Why Israel leads the world in vaccinating its population

By Charles Lipson

(JNS) — No country has been more successful in getting the coronavirus vaccine to its citizens than Israel. Why? Three reasons stand out, and the third one is likely to help people around the world.

Israel can vaccinate the population quickly because it has a very competent, comprehensive national health system, based on several Health Maintenance Organizations, all supervised by the Ministry of Health. The system includes digitized medical records for everyone in the country.

Israel bought enough vaccine. Earlier in the pandemic, it contracted for millions of doses from Moderna. More recently, it agreed to buy millions more from Pfizer so that everyone over 16 can be vaccinated by the end of March. To clinch the Pfizer purchase, Jerusalem gave the company two incentives: It paid well above the market price, and it offered to share medical data with the company — data that few other countries could gather.

Israeli biostatisticians can pair the medical reactions of millions of vaccine recipients with each one’s medical history and demographic data. This will allow public health professionals worldwide to gain a nuanced understanding of how the vaccine works, both in the entire population and in various subgroups, such as women over 80 or people with Type II diabetes.

The country could afford the mass purchases thanks to decades of economic growth, grounded in high-technology, medical research, water conservation, sophisticated weapons development, cybersecurity and more. The growth was spurred by market-oriented public policies, adopted after years of sluggish European-style socialism under Labor governments.

Israel’s financial resources — plus the government’s early bet on messenger RNA research, the basis for the Moderna and Pfizer vaccines — allowed the country to purchase enough medicine to protect its population of 9.3 million Jews, Arabs and Druze (slightly less than the population of the Chicago area). The inoculation program includes all Israeli Arabs, but does not include Gaza, under Hamas control, or areas of the West Bank administered by the Palestinian Authority. It’s conducting its own vaccinations, some with medicine supplied by Israel, which is prioritizing the authority’s frontline health-care workers.

To distribute the doses, Israel is depending on its effective public health system, which can reach the entire population in emergencies. It’s had a lot of preparation for those crises, unfortunately, after decades of threats from terrorists and hostile neighbors. Faced with these ever-present dangers, the government learned how to contact everyone quickly with vital information and respond to emergency conditions anywhere in the country. These communication and public health systems mean that the government can reach the entire population, tell people where to get vaccinated, explain why it’s so important and then execute this complex operation.

The vaccines arrive at Israel’s Ben-Gurion International Airport. There, they go to an underground facility, run by the country’s pharmaceutical giant, Teva, with enough freezers to hold 5 million doses. The doses are then sent to 300 to 400 vaccination locations, established by the Health Ministry. Those locations not only include major hospitals, but also drive-thru stations, numerous small sites and more than two dozen mobile stations, all equipped to keep the vaccines at the required temperature: minus 94 degrees Fahrenheit.

The idea is to spread these facilities across the country, beyond the big cities and large medical centers. All the shots are free, with priority for the elderly, health-care workers and patients with pre-existing conditions. “What we basically said to Pfizer and Moderna and to the others [including AstraZeneca] was that if we will be one of the first countries to start vaccinating, very soon these companies will be able to see the results. It’s a win-win situation,” said Health Minister Yuli Edelstein.

This win-win was amplified when Israeli scientists figured out ways to improve delivery, beyond the manufacturer’s own ideas. One, approved by Pfizer, was to repackage the large frozen packets of vaccine that were flown into the country into many smaller ones, the size of pizza-delivery boxes. The small ones could be delivered efficiently to remote sites. Reuters reported that Israeli doctors have also discovered ways to get more than the advertised number of doses from each vile.

Far less known, Israel offered Pfizer something valuable besides a premium price: It could provide the company with reliable, comprehensive data on how well the medicine works in a very large population. This data goes far beyond the 50,000 people Pfizer worked with in Phase 3 trials. It involves millions. Equally important, each one’s response to the vaccine can be paired (anonymously) with that person’s health record and demographic details. That’s possible because Israeli health authorities have maintained and digitized more than 30 years of medical history on the entire population. That history is available to doctors, nurses and emergency medical technicians as they treat patients. Now, with appropriate protections for privacy, it can be used for public health research.

Pairing this data with Pfizer vaccinations means that the company and public health officials around the world can gauge how well the shots work with different groups, such as “people over 65 with asthma” or “pregnant women.” Is the vaccine more effective with some groups than others? Are there any rare side effects that tests on smaller populations might have missed? How well does the vaccine work on more lethal, more communicable strains, such as the one from South Africa? Questions like those are what Pfizer and Israeli health officials hope to answer.

This data should be pouring in soon since about one-third of Israelis over 16 have already received a single shot; about one-sixth have received both. Both percentages are rising rapidly. (Among major countries, the United Kingdom is a distant second with 14 percent getting at least one shot, and the United States is third at 9 percent.) By late March, a majority of Israelis should be fully inoculated. That is the government’s goal, and it’s on track to reach it. Vaccinations rates have been especially impressive among older people, who are most at risk for COVID. Among those over 60, some 70 percent have received the required two doses. Among those over 70, 9 out of 10 have been vaccinated.

Don’t we already know how effective the vaccine is? We know a lot, but we need to know more. That’s because the Phase 3 trials include only limited numbers from various subgroups. Of the 50,000 participants, there might be only 450 with rheumatoid arthritis, only 800 on blood-pressure medication. The data we gather from such small subgroups is important, but it comes with a large margin of error. The massive Israeli program will reduce that margin of error and do it cheaply because it is already vaccinating millions of people and can couple each one’s outcome with his or her medical history, age and other characteristics.

What have we learned so far? The earliest data covers the whole population, not subgroups, but it is very encouraging. It shows that the vaccine is actually more effective than Pfizer reported from its Phase 3 trials. By Jan. 30, six weeks after Israel began inoculations, more than 1.7 million Israelis had received two doses of the Pfizer vaccine. Another 1.3 million had received their first dose. Of those who received the full inoculation, only around 300 later showed any significant COVID symptoms (less than ½ of 1 percent). Only 16 needed hospital care, less than 0.002 percent. A single dose seems to provide about half the necessary protection.

Encouraging as this data is, the country has suffered badly from the pandemic. Israel’s lockdown has been the longest in the world, and not everyone has complied willingly. Time after time, ultra-religious Jews have gathered in massive numbers for funerals. Those Jews and some Israeli Arabs are wary about taking the shots. International travel, vital for tourism and business, has been effectively closed. And despite a successful vaccination program, “herd immunity” is months away.

Still, Israel’s rollout of the new vaccines has set the pace for the world. The hope now is it generates data and distribution strategies that will help other nations achieve better outcomes.

Charles Lipson is the Peter B. Ritzma professor of Political Science Emeritus at the University of Chicago, where he founded the Program on International Politics, Economics, and Security. He can be reached at charles.lipson@gmail.com.

This article was first published by “Discourse” magazine.