Inside Story

Small wonder: How Israel rolled up its sleeves and became vaccination nation

Leading in COVID-19 inoculation, the country’s small size, high efficiency, and a healthy dose of chutzpah has it on its way to herd immunity; just don’t believe every bit of hype

Nathan Jeffay

Nathan Jeffay is The Times of Israel's health and science correspondent

A nurse prepares a vaccine at Rabin Square in Tel Aviv, December 31, 2020. (Miriam Alster/Flash90)
A nurse prepares a vaccine at Rabin Square in Tel Aviv, December 31, 2020. (Miriam Alster/Flash90)

Millions worldwide prayed for widespread vaccination by Christmas. Israel, where the day largely goes unmarked, got the closest.

Nurses are giving shots at turbo speed, and Israel tops the global table for the proportion of the population that is vaccinated, and is fourth in total shots given. In less than two weeks, nearly 800,000 people have received their first of two shots, which represents more than 9 percent of the population.

This is almost three times the next most needle-happy nation, Bahrain, and several times the population share of that in Britain, which started giving shots two weeks before Israel.

Companies were apparently keen to rush supplies to the small country, where a relatively small slice of the available doses, placed in the hands of a highly-professional health service, could quickly transform life and create an international poster child for vaccination.

Now, politicians, officials and doctors alike are predicting that this will be the first country in the world to achieve herd immunity — and inviting others to emulate it.

A vaccination center operated by the Tel Aviv Municipality with Tel Aviv Sourasky Medical Center (Ichilov), at Rabin Square in Tel Aviv, December 31, 2020. (Miriam Alster/Flash90)

“We hope we’ll be a model for the entire world,” said Arnon Afek, deputy-director of Sheba Medical Center and former director-general of the Health Ministry in a press briefing on Sunday. “Because once we do it, other people can learn from our experiences; they don’t have to start from the beginning.”

Feeling a sense of deja vu?

Just eight months ago, Israel’s leaders were more-or-less declaring victory over COVID-19 and suggesting they could show the world how to do it. This came after a lengthy spring lockdown full of self-congratulatory statements by politicians on how quickly and effectively they acted.

But soon enough, they found themselves fighting a vicious second wave and becoming the first country to reimpose a nationwide lockdown. Instead of looking to Israel for tips on how to subdue the virus, doctors around the world started using the country as a reference guide on how not to act.

So should the deja vu make us suspicious of the triumphalist talk now, and fearing hurdles in our race to herd immunity? Or is it just a nagging sense of post-trauma by a nation reeling from false hope back in the spring?

The short answer to both: Maybe.

Efficiency and fear of being a sucker

Caveats aside, there seems little doubt that Israel is in a stronger position than most people imagined.

Related: Vaccinated in Israel, I feel incredibly appreciative, and I’m daring to hope

It’s due to a mixture of factors: good supplies, excellent logistics and strong community medicine. The campaign is also benefitting from traits in the population: it’s tech-savvy, haunted by fears of missing out (also known as being a sucker), and the few anti-vaccination people are keeping mostly quiet.

Prime Minister Benjamin Netanyahu and Health Minister Yuli Edelstein watch the arrival of a plane transporting the first batch of Pfizer vaccines, at Ben Gurion Airport on December 9, 2020. (Marc Israel Sellem/Flash90)

Supplying Israel early was an attractive proposition for vaccine companies, firstly because Israel has shown a willingness to pay top dollar, and then some, to get the vaccine earlier than elsewhere. Some reports have put the cost at more than double what the US or European Union is paying for the Pfizer vaccine.

But Israeli officials have also said the pharma firms saw Israel as an excellent marketing tool for their vaccine, providing a mix of conditions that can showcase the power of their products.

Israel’s small size, densely concentrated population and highly developed infrastructure mean that with a relatively small number of shipments, it could swiftly immunize a wide swath of the country. This would hopefully give the world an early glimpse of what widespread vaccination, and a COVID-safe nation, can look like. The theory, proposed by Israeli officials, has not been confirmed by any of the vaccine manufacturers as a motivating factor.

People arrived to get vaccinated against COVID-19 at at a large vaccination center in Tel Aviv, on December 31, 2020. (JACK GUEZ / AFP)

So far, Israel’s drive has been boosted by its leveraging the military, and those with military experience, to deal with tough logistical challenges, like distributing Pfizer vaccines that need super-cold storage.

But the real key to making Israel Vaccination Nation has been the way its healthcare system is set up.

Unlike the US, where healthcare is privatized and payment is made through a web of employer-provided insurance schemes, Israeli healthcare is simple, overwhelmingly public and practically free. Unlike the UK, where the nation is served directly by the National Health Service, Israel’s four health maintenance organizations (HMOs) compete for prominence and patients, which pushes them to perform well.

A medical professional administers the coronavirus vaccine at a sports arena in Jerusalem, Wednesday, Dec. 30, 2020. (AP/Maya Alleruzzo)

“It makes a very big difference that Israel runs according to these health organizations, which really take care of their patients,” said Prof. Limor Aharonson-Daniel, head of the PREPARED Center for Emergency Response Research at Ben Gurion University.

An elderly Israeli soon after vaccination, at Tel Aviv Sourasky Medical Center (courtesy of Tel Aviv Sourasky Medical Center)

Afek noted that each healthcare provider has a huge staff that has quickly been deployed to vaccinate, and that motivation levels are high.

