It would take the talents of an army of physicians and detectives to untangle the mess that’s been made of Corona care in Israel. Some policy has been right on the money: especially the Pfizer vaccine story. However, treatment was botched, in that monoclonal antibodies were not used en masse, as in the US; and testing has been messy, interfering with the economy and education.
While in the US recently, PM Bennett “referenced his high-tech background, where …trial and error is key, and every day is a new day, with new data and new decisions”. Problem is, the PM is ignoring the elephant in the room: the US has 350 million citizens and 43 million cases of Covid-19 since February, 2020. Moreover, the US has given out millions of doses of monoclonal antibodies as treatment for mild Covid disease, starting with the Eli Lilly and Regeneron products in November, 2020, when both received approval for emergency use. This was after President Trump was treated with them a month earlier. Israel, however, only bought a large quantity of the Regeneron product last week, enough for 6,000 patients. This is despite the fact that Israel was diagnosing at least 2,000 mild cases A DAY (on Sep. 28, there were 4600 positives, of which 45% would be mild cases, and thus candidates for Regeneron). Figure half those positives are low risk (young age, no chronic disease) and Israel has enough Regeneron for a week. How did this happen?
The answer is in bungling by the Ministry of Health, and miscalculations by Israel’s best infectious disease physicians:
The story starts with Bamlanivimab (BAM), a monoclonal antibody against the spike protein of the Corona virus which causes Covid-19 disease. Eli Lilly had FDA approval for emergency use of the drug in November, 2020, and received Ministry of Health (MOH) approval as of January 12,2021 (MOH memo from Dr.Sigal Libernat-Taub to MOH CEO Prof. Chezi Levy). These approvals were based on the Blaze-1 study published in print in the New England Journal of Medicine on Jan. 21, 2021( but epublished much earlier, on Oct. 28,2020- which formed the basis of early use of BAM, and the Regeneron product, in the US in 2020). Blaze-1 showed that BAM cuts hospitalizations by 75%.
However, that MOH approval itself was problematic, as it gave "preference to dialyzed patients who have Covid, as well as to Emergency Room patients who have transplants (kidney, liver, heart, lung)". No such limitations were noted in the inclusion criteria of Blaze-1.
Worse, the MOH recommended to not treat those patients 75 years old and above- which at that time accounted for some 20% of all Israeli hospitalized patients. Worst of all, the MOH ordered only some 650 doses of the drug.
Things got worse, when on January 10 the Israeli Society for Infectious Disease (ISID) panned BAM as being impractical to give, since a family member could not (sic) safely drive the Covid positive patient to the hospital to receive the IV drug, as that would expose the family member to Covid. This was clearly nonsense, as a Covid patient exhales the virus for at least two days before he turns symptomatic; thus a quick trip to the ER adds nil risk to the family member who is driving. Yet, given the ISID logic, patients needed an ambulance to get to the treatment center, usually an ER. However, Catch- 22: since these were mild Covid patients, who were not being hospitalized, the Kupot (Israeli HMO’s) would not pay the 800 shekel each way for an ambulance for these outpatients (Kupot only pay for ambulance rides that end up as hospitalizations).
Bottom line: some 20 patients got treated in the whole country (besides dialysis and immunosuppressed Covid positives) – mainly pregnant positives.
Remember, this was while the US was treating hundreds of thousands of Covid patients with BAM and while Israel went through the winter surge, with 1,500 patients dying in the 30 days starting January 24. This 1,500 Covid deaths was two and a half times the present surge that started August, 2021. One group of religious Jewish doctors (using twelve volunteers in a call center), Coronary Plasma Initiative (CPI), was getting at least 120 patients a day, in 15 states, to BAM therapy (see my article “Why Isn’t BAM Being Used”- Israelnationalnews, Feb. 14,2021).
Yet the Israeli press, on September 24, was touting monoclonal antibodies as a “SCOOP”, and was crowing that all of 17 patients were treated the next day. CPI has now treated 40,000 Americans, Jews and non-Jews; millions of Americans have been treated by other docs, besides CPI. This difference between US and Israel is scandalous.
