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Learn from Spain:

We WILL Err – but how?

By Shlomo Maital

Spain has suffered terribly from the new coronavirus. The numbers tell the tale:

Cases overview








For a nation of 47 million, this is a terrible toll. It is explained in part by Spain’s late start in lockdown, and its Mediterranean open lifestyle, in the cafes and markets, during a warm spring.

   But it seems to have peaked. The number of new cases peaked in Spain, at 8,000, daily, on April 2, and has now declined to about 4,000. So Spain is gradually beginning to emerge from lockdown, to revive the economy, in a planned careful and staged manner.

   I think other countries should watch Spain carefully, talk to Spanish experts, learn about their plan, adapt the plan to their own nations’ needs and nature…and in general, we need a global brainstorming conference. An international Zoom of experts.

     Take Korea. There has been a resurgence, there, a second wave, but not huge, 100 cases. OK – what happened? Is the immunity conferred by having the COVID-19 and recovering from it sufficient to give permanent immunity? Or can a huge dose of the virus come back and attack you again? Let’s find out from Korea.

       How is Singapore handling the ‘track down those who spread it’? We will need to have a system for that, when we (many of us) return to work.

       We should have a website clearing house for things countries have learned, but a credible one, with only vetted proven entries by real experts.

         What do we know about this vicious viral enemy? Can we compile a COVID-19 handbook – here is what we know, and how we know it, and what the source of the data is.

     And regarding emerging from the ‘shelter at home’ lockdown — Trump says this is the most important decision of his life. HIS decision? If I were an American, would I feel reassured in having TRUMP???? make the decision?   When his ‘base’ is calling for the resignation of Fauci, a credible epidemiology expert, who urges caution?

       We will make mistakes and already have. Trump’s January-February fumbling cost many lives. Maybe, it is best to err on the side of caution, as we emerge from lockdown. Let’s study Spain carefully.  

Emerging from Virus:

Academics Step Up

By Shlomo Maital

   Public health officials, who are in control in most countries, have their hands full, dealing with the medical crisis. So it is up to us, academics and others, to begin weighing options for emerging from the lockdown.

 An interuniversity team led by Tel Aviv U. President Ariel Porat and Weizmann Institute President Alon Chen, have prepared an excellent 27-page plan. Details are reported by Haaretz journalist Meirav Arlosoroff.

  (Suggestion to other countries:   why not set up a similar team? Include epidemiologists, virologists, economics, psychology, law, computer science, even quantitative physics, and of course public health).

   Here are the options the experts present. Option One: Maintain the strick lockdown. Option Two: the opposite, speed up the rate of infection among Israel’s non-vulnerable population (is there such a thing?) to achieve ‘herd immunity’ (VERY bad term – we are NOT a herd…   why not population immunity? Or mass immunity?). Under the second option, the elderly would remain in isolation for their protection.

   Neither are very attractive, are they? There is a missing link – widespread testing, to provide detailed data. The required number of tests is not available.

    So the committee suggests a third option — a “gradual lifting of the lockdown while officials carefully monitor numbers related to the pandemic. Divide Israel into equally sized ‘risk zones’ based on how far and wide the coronavirus has spread. Red zones would maintain total lockdown. Yellow zones would be where people are allowed to leave their homes for work, provide they stay inside the yellow zone!  In Green Zones residents are free to go to their jobs, including jobs outside their zone. Those showing symptoms remain in quarantine in all three zones. Those shown to be immune are free to go wherever they please. (A key here is a serological antibody test, not yet widely available) Places of work would reopen, subject to strict rules on hygiene and social distancing. Workplaces would be graded, according to how risky they are for a ‘second wave’ outbreak. Workplaces barred from opening would be exempt from rent.

The committee also recommended tax incentives to encourage work from home.

Division into red, orange, green zones is based on sophisticated mathematical models that predict the epidemic’s spread – along with high levels of testing. Sampling tests that show less the 2-3% infection rates would enable ease of the lockdown. Green zones are where the number of serious cases doesn’t exceed 100 and the infection rate is less than 8 %. Technologies like location technology and artificial intelligence will be used to predict the possible rate of contagion.

Since test kits are in short supply, a model for sampling should be used, for each cone, including children, so schools can reopen.

The Committee says that a measured exit from the lockdown can and should already begin. It calls for allowing between 900,000 and 1.5 million workers to return to their jobs. This is between one quarter and a third of Israel’s work force.

“Data from the math models shows that the virus’ high infection rate does not allow for complete release from lockdown, even for Green zones”, they note. Social distancing still is the main tool, to reduce infection parameters by a factor of 2 to 3. Areas of especially high infection must receive special treatment, such as the ultra-Orthodox areas.

I believe that each country needs its own inter-University committee of this sort, because each country has its own culture and unique circumstances. It needs to be a non-governmental civilian effort, because governments are simply focused on the day-to-day.

Emerging from Plague: Thinking Ahead

By Shlomo Maital

With many nations still weeks from the ‘apex’ (the peak number of COVID-19 cases), it seems premature to discuss what the press and experts call ‘exit’ strategies – the period AFTER the plague. The word itself is wrongheaded. Exit strategies are what startups do, when they succeed in creating value and need to capture the wealth and return it to their investors and founders. Usually, by acquisition or issuing shares and selling them.

We do not seek an ‘exit’ strategy. We need an ‘emergence’ strategy, when we come out of our tunnels and rabbit holes and resume our regular lives. Words matter. There is no ‘exit’ from COVID-19, because it will remain endemic for a long time. There is ‘emergence’…with great caution.

