How Israel conquered the coronavirus

 

As of June 7, 80% of Israel’s over-15 population has been fully vaccinated. Israel has the highest vaccination rate in the world, followed by the United Arab Emirates, UK, Bahrain and the US.

How was this achieved? How did Israel conquer COVID-19 and transition from initial chaos to ultimate success?

Here is the story. I gleaned it from the opening episodes of a new podcast, DisrupTALK, by Start-up Nation Central, an NGO that builds bridges to Israeli innovation. My son, Yochai Maital, co-founder and senior producer of the Israel Story podcast, created this three-part series on how Israel conquered the virus. 

Israel is essentially an island state. The easiest method for controlling the pandemic would have been to screen all those entering at Ben-Gurion Airport. 

However, notes Harvard Medical School researcher Dr. Ben Reis, “it’s basically the gateway to the country. And whereas many other countries around the world had required testing, before flying there, and testing at the airport for COVID-19, you’d imagine Israel could do that as well. Countries like Singapore, Australia and New Zealand implemented this strategy very successfully. But Israel was very late in the game in setting up testing at the airport.”

By late February, Israel had its first COVID-19 patient. A toy store owner from the city of Rishon Lezion had brought it back from his vacation in northern Italy. He was diagnosed only after he had spread it to several of his workers and family members. Other cases quickly started appearing.

As the number of cases started to rise it became clear that Israel would not be able to insulate itself from the pandemic. Unlike Israel’s ultimate vaccine roll-out, Israel’s initial reaction to COVID-19 was far from orderly and well managed. It could more accurately be described as a balagan – a really big mess. It was a nightmare. 

While the public and to a large extent the political leadership were still trying to understand what was going on, the medical establishment was in a frenzy, readying itself for battle. And at least in the early months – February, March and April of 2020 – the enemy had the advantage of surprise.

Dr. Gal Segal, head of Internal Medicine at Sheba Medical Center, observes: “we did not know what would be the nature of the disease. It could have been Ebola-like as far as we knew, very contagious, very lethal.” He was charged by hospital management to set up Israel’s first coronavirus ward, the one the first COVID-19 patient was sent to.

Segal notes: “since the technology guys and the logistics guys here in Sheba are all IDF veterans, this process was very, very fast. And it took like two weeks to establish a full [COVID-19] hospital.”

The relatively strict lockdown measures implemented early on seemed to be working. By the end of March and early April, at a time when Italy, Iran, Spain, the US and many other countries around the world saw mounting numbers of cases and deaths, Israel seemed to have things under control, at least so the numbers were showing. But the social and economic ramifications – on the other hand – were stark. In the second quarter of 2020, Israel’s economy saw the sharpest contraction in 45 years; GDP dropped by 28%.

On May 26, the government, under intense public pressure and against the advice of many health experts, started to ease the lockdown measures. Prime minister Benjamin Netanyahu addressed the nation with the happy news. Restaurants, bars, parks, pools would all open. He invited everyone to go out for a coffee, or a beer.

Unsurprisingly, as soon as the lockdown was eased, the number of cases started to climb rapidly. Pretty quickly, Segal’s ward and the other coronavirus units around the country started filling up. The medical staff worked around the clock caring for patients.

From the start, it was clear that in order to treat this new and unknown disease, Israel would have to think out of the box. Segal observes: “I’m a physician for 21 years. I’ve never met a new disease. This is the first time for me and for many of us, when we are looking for solutions, it is only natural that we will make use of our most advanced technologies.”

To help achieve their goal, the entire Israeli health apparatus started to fast track promising technological solutions, many of them coming from the private sector.

Collaborations with swift execution could be seen across the board. Some initiatives came from the field; others came from the top. The IDF’s technological and intelligence units were busy working with Health officials to try to come up with solutions. The Mossad was sent to find medical equipment and the Shin Bet (Israel Security Agency), was authorized to trace citizens. 

Even school kids were enlisted. The members of Steampunk 1577, a high school robotics team, spent long hours after school putting together a rudimentary respirator implemented in Rambam and Hadassah hospitals.

Reis observes, “In the back of every Israeli’s mind, there seems to be a kind of button, called ‘there is a national emergency, you must act in a certain way right now to fulfill your collective responsibility’. And that button is pushed, unfortunately, once every few years when there is a conflict or some sort of geopolitical crisis. Well, some have said that button was pushed again.”

Israel paid a price for its initial balagan and for its failure to implement effective measures at the border. After mounting cases throughout the summer, by mid-September the country entered a second national lockdown. And then, with the signing of the Abraham accords, flights began to operate to Dubai. A crush of Israelis returning from there brought on a third wave.

