How did Israel keep its death toll so low and does it now risk a new spike?

Twice in recent weeks, The Times of Israel has interviewed Professor Yehuda Carmeli, one of the medical professionals leading the Israeli Health Ministry’s response to the coronavirus pandemic — once in the early stages of the crisis, and then again when it appeared that Israel might have turned a corner.

This week, as the number of new cases fell significantly, and Prime Minister Benjamin Netanyahu hailed Israel’s “great success” in facing down COVID-19, we contacted him again with a fresh round of questions that include: How risky is the raft of new decisions to gradually reopen Israel? Should we brace for a second wave? How did Israel keep its death toll so relatively low?

After more than a month in lockdown — including the period from March 25 to April 26, during which Israelis were for the most part not allowed to venture further than 100 meters from their homes — the government has begun dramatically easing coronavirus restrictions, buoyed by a stream of encouraging statistics.

As of this writing, Israel had close to 16,000 confirmed cases of COVID-19, of whom some 10,500 had recovered. Daily new cases were in the low dozens. And there were almost 240 fatalities. These figures are much less severe than countries of comparable size, including countries that imposed stay-at-home orders relatively early in their outbreaks. Sweden, for example, which chose a radically less interventionist approach, has about 10 times as many deaths as Israel — about 2,500 — in a population only slightly larger than Israel’s, at 10 million. Belgium, with a population of 11 million, has over 7,500 fatalities, 34 times as many as Israel. Britain, with a population six times ours, has buried 26,000 victims. Spain, with five times our population, has 24,000 dead. Italy, population 60 million, has a death toll closing in on 28,000. And the United States, with 36 times our population, has almost 300 times as many dead.

We began by asking Carmeli, head of the Department of Epidemiology at the Tel Aviv Sourasky Medical Center and a professor at the Sackler School of Medicine at Tel Aviv University, whether Israel was taking an undue risk in easing restrictions to the extent it has, and whether this will lead to a new spike in coronavirus cases.

1. If you walked around Tel Aviv or any other city in Israel over the past few days, you saw lots of people in the streets, shops open and some children back in school. Is this going to cause a spike in coronavirus cases a few weeks from now?

I think it might. We are at the stage where the number of carriers in the population is probably quite small. The number was reduced dramatically by the curfew. But we had a similarly small number of carriers at the beginning of the outbreak, and nevertheless we almost had an epidemic. So we might be exactly in the same position if we go back to the same behavior that we had before.

Our options were either to continue with a curfew, a semi-curfew or some type of stricter measures, on the one hand, or [as was decided] to reopen the economy while wearing masks and keeping more distance. You can see that people are truly behaving very differently than they did before — [wearing masks, social-distancing]. Will that be enough to prevent a new outbreak? I don’t know.

Professor Yehuda Carmeli (Courtesy)

Any health professional would have wanted to be more cautious and to return to normal life more gradually. But the toll on the economy has been so enormous, and not just the economy — also the toll on our social lives and the isolation of older people.

So we had to strike a compromise between what was needed to control the outbreak and what is needed to maintain a reasonable life.

This virus will probably stay with us for a very long time. Even if we are able to control it fantastically within Israel, at some point we will once again have more ties to the rest of the world. We will have to adapt to a different way of life.

Truly, none of us has experience with that. We don’t know exactly what is needed. We know in theory, but we don’t know if the level of contact we are attempting right now is too much or too little. And that’s why there is tension between economists and health professionals. We are at a dangerous juncture. We health professionals would have preferred a slower pace of relaxing the restrictions. But the economy demands that we do more.

A lot will depend on what we see happen in the coming weeks. It will be very difficult emotionally and socially for all of us if we have to go back to curfew at some point. [On May 4 the government stipulated that if the number of new cases per day reaches 100 or there are more than 250 patients in serious condition, restrictions will be reimposed.]

That was the dilemma: should we go slowly now and lift more restrictions only if we see [no major rise in contagion], or should we progress faster and then, if we see a problem, go back?

2. Dizengoff Street in Tel Aviv was crowded today — stores were open, there were even people sitting in cafes. How soon might we begin to see the consequences of that?

Probably in a week and a half to two weeks. It’s been about one week since the lifting of the really strict curfew. People are starting to do much more. They are allowing themselves to go to a shop, to meet a friend or go to work.