How best can this be done? How should our governments be planning emergence?

Here are some wise thoughts by Prof. Ron Balicer, a person with whom I’ve worked, Chief Innovation Officer at Israel’s Clalit Health Services (a large HMO) and a member of the Health Ministry’s Epidemic Management Team. His article was published in the daily Haaretz newspaper.

“Mathematical models and past experience show that the spread of infection in communities living in overcrowded conditions can spark a renewed and serious outbreak among all segments of society. From an epidemiological perspective, Israel’s population (as well as, to a large extent, that of the Palestinian Authority) constitutes interconnecting “communicating vessels” with immediate collateral impact.

“In the current setting, the most stable and reliable marker of population-based trends in disease dissemination is the trend in the numbers of severely ill and respirator-aided Covid-19 patients. However, this marker lags behind the real-time spread by several weeks. If we continue to see that this marker is stabilizing – a collective sigh of relief will be heard. In the meantime, we must not wait for absolute certainty before planning the next phase of contending with this crisis and its attendant closure: the exit strategy.

“I propose two preconditions for initiating this strategy:   The first is a significant halt in the exponential rate of the disease spread, and the availability of a substantial number of free beds in intensive care units, which will serve as the buffer and allow a margin of error to prevent a collapse should easing of the lockdown spur a sudden increase in infections.   Let’s use some numbers as an illustration: In the optimistic scenario in which there are up to 100 seriously ill or respirated people in Israel on the eve of Passover, the distance between where we are now and the point of health system insufficiency is 4-5 doublings of the number of people needing artificial respiration. In recent weeks we’ve seen that the doubling time is three days, with faster rates in some localities.

“The second condition required before embarking on that strategy is to obtain a real-time intelligence assessment, detailed and updated, regarding the rates of infection among different communities. This is a precondition for resorting to a rapid intervention vis-a-vis every new patient, as is happening in countries that have managed to successfully curb the epidemic to date.

       “In other words, there needs to be an efficient system of conducting lab tests for Covid-19 among a wide swathe of the population, in order to exercise an effective exit strategy. To that end, Israel is hopefully gaining what will be an exceptional per-capita testing capacity, even in comparison to the advanced countries. The 30,000 daily tests we hope to be able to conduct in a few weeks’ time should be conducted dynamically and judiciously in order to facilitate this intelligence assessment.

“An exit strategy requires a change: a transition from social distancing and full lockdown enforced on the entire population in a sweeping and non-selective manner, to a new status quo. This new routine could be based on three components: a fast and focused effort to locate and tackle infected individuals; a differential and dynamic lockdown policy among targeted communities; and designated policies for allowing recovered immune patients to return to normal life and take a continuously increasing role in sustaining the economy.

“All this needs to be done while adapting the economy to working remotely with strong delivery services, to daily conduct based on social distancing and environmental hygiene in every workplace, and to continued construction of medical infrastructure, with maximal protection of medical teams.

“As part of the new status quo, the older population will remain as isolated “islands” within each community for a longer period, having its physical, emotional and social needs met on a daily basis.

[“There are several components –] The first component involves the efficient and determined tracking down of newly infected people and their rapid removal from the infective pool. This demands a rapid “closing of the circle” capacity. The multi-stage process of locating people suspected of being infected and having them tested for Covid-19, the rapid quarantine of sick people removed from home, an epidemiological investigation and a quick isolation of their contacts – all this must be accomplished with speed and precision. Moreover, it must be done in large numbers of cases and contacts.

For this condition to be met, a combination of capabilities – which at present are suboptimal – must be achieved. These include extensive and carefully thought-out testing of all people who have been in contact with the new cases; the ability to obtain results quickly for those who tested positive, and their removal from their families to hotels or other facilities; both manual and electronic epidemiological investigation, contact tracing and their quarantine; and firm enforcement of social-distancing instructions, among all segments of society.

“The second component is a geographically differential lockdown/quarantine policy, dynamically updated according to the available data. Communities in which there is persistent transmission of the virus, and those with individuals who are particlarly vulnerable, must remain under a stricter lockdown, whereas communities in which transmission has effectively been mitigated can enjoy a continued easing of restrictions.

“The country can be divided into sub-regions. Imagine that one day the radio announces that areas A, B and D can go to work from now on, whereas area C (i.e., Jerusalem or Rahat) is still to be confined to home. On another day, area A might be asked to reinstate a four-week lockdown, in view of ensuing infection. Obviously, such a policy won’t completely prevent “leakage” between areas and communities, but it will significantly head it off, and with the other components in place, this may be sufficient.

“In order to facilitate and supervise such a policy, an ongoing process of real-time intelligence-gathering must be established, including the continual monitoring of self-reported symptoms and continuous screening for infected people, in order to detect potential outbreaks as early as possible.

“The third component: Once serologic blood tests will become largely available, we will be able to conduct mass testing and define a growing number of recovered immune individuals. This group will assume an increasing role in re-operating businesses with few restrictions. Moreover, older people who got sick and recovered could also return to a “new normal” routine.

“In my view, easing of the closure will take place as a continuous, gradual process of experimentation and re-assessment, in cycles of several weeks each. In each cycle, significant restrictions will be lifted, followed by a tense watchful waiting period of several weeks, required to evaluate its impact on the dissemination rates. If the doubling time does not accelerate significantly, and the safety margin of available intensive care beds has not been reduced to the danger level, further easing of measures can be then implemented.”

Blog entries written by Prof. Shlomo Maital

Shlomo Maital