‘Hindsight is 20/20’: Israel’s lessons after 3 years of COVID-19

Science and Health

Lessons learned from three years of managing the COVID-19 pandemic in the country should ensure Israel is more prepared for the next public health emergency, whatever that may be, said coronavirus coordinator Prof. Salman Zarka.

“We need to formalize the processes we developed for managing coronavirus, so we can roll them out again,” he said recently. “The next emergency could be an earthquake in Jerusalem or a massive forest fire on the Carmel, but the same systems would be needed to manage it.”

COVID-19 entered Israel on February 21, 2020, when 11 Israelis aboard the Diamond Princess cruise ship returned home and entered quarantine in Israel’s first coronavirus ward at Sheba Medical Center at Tel Hashomer. That same day, doctors discovered that one of the female travelers had the virus.

Then, joining the rest of the world, Israel began its fight against the “invisible enemy that must be located,” as Prime Minister Benjamin Netanyahu referred to COVID.

“We managed the virus as well, if not better, than most Western countries.”

Prof. Salman Zarka

How did Israel, underequipped and understaffed, manage COVID so well?

While Israel has a well-tuned army, sophisticated weaponry, defense technology and intelligence to battle its adversaries, the country entered the pandemic with a severe lack of hospital beds, with medical professionals who were already stretched too thin and a health minister who was later convicted of breach of public trust. Yet, “we managed the virus as well, if not better, than most Western countries,” Zarka said.

CORONAVIRUS ‘CZAR’ Prof. Salman Zarka attends a press conference in Jerusalem in August 2021. (credit: OLIVIER FITOUSSI/FLASH90)

Now, three years on, Israel is preparing to dismantle, by the end of March, the IDF’s Alon Headquarters for the management of the virus, and Zarka, the third COVID “czar,” who has been in this role since August 2021, will retire from this position and transfer authority for managing coronavirus to the health funds.

He said he would leave his post feeling that he and his predecessors, professors Nachman Ash and Roni Gamzu, are leaving the country in a healthier place than when they started. He admitted they had to do many things that seemed difficult or perhaps should have been unnecessary to achieve success. But he believes they won.

Fighting Israel’s politicians, building an emergency health response system

When Gamzu took on the position of Israel’s first coronavirus coordinator in late July 2020, politicians were managing the pandemic, which had led to a spike in mistrust by the public, Gamzu told The Jerusalem Post.

“There was too much political involvement,” Gamzu said. “Professionals were not in the front…. As a result, there were a lot of questions and not enough leadership to answer them.

“I quickly realized that my greatest challenge would be to put professionalism above politics and populism” in the fight against COVID, he continued.

As the first “czar” in office before the vaccines arrived in Israel, he threw punches over lockdowns and banned travel to Uman for Rosh Hashanah. But ultimately, he fought to build an emergency health response system.

Gamzu established Israel’s coronavirus headquarters, recruited the Home Front Command, and built a system to increase testing, decentralizing it from the Central Virology Laboratory at Sheba. He also increased efforts to cut the chain of infection and helped design the protocol that enabled Israel to focus on super-spreaders instead of everyone with a positive COVID test result.

“People told me I was wasting money building the Alon Headquarters, because we would only need it for a couple of months,” Gamzu said. “Here we are, and it has been around for more than two years.”

He also established desks to deal with the ultra-Orthodox, Arab and senior citizen communities and their diverse needs.

“Even though we are a small country, we have a lot of diversity, and we need to take this into consideration in all crises,” Zarka said.

He credited Gamzu with starting these desks, and highlighted how he carried this concept into his role – meeting with sheiks, rabbis and others to put his finger on the pulse of their situations. In addition, Zarka traveled to Uman before Rosh Hashanah to help establish local safety standards and went to a soccer game to set up a protocol to reduce infection at these significant events.

During most of the crisis, the IDF Intelligence Corps ran the Coronavirus National Information and Knowledge Center, providing insights to the Health Ministry and the public with an eye on what was happening abroad. Under Zarka, the ministry brought such a research center in-house and has now hired and trained a team of researchers to monitor global health trends, with the aim of raising a red flag before the next emergency.

Zarka also encouraged the recent extension of the “coronavirus law” that allows the government, with Knesset approval, to impose restrictions quickly if required. He said that this is part of being prepared for future outbreaks.

“By extending the law, we are sending a clear message: You can live normally; we are moving COVID management to the health funds. But we are keeping the option open that if a variant of concern enters Israel, we have a decision-making mechanism, with checks and balances, to rely on rather than emergency regulations,” Zarka said.

He added that leveraging the Home Front Command, effectively communicating with community leaders and sectors, empowering the local authorities, and having access to data from abroad would put Israel at a better starting point in any future emergency.

ALTHOUGH ISRAELI media highlighted the complaints of Israeli citizens about how the country handled COVID-19 amid five elections in three years, a Pew Research Center survey published over the summer showed that, in fact, a large majority (71%) of Israelis believed the country had generally handled the pandemic well, compared to 26% who thought it did so poorly.

Out of 19 countries surveyed, citizens of only five other countries ranked their responses better.

“We managed the virus as well as or better than most Western countries,” Zarka said.

Gamzu agreed: “Israel is a country with many difficulties,” he stressed. “Sometimes we are not well accepted in the world. People look at us negatively. But corona has done well for us. We gained much respect for how we dealt with the pandemic.”