For now, we continue to see a decline in cases, but we’ll have to wait another week or two to see how things progress.

A boy visits his grandmother at her home in Moshav Haniel, on May 5, 2020. (Chen Leopold/Flash90)

3. In terms of the number of fatalities, why is it so low here compared to other countries?

Mostly because the outbreak was handled very well by decision-makers. We shut down many activities early and we protected high-risk populations. When you look at the number of cases in Israel, it’s relatively low per capita, but still not as low as the mortality rate.

And the reason for the low mortality rate is that although there was a lot of criticism about how many tests were done, Israel is among the leading countries in the world in testing people. We do a lot of tests so we detect a lot.

A woman orders coffee on Tel Aviv’s Dizengoff Street on May 4, 2020 as the government loosens coronavirus restrictions, allowing shops and restaurants to open (Simona Weinglass/Times of Israel)

Also, it’s because most of our affected population are young people, and they have a very low mortality rate. If you look at the distribution of sick people in Israel, fewer than 5% are over the age of 80. That’s the age where you start to see very high mortality rates. And in Israel, the population over 70 and 80 was quite well protected.

4. So, for instance, the Haredi community was quite widely affected, but they have a high birth rate, so they’re pretty young on average?

Yes. Part of the explanation is that many of our cases [in the early weeks of the crisis, were Israelis coming back] from ski resorts [in Europe]. Usually, it’s not people over the age of 80 who go skiing.

Another source were Purim parties, which were mostly attended by young people.

And then you had the ultra-Orthodox population who were affected. So the three major drivers of the spread were groups of relatively young people.

One of our weaknesses was the outbreaks in some nursing homes. This got a lot of attention but the overall numbers of affected people were not high. Even though it was a little bit late, the response of the healthcare system to stop that was quite good.

5. Now that schools have reopened, aren’t a lot more people at risk?

The children and their parents are not really a high-risk population. Below the age of 50, the fatality rate is maybe 0.2 percent, very low. The problem is whether you start to have a wider spread in the community. That’s the problem with schools or with any type of gathering.

Israeli students wear protective face masks as they return to school for the first time since the outbreak of the coronavirus, May 3, 2020 in Jerusalem. (Photo by Olivier Fitussi/Flash90)

It’s very clear that we needed to return at least the young age groups to school because if they’re at home it prevents their parents from going to work.

In my opinion, the best solution would have been to allow children under the age of 10 to go to school and have small classes. All the teachers would teach small groups of fewer than 10 children. We should have just ended the school year for the older children. It’s close to the summer anyway.

6. Why age 10?

A child of 11 can stay at home even if his parents to go to work. What keeps parents at home are children under the age of 10.

7. Are there different strains of the virus?

We don’t know of different strains that behave any differently from each other.

8. Is the coronavirus affected by climate or heat? Will it spread less now that the weather is getting warmer?

Many of us want to believe that. But we have no good reason to. Some of the [most] affected countries are warm countries, but the virus still spreads there.

In our normal lives, heat probably does not matter to the spread of the virus. At temperatures of 60 degrees celsius, it does.

9. Is coronavirus more contagious indoors or outdoors?

Any virus usually spreads much more easily indoors, especially in crowded and closed spaces.

10. Prof. Isaac Ben-Israel of Tel Aviv University has a theory that the virus plays itself out two or three months after hitting a country, regardless of what measures the country takes. What do you think of his study?

When you look at many of the graphs, that is indeed the way it appears. But there is no biological rationale for that. The virus itself doesn’t know whether the person carrying it lives in China, Japan or India. I think the explanation is that after the outbreak comes to a country, it is our human nature that we adapt.

People walk at the Mahane Yehuda market in Jerusalem on May 4, 2020, which has been closed down for several weeks in an attempt to stop the spread of the coronavirus. (Yonatan Sindel/Flash90)

So when there is an outbreak, people stay at home, people start wearing masks, people keep their children at home. People start to do things differently and change their way of life to protect themselves.

A second explanation is that we live in clusters. The people I meet are my close family, my friends, the people I work with. I have very little exposure to people who live in another town or people who do not belong to my group. Although we think about society as homogeneous, it’s not homogeneous.

