On New Year’s Eve, journalist Nadav Eyal tweeted out a scene from a neighborhood in Tel Aviv: Health clinic workers giving COVID-19 vaccinations found themselves left with a few extra doses when a pizza delivery guy went by. “Guy with the pizza, come here,” one of the workers yelled out. He got a vaccine. “That,” Eyal noted, “is efficiency.”
A story in Houston two days earlier stands in contrast and is considered representative of some of the stumbles in the United States right out of the gate.
Dr. Hasan Gokal, medical director of the Harris County Public Health Department, was working at a vaccine station for emergency workers Dec. 29 and was left with 10 expiring doses and six hours to use them, with no one left at the event. He searched for vulnerable people, such as a mother with a child on a ventilator, also administering the last dose to his wife, who has a pulmonary disease, minutes before its expiration time, the New York Times reported. For that, he was fired and charged with stealing vaccine doses. Gokal said he got approval to find anyone who could use them. Officials said he violated protocol and should have dumped the extra doses.
It’s not terribly surprising, then, that Israel has consistently been the world leader in distributing COVID-19 vaccines since late December, with roughly 70 vaccine doses administered per 100 people as of this writing. On Feb. 10, 2021, Israel, with its population of 9 million, was fifth in the world in total vaccine doses administered, behind only the U.S., China, the United Kingdom, and India — all far more populous countries. By the second week of February, Israel was the leader in the percentage of people who were fully vaccinated, at 26.88%, and in those who received at least one dose of the vaccine, 42.58%. That’s more than eight times as much as in the U.S., which came in second place at 3.13%. Israel has even begun sending thousands of doses of COVID-19 vaccines to the Palestinian Authority.
Of course, Israel’s handling of the novel coronavirus has been far from perfect. In recent weeks, the virus has spread faster there than in the U.S. Israel just came out of its third strict national lockdown, and as of early February, children in fifth to 10th grade had spent 300 of the previous 365 days out of school. Unemployment was at 3.9% in 2019, the lowest in Israeli history; by January 2021, it had reached 16.7%.
But when it comes to vaccines, Israel is at the top of the list. Unsurprisingly, leaders and public health departments from around the world have been calling Jerusalem to understand how the country did it.
One answer is neither quantifiable nor transferable but seems clearly to play a role. That would be culture, or rather national character. It sounds silly, but the word that makes the most sense is chutzpah, a Yiddish word that is loosely defined as “audacity.”
“An outsider would see chutzpah everywhere in Israel: in the way university students speak with their professors, employees challenge their bosses, sergeants question their generals, and clerks second-guess government ministers,” Dan Senor and Saul Singer write in their 2009 book Start-Up Nation. “To Israelis, however, this isn’t chutzpah, it’s the normal mode of being. Somewhere along the way — either at home, in school, or in the army — Israelis learn that assertiveness is the norm, reticence something that risks your being left behind.”
It’s not just “pizza guy” who was getting leftover doses in Israel. Many showed up to vaccination sites repeatedly to check if there were spares.
And in Israel, Dr. Gokal would have been applauded, not just by a sympathetic public, but by the government and medical establishment. Israeli HMOs, after all, were sending out text messages to members to come to the local clinic for extra doses.
One part of Israel’s success that is transferable: flexibility.
“We were not stuck to strict guidelines,” Israeli Deputy Health Minister Yoav Kisch explained. “We had central planning and distribution but gave a lot of flexibility to the local management of the health clinics. We gave the HMOs a certain amount of doses on a daily basis, based on our expectations, but once a problem arose, they would solve it themselves. They went with the plan but had the flexibility in order not to lose any doses.”
Chutzpah is the fun answer to the vaccine success question, but policy still did most of the heavy lifting.
Who gets the credit? Was it Prime Minister Benjamin Netanyahu and his government’s leadership, fast action, and creativity? Or was it Israel’s excellent public healthcare system, the current incarnation of which is the brainchild of former Labor minister Chaim Ramon?
