One Country Has Jumped Ahead on Vaccinations

Israel has vaccinated six times more of its population than the United States. Can others learn from its success?

People getting vaccinated in Israel
Oded Balilty / AP

About the author: Uri Friedman is the managing editor at the Atlantic Council and a contributing writer at The Atlantic. He was previously a staff writer and the Global editor at The Atlantic, and the deputy managing editor at Foreign Policy magazine.

One nation has already provided more than a quarter of its people with at least one dose of COVID-19 vaccine, outpacing every other country in the world and more than sextupling the percentage in the United States. During one recent three-day period, in fact, it administered a dose of the vaccine to a higher percentage of its population than the U.S. has altogether. Nearly three-fourths of those over age 60 have gotten their first shot. And most of the population could be vaccinated by the end of March, which would be earlier than any nation except, perhaps, tiny Palau and the Vatican. The government is now preparing “passports” for the twice-jabbed that will exempt them from quarantines.

It’s the kind of standout success one would expect from the now-familiar stars of the global response to COVID-19—Taiwan, South Korea, or New Zealand. But it’s actually been achieved by Israel, in several respects a surprising country to be the world’s front-runner on vaccine distribution. A 2019 Johns Hopkins study ranked Israel an unspectacular 54th among 195 countries in terms of preparedness for a pandemic. After initially appearing to vanquish the coronavirus, Israel has since suffered some of the world’s worst outbreaks—something that remains true as it celebrates its vaccine advances. And during a pandemic in which public trust in government has emerged as arguably the most consistent ingredient across countries for success in combatting the virus, public confidence in Israel’s political leaders is dismally low. The Israeli government currently has the distinction of being one of the most unstable in the democratic world.

So how exactly has Israel pulled off this unlikely feat? The answer traces back decades to the embryonic health infrastructure created before the State of Israel even existed. That, in turn, should serve as a sobering reminder for Americans: Nations faring well against the virus are drawing on preexisting strengths, not flexing muscles suddenly conjured amid the crisis or, say, a change in administrations.

The countries that have performed best against COVID-19 have been those “that in general have good public-health infrastructures—and we [in the United States] just don’t,” Helene Gayle, the head of the Chicago Community Trust and a veteran of the CDC, told me.

“There’s a big lesson from this, which is: You’re not going to be ready for a pandemic if you don’t have your data systems in place, your surveillance systems, your state-level funding for the infrastructure, so that you can distribute [vaccines] effectively and fast,” argued Gayle, a co-chair of a recent study on how to equitably allocate COVID-19 vaccines.

And as the world shifts from focusing solely on containing the virus to rolling out vaccines as well, the key determinant of success is morphing from the credibility of the government to the credibility of the health-care system. As the scholars Jeremy A. Greene and Dora Vargha have observed, vaccines are at least in part “technologies of trust” that rely on people “maintaining confidence in national and international structures through which vaccines are delivered.”

The apparent paradox of Israel being both a “vaccine champ” and a “contagion chump,” as the Israeli journalist David Horovitz memorably put it, becomes less mystifying on closer inspection. Whereas some countries that did better in flattening the curve of coronavirus cases, such as Australia and South Korea, at first proceeded cautiously with plans to approve and procure vaccines, because they felt they had the virus under control, pandemic-battered Israel didn’t have that luxury. What the Israeli government felt instead was urgency.

Ahead of elections this March, Israeli Prime Minister Benjamin Netanyahu has cast himself as the face of the country’s vaccination campaign (he got Israel’s first COVID-19 shot) and its dealmaker in chief, negotiating directly with Pfizer’s CEO and reportedly paying Pfizer-BioNTech and Moderna top dollar to receive doses quickly and at scale when global supplies are tight.

Netanyahu recently announced an agreement with Pfizer that will send hundreds of thousands of vaccine doses to Israel per week. Israel, in turn, will serve as something of a national clinical trial—or, in the prime minister’s words, a “global model state for the rapid vaccination of an entire country.” It will send Pfizer anonymized medical information about the effects of the vaccine on the population and on curbing the epidemic. The statistical data could yield lessons not only for Pfizer and other pharmaceutical companies as they continue to develop COVID-19 vaccines, but also for other countries and international organizations working on their own vaccination campaigns.