Once you have an outbreak, for instance in the ultra-Orthodox community, it will spread in that community, but it will not spread quite as much to other groups. And then after some time there is a herd immunity within this small group. There is no herd immunity of the entire country, but there will be herd immunity of the small group, and the virus will not spread as easily within the groups because there are very few people who are susceptible.

11. If everyone wears masks, can that eventually lead to a situation where each carrier spreads the virus to less than one person and then the virus dies out?

Yes, and it doesn’t have to be everyone. You need about 80-90 percent of the population, or 80% of the encounters between people. And even then, we don’t know that both people have to wear masks. Maybe even if one of them wears a mask it will reduce the chance of transmission quite dramatically.

12. Now that a lot of people are going back to work and going about their lives, what are some of the do’s and don’ts? Is it okay to ride public transportation, for instance?

I can tell you what my own life is like. I try to ride in my own car and not share cars with other people aside from my immediate family. Even if we go to the same place, we take separate cars. It’s not very good for the environment but it’s good for preventing the spread of the coronavirus.

Second, one of my children lives with us but the other does not. He doesn’t come over very often right now. But when he comes we keep a distance of two meters between us. Even if we eat dinner together, it’s at a long table like that of a king, with all of us sitting apart from each other.

Israelis wear face masks for fear of the coronavirus as they walk through the market in Ramle on May 1, 2020. (Photo by Yossi Aloni/Flash90)

At my work, for example, we allowed two people to work from home. For the others, we created different hours of working so that there is just one person in a room at a time. In larger rooms, we put dividers between desks so that people can work without a mask; when they move around they have to wear a mask.

So you can adapt. It’s not the same as before. We cancelled our meetings and hold them over Zoom. Even though we see each other at work, we have separate meetings in the evening.

It’s not as pleasant, of course. But it can be quite reasonable. And these types of measures definitely allow us to keep the economy and workplaces going. In some places it’s more difficult, but if you can find ways think about the principle of keeping two meters apart and not meeting each other.

13. What things would you recommend that we totally avoid? Should we avoid going to restaurants?

I wouldn’t say don’t go to restaurants. If I go with my own immediate family that I live with, and we have a separate area that is separated by dividers, you can create a situation where you can still go to a restaurant. Probably you will have 50% occupancy; you cannot have 100% occupancy. But as long as people behave in a responsible way, you can do it.

14. How effective were measures like the Shin Bet cell phone tracking or the quarantine hotels?

In terms of the tracking, on a moral level I am very sorry that the Shin Bet had to do it. A civilian agency [would have been preferable if that were possible]. But it allowed the very efficient tracking of contacts between people and deciding who needed to be isolated. That was a big help.

The quarantine hotels were helpful for two reasons. First, because they relieved the pressure from hospitals. For people who tested positive but were not very sick, the only other option would have been for them to be isolated in the hospital, which is very unpleasant both for the patients and for the hospital itself. Medical staff are not used to handling healthy people.

The Dan hotel in Jerusalem was turned into a quarantine facility, on April 13, 2020. (Photo by Yossi Zamir/Flash90)

The hotels allowed for isolating people who needed to be isolated but could not be at home. In general, most people would prefer to isolate themselves at home and not go to a hotel. But for those who couldn’t be isolated at home, this was a good solution.

15. How disciplined were Israelis? We’re not usually known for being disciplined?

In general, Israelis are not very disciplined, however I think most people behaved in a very rational and reasonable way, at least in the places I went to, in my personal experience and from what I heard. There are always exceptions, but in general I think people understood the situation and the curfew worked well.

16. What do you think about this antiviral drug remdesievir that has shown promising results in a clinical trial?

It appears to shorten the disease. I don’t think that we have enough information, but probably it also reduces the severity of the illness in some people. If someone is sick now, it is probably the best treatment option. Will it solve the whole problem? It will not.

17. Some doctors have said that it’s actually not good to put patients on ventilators, that ventilators do more harm than good?

If you have a choice of whether to be non-ventilated or ventilated, it’s better to be non-ventilated. If the choice is to be ventilated or die, it’s better to be ventilated.

Overall if you look at the data, among people who are ventilated, between 80 and 90 percent of them die worldwide. It saves the lives of about 10 to 20 percent of the people who need it. It’s a last resort.