Over 840,000 Israelis contracted COVID-19, or about one person in 10. Some 6,418 Israelis have died. The harsh inconsistent public measures, including enforced lockdowns and fines, placed a heavy strain on society taking their toll on education, mental health and commerce. At the height of the pandemic, over one million Israelis were unemployed.

The Moderna and Pfizer vaccines, the key ones, work on a completely new technology, called messenger RNA (mRNA).

Reis explains: “What the mRNA vaccine does is, it says we’re not going to inject parts of the virus into your body, as with conventional vaccines. Instead, we’re going to inject a very, very small, disposable temporary instruction to your muscle cells that say, hey, muscle cells, could you please produce this protein for the next few hours? And the protein, which is just a little building block of biology that comes out of your muscle cells, when they’re reading this instruction, is basically a very small part of what the virus would look like.”

“In the case of the COVID-19 vaccine it’s a little spike on the exterior shell of the virus so it’s the most harmless part on its own. Instead of using actual virus DNA, the scientists have found a way to trick the body into creating these harmless ‘virus looking’ proteins that prepare or ‘train’ the immune system. And then if the real COVID-19 virus comes along those antibodies, those little recognition molecules are ready to go and your body can stop the virus dead in its tracks.”

One of the reasons this novel mRNA technology is revolutionary is the incredible speed at which scientists are now able to take raw genetic code and turn it into new vaccines and medicines. A process that took close to a decade has literally been condensed to days.

Reis: “A lot of people don’t know this. The vaccine was ready about a year ago, it was ready last February or last March (2020).

The chief medical officer of Moderna, Dr. Tal Zaks, notes: “The reason that we can go so fast is because we are starting from information. When the Chinese published the DNA sequence [of COVID-19] on January 11, 2020 – by January 13, we had all the information; we had decided this is going to be the sequence of the vaccine on January 13, and we started to manufacture our vaccine. Our processes are such that we can move in weeks and months and not years. That’s a tenfold improvement. The benefit would be larger than probably what we’ve seen in our lifetime.

And Reis agrees. “It is a real revolution that we’re living through.”

The officials at the Health Ministry had the foresight to realize that this new technology is a game changer. The trick was: how does Israel get their hands on millions and millions of doses while every country on the globe is trying to do the same? 

Israel’s negotiations with the Pharma companies were both very public and secretive at once. The actual negotiations were behind closed doors and the final agreements, though eventually published, were heavily redacted. We still do not know exactly how much Israel paid. On the other hand, the media covered the topic extensively and Prime Minister Netanyahu turned it into the central theme of his reelection campaign.

Albert Bourla, Pfizer’s CEO, told Channel 12: “He [Netanyahu] would call me at three o’clock in the morning. And he would ask me, what about the variants? What data do we have? And I said, ‘Prime minister, it’s three o’clock in the morning,’ and he said, ‘no, no, no, don’t worry, tell me!’”

Personal charm and just being a nudnik played a role, but there is obviously more to the story than that. How do these deals get made? Why did Pfizer choose Israel, when other countries were literally lining up to be the pilot, the test bed? What went on behind those closed doors?

Moti Crystal, a professional negotiator, explains: “I think that the COVID-19 negotiations with Pfizer and with Moderna began as in any market situation. When you are desperate to buy, demand and supply rules; you will by definition pay a price which is above market price.”

But Israel brought a few distinct advantages to the table. And the first one of those that Crystal chose to mention was surprising. It is called ‘boxes’.

Crystal explains: “These budget boxes are emergency funds accumulated during peaceful years, usually used in order to make sure that the overall Israeli economy does not completely derail in time of war or in times of attacks.”

So, baked into Israeli law is this unique fiscal mechanism that allowed the Israeli representatives to have much more flexibility in their procurement process than do most other governmental agencies in the world. [Note: the European Union stumbled heavily in acquiring vaccines, it had no such budget ‘boxes’].

According to Crystal, there are very few limitations on budget expense.

But aside from easy and quick access to funds, there was also another major asset that Israel brought to the table: Access to its fully digitized national health care system, made possible by the fact that the four Israeli HMO’s [health maintenance organizations] cover almost 100% of Israel’s population.

Reis explains: “The four HMOs already had a complete infrastructure for sending SMS messages to the appropriate members of their health funds, following them up with phone calls, automated reminders, etc. And finally, human phone calls, tracking all these, making sure that everybody knows where to go to their local clinic. Keeping track on the clinics and of who has been vaccinated, when their next turn is going to be for their second shot.”

For a company like Pfizer, data are the name of the game. In 2018, Israel invested heavily, nearly a billion shekels, in making its unique digital health database easily accessible to researchers and private companies. So the Israeli health apparatus was in a unique position to offer companies like Pfizer the perfect real-world test bed.