But the story of Israel’s success is arguably more about distribution than procurement. As Dany Bahar, an Israeli economist at the Brookings Institution in Washington, D.C., recently observed, focusing on what the Israeli government has managed to negotiate overlooks why it was in a strong negotiating position in the first place. It could present itself to pharmaceutical companies as an attractive “pilot country” for an effective mass-vaccination program for its 9 million–plus people because of its small size and the “vast public health infrastructure” that the state has invested heavily in over the past seven decades, building on a tradition of socialist-minded worker health-care cooperatives that preceded the state’s founding.

As Bahar noted, the modern manifestations of these cooperatives are Israel’s four nonprofit health-maintenance organizations, or HMOs, which offer health care to all citizens through an individual mandate and social-security payroll contributions, share a single electronic medical-record system, and benefit from a “centralized chain of command” that allows them to implement plans across the nation’s range of medical facilities. These HMOs don’t just help cover medical expenses; they also operate clinics and provide doctors.

“When it comes to understanding the early success and—perhaps as importantly—the reason why pharma companies trusted Israel in its ability to implement this massive endeavor, it comes down to its public-health system, inherited by those in power today,” Bahar argued.

The semiprivate, publicly funded HMOs, which don’t respond to the same profit incentives that private insurance companies in the United States do, are present not just in big cities but also in more remote and disadvantaged locations such as “poor, smaller Arab towns or Bedouin villages in the Negev” desert, Bahar wrote to me in an email. “The contrast in my mind here was rural America, which will be hard to vaccinate if people there have to drive one and a half hours each way to the closest CVS or clinic.” (In this regard, Israel benefits immensely from being a much smaller country than the United States.)

The HMOs have helped make Israel’s health-care system one of the most efficient in the world. And crucially—and in contrast to public sentiment regarding the government and other aspects of the health-care system such as surgery or queues for services—confidence in these health funds is widespread; roughly three-quarters of Israelis say they trust their HMO physician, and 90 percent say they are satisfied with their plan. This trust matters, because the HMOs are at the forefront of the vaccination campaign.

To execute that campaign, the Israeli Ministry of Health has acted as a hub for receiving the vaccines from drugmakers and distributing them to the HMOs. The HMOs tapped into the country’s digital medical records to determine the order in which population segments needed to be vaccinated, and speedily set up hundreds of vaccination centers across the country.

While Israelis must be members of an HMO, they can choose which one and have the option each year of switching to another if they are unhappy with the services they’ve received. “The competition between these HMOs facilitated a much more efficient vaccination rollout,” as did additional competition with independent hospitals, Cyrille Cohen, a professor at Bar-Ilan University and member of a coronavirus vaccine advisory committee to the Health Ministry, wrote to me by email. It helped foster what he called “‘vaccinal capitalism.’”

Cohen told me he got his shots by tuning into regular updates on the news about which demographic group was eligible to be vaccinated next. He logged into his account on his HMO site when he learned it was his turn, chose a vaccination center based on his location, and scheduled an appointment. “Thirty seconds after confirming, I got a text on my cell with all the info, including date, time, place and already a second appointment for [the] next shot, exactly three weeks apart,” he told me. It all took “less than two minutes.” There are alternative options if you don’t use the internet or prefer to get your vaccination at a hospital rather than through your HMO.

As Bahar sees it, Israel’s HMO infrastructure and medical-record system have enabled it to achieve two of the three requisite goals for a staged national vaccination program when supplies are short: targeting shots to the people who most need them and ensuring that those who are eligible can access the vaccine for free. But he told me that what he sees as the third requirement—a public understanding that the vaccine is safe and that the whole population must be vaccinated to end the COVID-19 crisis—still depends on the confidence in government that was so essential for countries to beat back the virus during the pandemic’s first phase.

Israel has also performed well on this third front. “Only 9 percent of the population has declared that they won’t get the vaccine,” which is low compared with many Western countries (including the United States) and in keeping with the practical, “start-up nation” mentality of Israelis, Cohen observed.

But he added that Israel’s success looks more uneven when you zoom in on the specifics, noting that vaccination rates in the Arab population and Ultra-Orthodox populations are only half those of the general population. Misinformation and a lack of trust in Israeli authorities, among other challenges, are tamping down rates among both groups.