The answer is both, and more.
Arnon Afek, deputy director of Israel’s highly regarded Sheba Medical Center, credited Netanyahu’s hands-on approach at the start: “The prime minister took it upon himself to procure the vaccine for Israel, which I think is quite the important contribution on his part.”
The government also made sure it moved very quickly once the Pfizer vaccine received Food and Drug Administration approval.
“We are a very small country,” Afek explained. “We realized that once the other countries started their campaigns, we had no chance of being a priority, so our only chance was to react very quickly.”
Israel paid more for the Pfizer vaccine than other countries and once it completed the first shipment of vials came up with a creative way to convince the company to send more continually so that the entire adult population would be inoculated: Data-sharing.
“It’s very valuable for pharmaceutical companies like Pfizer to have the opportunity to learn the effects of vaccinating the country in a very short time,” Afek said. “We became the test case.”
Then, there was also the simplicity of the Health Ministry’s vaccination rules. There were none of the arguments about “equity” seen in parts of the U.S., where disadvantaged communities were to be prioritized in some cases over those more at-risk. The rollout began with medical staff and the elderly and continued to those aged 60-plus and educators; the minimum age then gradually dropped until early February, when everyone over 16 could get vaccinated.
“In the long term, I think having public healthcare based on principles of solidarity and equity is important,” Afek said. “In the short term, I believe in creating a vaccination campaign that is simple and accessible, with simple criteria like age. Don’t complicate it.”
But none of that would be possible without Israel’s healthcare system. Israel came in third place in Bloomberg’s Health Efficiency Index last year. The Israeli system is based on universal healthcare, in which having a medical insurance plan is required by law. All Israelis are entitled to basic healthcare and can choose between one of four not-for-profit HMOs for their insurance.
The healthcare system dovetails with Israel’s success in the tech sector, with interconnected electronic medical records that can be shared across the entire system, subject to some privacy restraints. While that normally means the hospital knows what prescription drugs you’re taking without asking, in the case of the vaccine rollout, it means an Israeli can go anywhere in the country and not just the usual clinic to get a shot. It also means the HMOs knew how old people are and what health conditions they have and sent them messages when they qualified for the vaccine.
Kisch cited logistics as a major factor. Israel established a central, deep-freeze storage location, which allowed the doses to last longer than 15 days. And of course, there were impressive logistical capabilities for distribution, with the ability to reach 250,000 doses per day. At certain points, vaccine distribution centers were open 24-7, with nurses taking on extra shifts to give shots.
The intersection of health and the Israeli military is also important here. Afek pointed out that large numbers of Israeli doctors are veterans of the Israeli Defense Forces and are used to acting under pressure and commanding complex operations.
“At the end, this is no different than any other emergency situation that Israel has experienced,” he said.
Kisch and Afek also highlighted the importance of public relations in motivating the public to get vaccinated. Afek got his first dose of the vaccine live on a talk show, as did other prominent doctors, as well as Netanyahu, which he said built trust in the public.
“We had full support of the prime minister and all the prominent doctors and relevant media figures. They were all on TV strongly supporting vaccination, which got us major public acceptance,” Kisch explained.
In recent weeks, Israel’s vaccine rollout has been slowing down. The distribution began with older people, who are more susceptible to COVID-19, and they rushed to get vaccinated. But around the point when the shots were available to people aged 35 and up, it became clear that motivation was much lower among young people.
The government has come up with a “green passport,” a digital vaccination certificate, meant to grant incentives, such as the ability to go to the mall or even travel abroad — Greece and Cyprus already signed on to the program — to those who are vaccinated or have antibodies.
“Don’t take for granted that people will want to get the vaccine. Prepare yourself for that and start a promotional campaign,” Afek advised.
Lahav Harkov is diplomatic correspondent and senior contributing editor of the Jerusalem Post . You can follow her on Twitter @LahavHarkov.