Handling Israel’s vaccine rollout

The highlight of Israel’s successful efforts came at the end of December 2020, when it managed to secure enough Pfizer vaccines for all citizens and then inoculate them in only months. In addition, with its vast electronic medical history database, Israel became a giant laboratory for evaluating the vaccine’s effectiveness and side effects.

During the pandemic, Israel consolidated the anonymous records of people who got their shots, enabling the country to analyze the data and understand what was happening, Ash explained to the Post. That was how Israel understood that the vaccines started waning at around six months and that they were less effective against specific variants. It also led Israel to approve a booster shot, something the World Health Organization and the US Food and Drug Administration recommended later.

But Ash admitted that after the first campaign, the shock Israelis experienced when the Delta variant arrived and vaccinated people got sick made it harder to convince people to take subsequent shots.

Only 4.5 million Israelis took the third shot, and less than a million the fourth. When the Omicron vaccine arrived in Israel, the ministry recommended it for the elderly and people with underlying medical conditions, but some refused to be vaccinated. To date, less than 400,000 Israelis have gotten the Omicron shot.

Nonetheless, recorded virus cases remain low, and the percentage of infected people who develop a severe disease is small and manageable by the health funds and hospitals. Finally, said Gamzu, Israel has achieved the ever-coveted herd immunity.

He said that “the number of vaccine doses that were taken here, and the number of people who were infected with coronavirus, especially the more virulent but less deadly Omicron variant, have created herd immunity.” Gamzu compared this to countries that continue to have disease spikes, such as China and New Zealand, where three years of “zero COVID” policies did not succeed.

Based on data gathered from the southern hemisphere, Israel had predicted a strong COVID wave with a deadly round of flu this winter. But ultimately, that wave never came.

Zarka said herd immunity and Israel’s efforts to vaccinate the elderly and at-risk with the new COVID and flu vaccines before the cold struck could explain why the wave was not as high as it was in most of Europe.

EARLIER THIS week, the ministry announced that the obligation to wear masks in medical facilities, hospitals and geriatric centers would no longer apply. The requirement to isolate after testing positive for the virus was extended only through May 15. 

Ash said that he supports these decisions.

“We can now treat COVID-19 like any other disease. We must be vaccinated against COVID again, maybe even once a year, but all other restrictions should be canceled.”

Nachman Ash

“We can now treat COVID-19 like any other disease,” he said. “We must be vaccinated against COVID again, maybe even once a year, but all other restrictions should be canceled.”

He said this is despite an announcement last month by the WHO that COVID-19 continues to constitute a public health emergency of international concern.

Zarka stressed that COVID has not disappeared and that he does expect peaks and nadirs in 2023. However, he also said that the number of daily infections or severe cases would not be the focus this year. Instead, 2023 should center on long COVID and the mental health crisis that resulted from living with COVID for the past three years.

He said that the health system is planning to host a long COVID working conference in March to help better define the phenomenon and develop new answers for managing it in the clinic.

It is still unclear how many people suffer from long COVID, with estimates ranging from as few as 5% of infected people to more than 30%. Last month, Israeli research published in The BMJ said COVID symptoms such as shortness of breath and loss of smell and taste tend to ease over time and may be gone within a year, although some critics of the study said that because the team relied on medical records rather than hearing directly from patients, the findings could underestimate long COVID symptoms.

The pandemic’s psychological impact is also expected to be a focus, with the WHO reporting a 25% increase in anxiety and depression since the start of COVID. Zarka said that at Ziv Medical Center, where he serves as director-general, the hospital’s eating disorder unit is overflowing with people occupying its 15 beds and another 20 on the waiting list. In a separate interview, a Mayanei Hayeshua Medical Center representative said the hospital is experiencing a similar increase in demand for the eating disorder unit.

“There is a mental health pandemic,” Zarka said. “People are suffering, and we need to find answers for them.”

Since the pandemic, there are also concerns about declining rates of routine childhood vaccination.

“If this is not changed, it could be a public health disaster,” Ash told the Post. “We could start to see measles and other outbreaks.”

He said that one of the goals should be to combat the growing anti-vaccination movement which centers on emotion rather than data.

“Anti-vaxxers claim that young people are dying because of the vaccines, and then every young person who dies that was vaccinated becomes one of their statistics,” Ash said. “But young people died before the vaccines and certainly before the pandemic. In addition, we published peer-reviewed studies that showed no rise in sudden or cardiac deaths since the vaccines.”

Moreover, he stressed that today many people have been infected with the disease and have also been vaccinated, so if someone dies from myocarditis, for example, knowing whether the individual died from the virus or from the vaccine would be impossible. What scientists do know is that the rate of myocarditis from the virus is higher than from the vaccine.

“But a simple statement like ‘vaccines kill you’ is much easier to understand,” Ash contended.

Other issues – such as climate change and its effects on people’s health; and noncommunicable and chronic diseases – were not being adequately addressed in Israel even before the pandemic, Ash said, and the situation has become more acute since.

Delayed or avoided medical care during the pandemic has increased morbidity and mortality associated with chronic diseases in Israel and globally.

Zarka said that, retrospectively, some decisions the country made were right, and Israel could have made some decisions differently. The real test will be what happens when the next crisis strikes.

“Hindsight is 20/20,” Zarka concluded.