Israel’s vaccination drive also doesn’t include Palestinians in the West Bank and the Gaza Strip, as Israeli and Palestinian authorities each accuse the other of shirking their responsibility for these populations. Even when you zoom back out, Israel’s successful procurement of vaccines raises broader questions about the inequitable global distribution of vaccines between rich and poor countries that may only grow more pronounced in the coming months.

While the Biden administration has ambitious plans to invest $20 billion in a new campaign to vaccinate the nation through federally supported vaccination sites, the reality is that there are limits to what a country can do if it neglected to invest in the prerequisites for an effective response until the crisis was already upon it.

"We would never think, Let’s wait until we’re in the middle of a war to fund our military. But we do that all the time with our public-health infrastructure” in the U.S., said Gayle. “That’s the backdrop against which we are now trying to do what is the most complex public-health implementation that we’ve ever had, which is getting this vaccine rolled out and effectively given to diverse populations.”

To make progress, the United States would do well to play to its unique strengths, just as Israel did with its HMOs. To cite an example that’s especially relevant now, as new coronavirus variants emerge around the world that could undermine the effectiveness of vaccines: The United States has so far sequenced only 0.3 percent of its COVID-19 genomes—a process that would help it track the virus’s genetic changes—even though the U.S. has more genomic-sequencing capacity than any other country, according to Peter Hotez, a vaccine expert at Baylor College of Medicine. It currently ranks a middling 43rd in the world on percentage of COVID-19 cases sequenced. When it comes to combatting the coronavirus, America has the science in spades. But that scientific knowledge has repeatedly been detached from its public-health response.

The United States has failed at every stage in the fight against COVID-19, from its inadequate diagnostic testing and genomic sequencing to what now appears to be its botched vaccine rollout, Hotez told me. “There was never a plan to vaccinate the American people,” he argued, noting that the military-led logistics for the Trump administration’s Operation Warp Speed seem to have been “all about loading boxes off UPS and FedEx trucks and keeping them cold,” rather than focused on fashioning efficient, effective, and equitable systems for getting the vaccine doses in those boxes into Americans’ arms.

“The states put in place an adult-vaccination infrastructure that was basically just the pharmacy chains and the hospitals, maybe a few community clinics,” Hotez said. “It was not nearly adequate for the task at hand: to vaccinate three-quarters of the American people. And we’re backed into a corner now because, since we failed to even attempt to do COVID-19 control, we’ve put all of our eggs in the vaccine basket.”

The way out might be leaning more on the few institutions that still retain high levels of trust among Americans—the equivalents of Israel’s HMOs. In a new survey, the communications firm Edelman identified a striking dynamic in the United States (and many other countries): Although public trust in government is low, trust in business and particularly people’s employers is higher, even across the country’s political divide. That argues for the U.S. government to work more closely with the private sector on vaccinations, as Washington State’s health department just announced it will do by establishing a “Vaccine Command and Coordination Center" in partnership with companies such as Starbucks and Microsoft.

But the fact that this public-private innovation is happening at the state level is revealing. The federal government’s decision to send vaccines to states but then delegate the administration of the vaccines to under-resourced local authorities has produced a bewildering, disorganized patchwork—what often amounts to public health by happenstance. In contrast to Israel, far more doses have been distributed across the United States than shots given. Americans are scrambling to track down doses however they can—whether a tip from their mail carrier, a text from a friend, or a trip to the grocery store to buy Hot Pockets. Even when they are deemed eligible to be vaccinated, too many Americans are finding that maxed-out appointments, crashing websites, and endless hold times mean they can’t avail themselves of the opportunity. Cyrille Cohen’s two-minute sign-up this is not.

Israelis know exactly where to turn for their vaccine: their familiar HMO, which provides for all their family’s primary-care needs. Many Americans, even when their time for a shot has finally come, don’t know what to do or where to go. Employers, having built up trust and personal connections with their employees, could potentially fill that void in the United States.

Israel has “a system of community clinics and community public health. We don’t do that. I mean, what do we have? We have Sam’s Club and Rite Aid and Walgreens and hospital chains,” Hotez said. In the U.S., “it’s all privatized. And it works for some things. But for an ambitious undertaking to vaccinate the American people, it’s an abysmal failure yet again.”