Fighting Covid: The Israeli Doctrine

A deep dive into how Israel has fought COVID-19, how it has fought it differently from other countries, and what the results of its struggle have been.

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The “First to beat COVID”; the “First to mass vaccinate”; and now the “First to give boosters.” Israel has self-consciously become a case study for the world in the matter of responding to the coronavirus pandemic. Israel is routinely cited as both the best case of what to do (e.g., with vaccinations), and as a cautionary tale of what not to do (overly-rapid reopening after lockdowns and the chaos in schools, for example).

Israel’s management of the pandemic has spanned three governments, two elections, three lockdowns, and four waves of the virus. As the Delta variant wave subsides, now seems a good time to ask: What has been the Israeli doctrine for fighting COVID-19?

Before thinking about the Israeli doctrine, some baggage needs to be left behind. The established dividing lines on COVID-19 in the English-speaking world don’t map neatly onto the political debates of other countries and cultures. From lockdowns to vaccines to masking, the dominant English-language discourse has been heavily influenced by the political debate in the United States. There, the Trump Administration’s skepticism about the danger posed by the virus, and its opposition to any mitigating restrictions, continue to divide the country nearly a year into a new administration. That framework—of the Right broadly opposing any action against the virus, and the Left supporting faster and stronger measures—is mirrored in the UK, Australia, and in some other countries with right-populist governments, such as Brazil.

Israel, quite easily, could have fallen into the same pattern. Certainly, at the start of the pandemic, there was no great public or political clamor for the government to take action to prevent the spread of the coronavirus. Israel had recently voted in two general elections in the same year. Both proved inconclusive, pushing the country towards an unprecedented third vote. The initial Israeli response to the virus was inevitably shaped by both the political needs of the incumbent government to secure re-election and—more immediately—the need to physically conduct the election, on 2 March 2020.

Israel had several structural advantages over other democracies when it came to battling the pandemic. First, its political system is highly centralized: a strong national government, weak local authorities, and no devolved regions or states. This meant that central government could enact a unified (at least in theory) national policy.

Secondly, Israel’s emergency powers framework meant that the Cabinet could enact major public health regulations like lockdowns without the need for immediate legislative approval. These powers included the 1940 Public Health Ordinance, a relic of the British Mandate era, and the broad authority given to the Cabinet by Israel’s continuous state of emergency, which has persisted since the state was founded in 1948. This was particularly relevant at the start of the pandemic when the Knesset was in recess, due to the forthcoming elections. The government had no need to consult or legislate; it could simply rule by fiat.

Thirdly, Israel’s health system is also unified, its four health maintenance organizations able to track the coronavirus status, vaccination status, and health history of every citizen and permanent resident, and to provide standardized data to the Ministry of Health. This unified healthcare approach made it possible to track active COVID-19 cases, enforce quarantines, administer vaccines efficiently, and to monitor their effectiveness. Israel’s vaccine deal with Pfizer rested largely on this capacity.

However, it wasn’t all good news. On paper, Israel does have a strong central government, but its writ barely runs in Arab towns, which are largely characterized by skepticism toward the authorities and limited law enforcement. The same is true of Haredi towns and neighborhoods, which possess both an independent anti-government attitude and significant political leverage. Haredi and Arab areas tend to have larger families and more multi-generational households, both risk factors in the domestic transmission of COVID-19 transmission; they are also more likely to have a lower socioeconomic status vis-à-vis the general population. Both populations are more vaccine-hesitant, and also have higher birth rates meaning more children who are not (yet) eligible for vaccination. Across Israel’s four pandemic waves, the Arab and Haredi communities represented a disproportionate number of cases.

Of course, there is another area where the State of Israel’s writ does not run de jure or de facto: Area A of the Palestinian Authority. Thousands of Palestinians from West Bank towns, mostly day laborers, enter Israel with entry permits; several thousand more enter illegally without permits. Palestinians took coronavirus home from work with them, creating a parallel epidemic with its own cycles and waves that the Palestinian Authority has struggled to control.