“People volunteer to work day and night because we understand this is our true chance to get out of the pandemic,” he said of both the HMOs and hospitals.

It also doesn’t hurt that Israelis are imbued with a special kind of FOMO that is more of a FOBAF — fear of being a frier, or sucker. Nobody wants to be last in line, and it is why people under 60 years old are showing up en masse to clinics to see if they can finagle a shot; and over 60s, who are supposed to be getting the first vaccinations, are trying to book appointments as early as possible. Clinics, which have to use vaccines in batches of 975 doses or risk needing to throw them out, are more than happy to speed through their supplies and not waste a single drop, though some nurses have reported being overwhelmed by the number of walk-ins.

A man receives a vaccination in Tel Aviv, December 31, 2020. (Miriam Alster/Flash90)

As far as the anti-vaxx crowd goes, officials launched campaigns aimed at boosting confidence in the vaccine and have pushed social media platforms to be vigilant in removing false information about the medicine.

The tech-savvy of most of the nation meant that unlike in the UK, where health officials felt compelled to send cards in the mail giving appointments, and leading to wasted slots if people didn’t get the message or can’t make their time, in Israel everyone chooses a time and location that works for them.

Feeling confident about tech ability among the elderly (or close-knit families who help parents and grandparents), Israel’s HMOs could send text messages and emails telling people to fix times and locations that work for them, and get huge numbers booked quickly, though it’s unclear if the system is truly reaching everybody it should.

Dr. Anat Engel, director-general of Wolfson Medical Center (courtesy of Wolfson Medical Center)

So far, only a small minority of citizens have been vaccinated, and there is much that can still go wrong. But with companies keen to supply shots to Israel, and various factors coming together to create good conditions, things are looking hopeful.

“There’s something unique in Israel, among Israelis and in the health system,” said Anat Engel, director-general of Wolfson Medical Center in Holon. “It’s the responsiveness of [the] public and strong success in logistics. We learn quickly and we act quickly. We’re alert and always on edge, which means we’re ready for things like this. It’s clear to everyone this is [a] game-changer, so people are getting ready to vaccinate quickly.”

This will only hurt a bit

Now, though, there are questions about supply, with officials announcing that first-dose vaccinations will stop in early January, to ensure there are enough leftover doses for the necessary second booster shot for those who got the first.

On Thursday, health officials said they were in talks to speed up a second delivery from Pfizer, scheduled for February. A report that Moderna may send 1 million doses as early as next week was swiftly denied by the Health Ministry. Until the rubber meets the tarmac, Israel’s operation can only be as strong as its supply.

Prof. Arnon Afek of Sheba Medical Center (Shai Pereg)

Even top doctors like Afek don’t know what is coming when. “What’s the arrival [schedule] of vaccines to Israel?” he said. “I don’t know that, and it largely depends on that. It will be more that issue than anything else.”

The start of the vaccine campaign was a dream — but not as much of a dream as suggested by the much-cited comparison between Israel’s first few days and the UK’s performance.

It’s true that Israel achieved the equivalent population coverage in about three days that took the Brits over two weeks (UK stats are lagging behind so it’s hard to make an up-to-date comparison).

But Britain has delivered more jabs in total, and is a much larger country. Its vulnerable population alone is nearly three times the size of Israel’s total population, and it is starting off by vaccinating only its oldest and most at-risk citizens.

In Israel, anyone aged 60 could get a vaccine from day one, and shots are being given to many below that age as well, often to people who just show up at clinics.

People arrived to get vaccinated against the coronavirus at a large vaccination center in Tel Aviv, on December 31, 2020. (JACK GUEZ / AFP)

In the UK, though, only the very oldest Brits are receiving shots now. They are strictly reserved for those 80 and over and for healthcare workers, who are invited by mail.

A nurse adminsters the Pfizer-BioNtech COVID-19 vaccine to patient William “Bill” Shakespeare (L), 81, at University Hospital in Coventry, central England, on December 8, 2020. (Jacob King / POOL / AFP)

Every aspect of vaccinating a frail octogenarian who shuffles slowly into a clinic, or arrives in a wheelchair or by special transport, is likely to take longer than giving a shot to a sprightly 60-year-old. Geriatric medicine takes time and patience and works more slowly. This by no means undermines Israel’s achievements, but highlights that the comparison is not quite apples to apples.

And there are worries that Israel’s being tops at vaccines could also lead to it leading in morbidity.

Impatient about getting vaccinated, Israelis are also impatient to return to normalcy. We saw this after the first lockdown, as people raced back to routine, and cases surged. A third lockdown, which began days after the vaccine drive, is dismissed as a joke, with few changes to business as usual. Officials believe at least part of the complacency can be blamed on the vaccine, which has led to the mistaken belief that the pandemic is behind us.

Tel Aviv residents wear face masks as they walk through the crowded Carmel Market in the coastal city, hours before the country goes into a third coronavirus lockdown, on December 27, 2020. (Miriam Alster/Flash90)

Getting shots to the entire nation will take time, and even those who get the shots won’t have immunity for the first few weeks.

“There is a lot of hope and optimism, but we have to be realistic and know we need two shots, and that it takes time before herd immunity,” Engel told The Times of Israel. “Until then, there are several months during which we need to use masks and social distancing.”

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