach a stage within two months where the health system is unable to function? as public testing increases together with operating the system of personal monitoring, the extent of the infection will become clearer, centers of infection will be located, and data will be collected on those who recover – people with antibodies, their immunity, and their ability to return to normal function. predicting the economic consequences: based on an examination of the central economic parameters: (i) economic growth – according to forecasts it will be zero in 2020; (ii) renewal of growth – not before the first quarter of 2021, depending on the renewal of growth worldwide; (iii) employment – some 750,000 workers laid off or on unpaid leave until the end of may 2020. continuation of the lockdown after may could lead to 18 percent unemployment, perhaps even more. even now, the latest figure is 17 percent; (iv) additional unemployment pay – some 5 billion shekels per month, with no increment for health or the self-employed; as the situation continues, the national insurance surpluses will diminish; (v) increased costs: about 5 percent of gdp (calculated with the drop in expenses and restriction of activity); (vi) drop in state revenues: about 10 percent, as a result in a drop in economic activity and deferment of tax payments; “stinginess” in the government aid package will be expensive in the long run; (vii) increase of the deficit to 9 percent of product, above the existing deficit; (viii) debt to product ratio: increase to 72 percent. therefore a central objective is a rapid return to work security for the public immediately after the passover holiday. performance of the health system: the longer the crisis continues, the more medical staff will be infected. are the assumptions guiding decisions to flatten the curve correct? there must be an optimum and immediate capability of protecting medical staff, along with their rapid release from quarantine following testing. assuming lifting of the lockdown, to what degree will it be possible to control the numbers being infected and provide them with suitable care, until a vaccination or life-saving treatment is found. public awareness and involvement: for how long will the public be willing to bear the loss of employment, the change in the daily routine, the suspension of the education system? will the public’s volunteer spirit and its willingness to help those in need and support the health system increase or decrease? societal resilience depends on the public’s trust in the governing system, the way it makes decisions and manages the campaign, and the absence of external considerations in decision making – even more so at a time of a serious political crisis in the country. the possibility of a widespread outbreak of the virus in the gaza strip and the west bank: it is vital to monitor the consequences of a collapse of the palestinian health system. the regional strategic situation: constant examination of how israel’s handling of the crisis is viewed in the surrounding region. will hostile elements exploit the situation to damage israel’s security? the decision making process. the main challenge involves asking the right questions regarding five groups of important issues and formulating the response:. for how long is it possible to maintain a lockdown without causing fatal damage to the economy and to society? and what happens if the lockdown is lifted and most of the population is still vulnerable to the virus or infected (even unawares)? what are the conditions for declaring a state of emergency on the civilian front, thus transferring responsibility to the idf home front command and the national emergency authority (nea)? this step requires a decision regarding the steps to be taken to ensure as much economic activity as possible, including the supply of goods and services, to provide a breathing space and functional continuity for the system as a whole, harness the resources of the government and local authorities, and maintain a minimum fabric of civilian life. transition from option to option or moving from stage to stage: when does an option cease to be relevant? (i) the price is too high (numbers of dead and in economic terms); (ii) lockdown and quarantine do not stop the spread; (iii) new capabilities are added (more respirators and hospital beds, a vaccination/medicine is found); (iv) the public is unable to continue complying with the lockdown conditions. how do we identify the point of equilibrium between the health cost and the economic cost? moreover, how do we calculate the ability of society and the economy to recover; how long will recovery take, with what investment, and will the resources be available? how can we prepare for the day after, and how flexible and fast does the government system learn the lessons and prepare for a renewed outbreak of the virus or other disastrous event. the coronavirus crisis exposes several weaknesses that undermine the ability to cope with it. the primary one is the damage to the health system over the years and the relatively low ranking on government’s order of priorities. the second is the high level of uncertainty and the absence of an accurate and up-to-date picture – what is the accurate infection curve? is it possible to control the rate of transmission? are the people who have recovered immune to reinfection? will there be time to prepare for a renewed outbreak? the third is linked to the crisis in the international arena – the absence of global leadership, the difficulty of obtaining help from others (countries and institutions), and the excessive reliance on the united states and its economy (what are the implications for israel if the us economy fails to make a rapid recovery? (it is possible that us security aid will then be frozen). finally, there is the question