One other disadvantage that shaped Israel’s initial strict response to the virus is the severe shortage of acute care hospital beds. In 2017, Israel had just 2.2 acute care beds per 1000 citizens, much lower than the OECD average of 3.7; hospitals had a 93.3% bed occupancy rate, the second-highest in the OECD. In the spring of 2020, Israel’s healthcare system simply could not absorb thousands of critical COVID-19 cases.

At the start of the pandemic there was no vaccine, no monoclonal antibodies, and no good treatments for severe COVID-19, leaving Non-Pharmaceutical Interventions (NPIs) the only available option in governments’ toolkits.

The Israeli genius is to solve problems quickly, minimally, and inelegantly. For precision-engineered solutions that will work flawlessly for decades, companies go to Germany, Scandinavia, Japan, accepting that it’ll be a few years before they see results. If you need something clever by next week, you come to Israel. It will only barely work, and might even fall apart by the end of the month, but you’ll get what you need.

This neatly describes the Israeli approach to NPIs for most of the pandemic. Restrictions were announced with mere hours’ notice at times, only to be scrapped at the last minute. Full lockdowns were imposed the day before the major Jewish festivals, forcing families to scrap their festive meals (or to break the lockdown). Contradictory rules were announced by the Ministry of Health, the Cabinet, and Israel Police, leading to confusion. Even today the rules remain unclear. How many Israelis knew, for example, that from August this year until just a few weeks ago outdoor dining required a Green Pass? Israel’s particular choice of NPIs at different phases of the pandemic reflects cultural values as well as political choices.

In the UK, for example, NPIs primarily targeted family life. People were banned from mixing with other households, even as pubs and restaurants were allowed to remain open. This was never a viable approach in family-oriented Israel, where bans on household mixing only applied during the strictest periods of lockdown, and never outdoors. The same family-led approach led to prioritizing large (and risky) life cycle celebrations like indoor weddings with food and dancing, even while less risky activities like outdoor performances remained forbidden.

At the other extreme, Israel kept schools closed for significantly longer than most other countries, with (non-Haredi) students aged 13-15 spending almost no time in the classroom at all between March 2020 and September 2021.

Israel’s most enduring tool against COVID-19 was one of the most draconian: Bidud, two-week mandatory home quarantine for people exposed to the coronavirus. Over the course of the pandemic, it became possible to shorten the isolation period to ten and then to seven days; vaccinated people were exempted. However, unvaccinated children (and their parents) still find themselves banned from leaving their homes when the dreaded Bidud strikes. For many younger people, Bidud became the thing to avoid, rather than the disease. In this sense, Bidud was and remains an effective tool, both for isolating infectious people and for preventing unnecessarily risky behavior. But these same knock-on effects mean that children are missing out on time in museums, shows and — until recently — schools, which even when open sent whole classes into Bidud when a student tested positive. A recent change, modelled on the British system, allows whole classes to attend school during their Bidud in the case of a school exposure, as long as they carry out daily rapid coronavirus tests. Children who were exposed elsewhere, though, must still miss school during their Bidud.

Controversially, the Israeli security services were used to enforce the Bidud system. Initially, the General Security Service (Shin Bet) used phone-tracking technology to notify people if they had been in close contact with an infected person, ordering them into quarantine. This measure was a step too far for politicians and citizens, and the phone-tracking scheme was scaled back and eventually shelved.

Perhaps because of the initial strict measures introduced by the Netanyahu government, Israel never saw the emergence of a political tendency campaigning for tougher restrictions to combat the virus.

There was, and remains, a small but passionate group of anti-vaccination extremists, insisting COVID-19 is a hoax, that the vaccines are poison, or that the government is lying—and sometimes all three at once. The group, a loose coalition of crunchy granola types, left-wing conspiracy theorists, and Anglo-influenced conservatives, posts misleading memes, holds small rallies and harasses government officials like public health expert Sharon Alroy-Preis. But it has no political power.