Access to vaccine doses – millions of them!

In November 2020, Israel signed the Real World Epidemiological Evidence Collaboration Agreement with Pfizer. So now, Israel had early access to the vaccine. But of course, every plan is only as good as its execution. Above all, a massive logistical effort was needed! All those doses need to be shipped at a constant temperature of minus 70 degrees Fahrenheit. Mass-scale infrastructure to do this did not yet exist in Israel.

According to the contract, if big markets like the EU and US buy out the supply, Pfizer would not be obligated to provide the vaccines to Israel until the end of 2021. So the onus of proving itself swiftly was still very much on Israel.

Michael Shteinman, the chief operations manager of the Health Ministry, sat in a nondescript, neon-lit office space that serves as the COVID-19 control center. Five computers behind grey desks and one large flat screen on the wall for Zoom and conferencing. 

The initial plan, Shteinman said, was for the army to lead the vaccination operation. “But four days before the first shipment was set to arrive, I was called in to an urgent meeting, where I was informed that will manage it! It was decided the Health Ministry should be in charge instead of the IDF. I said, Okay. Nice to hear. That was Wednesday afternoon. On Saturday, we started.”

Shteinman is a case in point for how integrated with the private sector Israel’s healthcare system is. He spent most of his career in the private sector, mainly working for Teva Pharmaceuticals, for about 15 years, and another couple of years in the irrigation industry. During the pandemic he was recruited by the Health Ministry, which was scouting for logistical management talent. That’s how, with just a few days’ notice, Shtainman found himself in the position of chief executive of the National Vaccine operations.

Shteinman: “We had several days only, yes. But look, it was supposed to start very slowly. We were supposed to do it in the first week only with the medical team, in the hospitals and in the HMO’s.

According to the initial plan, it would take Israel several months to reach full vaccination. This plan took into consideration several factors, but chief among them was supply. Israel received a million doses or so in its first shipment, nowhere near enough to conduct a nationwide vaccination campaign.

Shteinman: “It was not really clear how people will react to the vaccine. You know, it’s totally new, nobody really understands the side effects.” His initial plan was to start slowly, administering around 5,000 shots per day, maximum, then ramping up after they saw everything was going smoothly.

To help track the operation’s progress, Israel converted an existing program called “Nachlieli”, developed originally to track flu vaccinations. A proud Shteinman says “we were able to sit in the office, click a button and see the full picture of the whole country – who got vaccinated, first dose, second dose and so on, on my personal computer.” 

As actual data started streaming in, even Shteinman, in charge of the operation, was stunned. “We finished around 65,000-70,000 [vaccinations] in the first week. Per day!”

[A personal note: Israel’s vaccination operation began in mid-December. My wife woke at 1 am, accessed the website (normally, hard to access owing to the crush of applicants), and got us appointments. We got our first jab on Dec. 20, at Sammy Ofer Stadium, Haifa, without leaving our car – a smooth-as-silk operation run by the Maccabi HMO! By mid-January we were fully vaccinated.]

Reis says, “the healthcare workers and the logistics folks delivered beyond any of the wildest expectations of the drug companies on that first batch”.

Shteinman: “We were working every day from six o’clock in the morning to one o’clock at night. I would call it an organized chaos. At its peak the maximum number was 236,000 vaccines – per day!” This was much faster than anybody had imagined. The vaccine was quickly offered to all citizens over the age of 16 and even to foreign residents.”

Prof. Eyal Leshem, a director at Sheba Medical Center, told the BBC that herd immunity was the “only explanation” for the fact that cases continued to fall in Israel even as more restrictions were lifted.

“There is a continuous decline despite returning to near normalcy,” he said. “This tells us that even if a person is infected, most people they meet walking around won’t be infected by them.” COVID-19 cases are falling in all age groups including among children, even though under-16s are not generally being vaccinated. And there is strong evidence that young children will not need to be.

But there is a dark side.

In the kaddish, the Jewish prayer for the dead, the closing words ask God to bring peace to us and all Israel (al kol Yisrael). Reform and some Masorti congregations add, “and to all people of the world” (al kol yoshvei tevel).

COVID-19 still rages in India, Argentina, Brazil and other countries. Can we Israelis gloat while there is still great suffering in the world? For instance, have we transgressed by failing to vaccinate more Palestinians?

Let us temper our triumph with empathy and action for those who continue to suffer.

Postscript:  According to The Economist business weekly, “the Delta variant is the most dangerous SARS-CoV-2 mutation yet. The variant was first discovered in India and is the most transmissible form of the virus – and probably deadlier, too. Fortunately, vaccines are still effective against it.”  There are indications that travelers have brought the Delta variant to Israel. Hence, it is perhaps premature to declare victory.