of how the country functions without an elected government, and in the absence of an integrated and multidisciplinary vision and combined management of the crisis from a national crisis management center, which can constantly assess the situation, harness and synchronize the hard and soft strengths of the israeli system – political and civilian, and at the same time prepare to cope with future challenges. conclusion and recommendations. the state of israel, which has extensive experience in handling crises, particularly security crises, must treat the corona pandemic as a multi-disciplinary national security crisis, and not just a public health issue. this requires a systemic approach that combines the best of the state’s existing capabilities – government, security, scientific, and civilian. it is recommended that the crisis be managed in stages:. the current stage is quarantine and even lockdown, almost absolute, in order to control the spread of the disease. (it is not a matter of destroying the virus; developing a response needs time). the goal is to gain time until most citizens will be exposed to the virus only after a vaccine or treatment has been developed, and meanwhile without destroying the economy and causing severe damage to the quality of life and job security. in order to gain time by flattening the curve social distancing is critical, and the speed and volume of testing must be increased. south korea has managed to stem a sharp rise in morbidity through extensive testing (locating infected people just a few days after infection and stopping them from spreading the virus by two weeks in quarantine, until the symptoms of the disease are exposed, and at the same time, gaining the ability to allow people who recovered to return to work). there is a need for a constantly updated picture of the situation, which means extensive testing of the public and the ability to locate carriers and their environment. experts point to three types of tests: (i) a survey of about 60,000 people showing a clear map of where the risks are, where the lockdown should be intensified, and where it is possible to relax it; (ii) at least 10,000 tests a day to monitor infected people and chart the evolution of the epidemic; (iii) blood tests for those who recover, in order to study the antibodies and check the possibility of the these individuals returning to normal activity. the test results will make it possible to reduce the number of patients in critical condition who require respiratory treatment. the second stage is a relaxed lockdown, possible after flattening the curve, facilitates an effective testing system and greater capacity to provide respirators for the sick. less vulnerable groups and patients who recover can return to almost routine activity, in order to jumpstart the economy and restore a reasonable fabric of life. however, as long as the virus is present and no vaccine has been found, the whole population must adopt different behavior in the public space and in interactions with each other. at the same time, high risk groups must be kept in quarantine and lockdown s imposed on areas that are the focus of outbreaks. the third and perhaps the most important stage, which must therefore be implemented in parallel with the other two, includes the strategy for exiting the crisis. how can the economy be jumpstarted and the fabric of life restored in a new reality that is naturally influenced by the global reality? at the same time, preparations must be made for a second epidemic over the coming year. beyond these stages, there is a need to appoint a manager of the campaign who reports to the prime minister, can guide the staff work toward decision making (under the responsibility of the national security council), bring these decisions to the government or the security cabinet for approval, and track their implementation. the campaign manager will synchronize all efforts and coordinate the actions of the relevant entities: the prime minister’s office, the ministries of health, defense, finance, internal security, economy, transportation, education, and the social ministries. the campaign manager will have a spokesperson to manage contacts with the media and provide the public with information. the spokesperson will present a balanced, reliable picture of the situation and refute any false information on social networks and in the media. it is advisable to prepare for the decision to impose a national state of emergency, although responsibility should not yet be transferred to the home front command. however, the budgetary and logistical capabilities of the security system and the resources of the emergency economy mechanism (melach) should be mobilized. at the same time, it is important to maintain a high level of readiness in the idf for the possibility of an attack on israel along its borders. it seems that israel’s enemies are less motivated to attack it at present, but it is vital to maintain the defense of the borders, including while blocking any spillover of the epidemic across them. one important organization to lead research and development at this time is the weapons and technological infrastructure (mafat) in the ministry of defense. this organization can enlist scientific and academic institutions to study the global incidence of the coronavirus, develop tools for presenting as accurate an assessment as possible, carry out practical research, and make full use of the capabilities of research laboratories and technology. together with the health system and the research institutes, it will maintain contact with colleagues around the world and implement a shared learning system, in order to study which of the means used by other countries can help find solutions to the problems. the purpose is to develop immediate responses and to be ready for the future.