In practice, public reactions to coronavirus restrictions divided along the open fissures already existing between different groups in Israeli society. Instead of a unified call against restrictions like those seen in the United States and Australia, Israelis have engaged in internecine squabbing, demanding that other groups shoulder the burden. Secular Israelis pointed out that Haredi institutions were exempt from school closures; Haredim in turn pointed to the busy beaches of Tel Aviv. Gym owners complained that synagogues weren’t closed, while musicians protested when gyms reopened.

Cities with low virus rates demanded more restrictions on those with higher rates. This was the impetus behind coronavirus tzar Prof. Roni Gamzu’s much-debated Traffic Light Plan; the plan was only briefly and haphazardly implemented, opposed and blocked by Haredi politicians who argued that it discriminated against Haredi towns. In any case, hyper-local approaches in a country as small as Israel were never likely to be effective.

The biggest “what about them?”, though, was the weekly protest against Benjamin Netanyahu, outside the Prime Minister’s Residence on Balfour Street. The large outdoor gathering became a totemic issue for any group opposing NPIs, with different sectors across Israeli society arguing that restrictions on their businesses, weddings or overseas travel were unfair as long as the protests continued unchecked. Netanyahu was reluctant to ban protests against himself, especially in the face of legal challenges; limits on the Balfour protests were briefly imposed, but poorly enforced.

Poor—and unfair—enforcement of the rules was a constant feature of Israel’s coronavirus response. In January 2021, it was revealed that fines for violating the coronavirus regulations were handed out in Arab towns at more than three times the rate than in Haredi neighborhoods. Videos of large illegal weddings and secret parties angered the public; but nothing quite did as much damage as the revelation that both Prime Minister Netanyahu and President Rivlin hosted family members for the 2020 Passover seder, at the height of the strictest lockdown, reinforcing a sense of “one rule for them and one for us.”

The issue of wearing a mask in public spaces remained mostly apolitical. This is in sharp contrast to the debate in many other countries where, particularly before vaccines became widely available, attitudes to masks morphed into full-on culture wars. The Israel situation was probably due to how masks were introduced. When Israel made public masking mandatory in April 2020 (at a time, incidentally, that the World Health Organization was still cautioning against widespread masking as a tool to prevent the spread of the virus), the new measure was presented as the path out of the Passover 2020 lockdown. Some critics of the Netanyahu government’s policy, including current prime minister Naftali Bennett, did call for NPIs to be wound back more quickly and for a faster and broader reopening—but only in conjunction with stronger mask mandates.

Bidud aside, indoor masking has been the most enduring NPI in Israel and has continued despite 80% of over-16s (and 90% of over-60s) being vaccinated with two or more doses. Indoor masking was the very last restriction to be removed in summer 2021, but was restored just days later with the arrival of the Delta variant. The requirement is likely to linger again as Delta recedes. Most people do actually wear masks in shops and on buses, and asking someone to pull up their mask is unlikely to prompt an angry reaction. Personally, I’ve probably asked 100 people to pull up their masks, and I’ve only been shouted at once in response!

In the days after Pfizer announced the result of its Phase III trial for the first vaccine against the coronavirus, Netanyahu called Pfizer CEO Albert Bourla 30 times, part of a sustained initiative to secure doses for Israel. The two men stuck a deal: Israel would get as many vaccine doses as it needed, and in return the country would serve as a laboratory for the world, proving the effectiveness of the vaccines. Pfizer and Israel’s Ministry of Health have published academic papers based on Israel’s mass-vaccine experiences—providing both the data to help other countries plan effectively, and marketing for Pfizer.

Israel’s data showed the very high protection that the vaccine provided against infection and transmission of the coronavirus, giving real hope that the pandemic could be ended by suppressing the virus though vaccines alone. But months later, data from Israel was the first to squash that same hope, by highlighting the waning protection of the two-dose Pfizer protocol, and the need for booster shots.

To enable a safe reopening from the early 2021 lockdown, and to incentivize vaccination, Israel hacked together a vaccine passport in just a few days. The Green Pass, as it has come to be known, applies to indoor dining, hotels, gyms, and large events.