In my previous article on BAM, I speculated on the possible reason(s) for not using BAM in Israel. I pointed out that many hospitals had their own pet experimental medicines that they were giving instead of BAM, which had FDA approval for emergency use; none of these experimental drugs are any further along in FDA authorization than they were nine months ago. However, recent statements by the MOH show that the MOH had an additional reason for not using BAM in January: the fear that if a medication that eliminated 80% of hospitalizations was offered to Israelis, they would not go get vaccinated. This is outrageous negligence:
The antivaxxers are infantile, delusional cultists. Nothing will push the 800,000 antivaxxers in Israel to go get vaxxed. How do I know? I took care of J-H-V-H Witnesses (a cult) in the US, and to their dying breaths they refused blood products (although, in 1977, this intern was encouraged by Dr. Philip Troen, Monterfiore Hospital Pittsburgh Chief of Medicine, bless him, to get a court order to transfuse a bleeding ulcer J’s Witness. Her husband was the petitioner. As we wheeled her into surgery and hung the blood, she was still refusing it.)
The ISID physicians are some of the best clinicians anywhere, but they lack street savvy. They too misread the psychology of these cultists, thinking that the antivaxxers would consent to the vax if they had no therapy available to them. All the MOH and ISID accomplished was to prevent monoclonals from getting to patients who needed them.
The next development was that on February 25, the CPI (Covid Plasma Initiative) stopped using BAM, because the South African mutation, then 14% of cases in New York State, was fully resistant to BAM. Henceforth, all treatment was done with the Regeneron monoclonal antibody product (the one Israel got on board with only SEVEN months later).
Finally, in mid-March, the Pfizer vaccine took hold : hospitalizations and deaths plummeted. By June 10th, the third surge was so weakened, that PM Netanyahu removed mask requirements in even closed public arenas (theaters, concerts,etc.) – and his MOH announced that on July 1 the airport would open for tourists. Yet that didn’t happen- because on June 13, Naftali Bennett became PM,and Nitzan Horowitz Minister of Health (MOH). They shelved the plans to open up Ben Gurion, and studied the issue during July. By the first week of August, they nixed the plan to open the skies. They cited the risk of importing a new viral mutation. This was a major mistake:
The PM and MOH cited the fact that there had been a Moslem holiday in early July, and that many Moslems had travelled then to Turkey, and had returned infected with Covid-19. However, facts do not bear this out. Newspaper accounts say that in all of July, only 141 people flew into Ben Gurion who were found to be positive. Thus the overall positive rate of arrivals to BG was 0.25% for the month of July- at a time when native Israelis were testing positive at a 3.8% clip – and rising to 6% by the end of the month. Using MOH logic, smart money would’ve had Israel importing 0.25% - positive arrivals, and exporting 6%-positive native Israelis to anybody who would take them.
Moreover the PM and MOH had now created the perfect fall-guy: the antivaxxers now claimed that they were not the problem. They gleefully pointed a finger at Ben Gurion Airport and said that the whole problem was travelers bringing in delta virus. Were they right?
Maybe, but the odds are not in their favor. Remember, nobody can get on an airplane anywhere is the world without having a negative pcr test. Thus, the arrivals at Ben Gurion are pre-screened, and so their rate of positivity (0.25%) is extremely low- which is why the skies should’ve been opened up months ago. The Bennett government seems to have heeded bad advice and needlessly killed the peak tourist season, July 1 till after the Chagim (Jewish holidays, September 29).
Also, the way the virus mutates is against the antivaxxers reasoning. There was a report of a Covid-19 patient in England who survived Covid for 6 months, until dying. He first grew the Chinese, alpha, original virus; then the South African (beta) virus was cultured from him; then the Brazilian (gamma); and finally, his cultures grew the Indian, delta mutation. That and other evidence indicates that the natural evolution of the virus, if it lives long enough in a person or population, seems to be to mutate from alpha to beta to gamma to delta. Thus, once the virus enters a population, no travelers are needed to “bring the delta mutant into Israel”- it can grow among the native population, contrary to the claims of the antivaxxers and fears of the MOH.
Even more importantly, this leads to the conclusion that the antivaxxers are a threat to us responsible, vaxxed citizens for yet another reason (besides threatening to bankrupt and fatigue the health system). On July 22,2021, the New England Journal of Medicine published an article by Thompson et el, proving that the virus circulates for a longer time among unvaxxed infected people,than among vaxxed persons. Specifically, the “virus was detected for only 1 week in most (75%) partially or fully vaxxed persons; and was detected for more than one week in most unvaxxed persons (72%)”- sometimes taking weeks to clear (NEJM vol. 385, page 325). If one were to view the unvaxxed population as a big pot cooking up virus, the longer the virus circulates, the more it evolves and cooks up virus. Therefore, the likeliest source of the next mutation is that big unvaxxed pot.