Most complaints about the Green Pass system have focused, justifiably, on the status of children who aren’t eligible to be vaccinated. At different points in time, this group has variously been exempted from the scheme, required to have a Green Pass (in effect, a blanket exclusion from regulated locations), or permitted to take a rapid test as proof of health status.

Israelis have largely acquiesced to Green Passes. But perhaps that’s because enforcement of the Green Pass in many areas of life is so weak that it has very little impact. For example, I’ve been asked to produce a valid Green Pass exactly once to date. Hotels and old-age homes are often strict about Green Passes, but most restaurants and cafes seem to ignore them.

When the Ministry of the Interior banned flights to Israel from Italy in February 2020, it seemed like a major overreaction. Nobody thought that Israel’s borders would remain closed to most visitors for more than a year and a half—only reopening fully, to vaccinated tourists, in November 2021. Some industries and sectors secured financial support from the government, while others were left to waste away. Even if COVID-19 were to disappear tomorrow, the long-term effects of the pandemic would still be felt for many years.

In April 2020, Israel declared victory over the coronavirus. The lockdown had worked, daily cases were in the low double digits, and restrictions were removed overnight with only 200 COVID-19 fatalities. Almost exactly a year later, Israel declared victory once more—two further waves and 6000 deaths later— as vaccinations tipped the country over into population immunity.

This winter, the temptation to celebrate again still lingers. The vaccine booster program has restored Israel to something approaching herd immunity, even from the highly infectious Delta variant. Extending vaccination to children will widen and deepen this mass protection.

Eventually, though, COVID-19 will be back. Some influential voices in the Ministry of Health are already thinking about the need for another booster dose, possibly a yearly campaign similar to the flu shot. But boosters won’t be, and can’t be, the final word on the coronavirus. Rapid home testing,now used to keep schools out of Bidud, can help control the spread of the virus more generally. The hope is that ventilation, better therapeutic drugs and some seasonal NPIs can all combine to enable an enduring return to something resembling normal life.

From a structural perspective, only three broad approaches to the pandemic were available: Prevention, Management, and Cure. The last has a certain resonance in the self-styled “Start-Up Nation”; Israel’s biotechnology sector might have fancied its chances of devising a lasting remedy for COVID-19. But therapeutics take time, and Israel’s drug expertise is more in cheap biosimilars rather than innovative pharmaceutical therapies. Powerful treatments for COVID-19 are coming, from Pfizer, Merck… but not from Israel.

Back in spring 2020, it looked like Israel had opted for prevention. A strict and early lockdown reduced coronavirus cases to almost zero. A couple more weeks of major NPIs and strong border controls like in Australia and New Zealand could, perhaps, have brought Israel to “COVID Zero.” But that approach was never viable either; Israel is not New Zealand, and Israelis would never be comfortable pulling up the drawbridge and sealing the country off indefinitely from the rest of the world.

And so Israel, like every other country, has ended up in a game of management; a game that pitted Arab against Jew, secular against Haredi, residents against tourists, bar owners against Balfour protesters. Luckily for everybody, it was always someone else’s fault.

Vaccines have added just enough background prevention to allow Israel’s management of the pandemic to maintain some kind of equilibrium; an equilibrium that has periods of calm punctuated by waves of crisis, necessitating rushed and dramatic activity (lockdowns, boosters) to try and restore the fragile and temporary quiet until the next wave hits.

And maybe that, at its core, is the true contemporary Israeli doctrine. Israel tries grand prevention strategies, from early mass vaccination to unilateral disengagement from the Gaza Strip, but in real life things are more complicated. So, as with Hamas rockets from Gaza, settler violence in the West Bank, gang warfare in Arab communities and even the limbo of the Occupation itself, neither an annexation nor a Palestinian state — as with all of these, the Israeli doctrine is eternal management, doing just enough to get through the crisis but never enough to break the cycle.

But COVID-19 is here to stay, forever. The cycle can’t be broken. So perhaps the Israeli doctrine is, in the long term, the only possible approach to the pandemic: managing the waves with reactive measures, living with the uncertainty, ignoring the danger in the quiet times, and getting on with our lives despite it all.

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