One bit of good news: viruses generally tend to evolve and mutate themselves to something not sustainable. That is how the Spanish Flu of 1919-1921, as well as SARS and MERS, vanished. We should all pray to G-d that that is what will happen with this viral menace.
This finally leads us to the present, fourth, delta surge. It began around August 1 and is now showing signs of lessening- probably due to PM Bennett’s correct decision to give the Pfizer booster vaxx to everyone age 16 and up. With a menace at the door, it was proper strategy to boost and NOT wait for statistical medical proof that the booster would be beneficial also to under- 65 year olds (for them, the proof came from our MOH- see Bar-On et al, NEJM, Sep. 15,2021- Protection of BNT162b2 Vaccine Booster).
It was also wise to finally limit testing and isolations (bidudim) so that a third school year would not be wrecked by Covid (I would even use Ministry of Ed computers to target the 39 year old -and- under parents of schoolkids, and leave them out of testing programs; they are at minimal statistical Covid risk).
Spend less money and effort on testing, and more on monoclonal antibodies for mild positive cases.The latest “news”, again, is that the MOH has re-discovered the Regeneron monoclonal Ab. They’ve agreed, finally, that the elderly deserve priority. However, they’ve unbelievably given highest priority to the unvaxxed! Their logic was revealed in a Jerusalem Post article in which one MOH PhD said: “We treat smokers who get sick, don’t we? We treat drunken drivers who go out and injure themselves and others, don’t we? They also ignore our advice.”
Rav Aaron Soloveichik used to say that many questions had a Balabatishe answer as well as a Lumdishe answer.
The Balabatishe answer is the common sense answer that would be given by a layman: “Listen, Dr. PhD of the MOH, you were born in Israel- but I grew up in Chicago. Maybe you cannot, but I can spot Chutzpah when I see it. Don’t let an antivaxxer tell me that he doesn’t believe that the virus causing Covid-19 exists; or that the disease Covid-19 exists; or that the pcr tests are fraudulent; or that the Pfizer vaccine is a killer. Don’t come to me with all that nonsense, and then when you get sick, come to me and expect me to pull your coals out of the fire, giving you 90% of all the ICU beds, ventilators and ECMO machines”.
The Lumdishe answer is the Torah answer: “Don’t come preaching morality devoid of Torah. Our tradition teaches that man has a Yetzer Hara, as well as a Yetzer Tov (good and evil inclinations). Please do not compare these antivaxxer cultists, with their infantile delusions, with smokers and drinkers, who cannot stand up to their physical addictions. Every clinician (as opposed to MOH PhD) who’s talked to a patient has heard the story:
‘I’ve quit smoking six times. Last time, I quit for six years, but then I got under pressure at work, I felt the urge to light up- I know it’s wrong, but I just can’t do without that nicotine to calm my nerves’. Same thing with the alcoholic. Not so the antivaxxers who never grew up to have responsible, adult thinking- there is no Yetzer Hara, no physical addiction, in their case. They are tragic, but they don’t deserve preference to treatment on the basis of their childish nonsense and the predictable results of that nonsense.”
What to do with the antivaxxers is obviously a political hot potato. Nobody in this country - or any country, except maybe the US’s former President Trump - has the Churchillian guts to set up Army field hospitals, give them 10% (as per their numbers) of the ECMO machines, and Shalom al Yisrael- let them go in peace. However, sanctions of all types are clearly warranted, as they represent threats to the responsible, vaxxed majority.
PM Bennett will need wisdom to know whose advice to accept- the MOH, with its poor track record, or more savvy, clinical doctors.
As far as the antivaxxers, they should ask themselves one question: Is it possible that the stuff that I believe, had as its origin in Chinese Communists, or Muslim anti-Semites, who disseminated this disinformation with the intent to kill as many Americans and Israelis as possible?
Rabbi Dr. Aryeh Hirsch is a physician residing in Beit El who works at Hadassah Hospital. He recently completed Rabbinical ordination of the Chief Rabbinate of Israel through an adult study program at Yeshivat Merkaz Harav.