What the Hell Is Happening to COVID in Israel?
Just a few months ago, it seemed Israel had all but beaten COVID-19. Infections, hospitalizations and deaths were vanishingly low.
It’s not hard to see why. The country’s vaccine uptake was high. Most vaccinated Israelis were also boosted, and the health ministry had begun offering a second booster to the most vulnerable residents. Masks were required in indoor public spaces, and a vaccine card was required to enter the most crowded spaces, including restaurants, bars, theaters, and music venues. This strict approach to COVID was working.
Then Omicron hit… and everything changed. Israel is now having its worst COVID surge, with record infections, hospitalizations, and deaths, all in the past few weeks.
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The numbers are pretty startling: On Jan. 1, Israeli authorities logged only 6,000 new COVID infections. On Jan. 19, they tallied a record-high 243,000 cases in a single day. At the peak of the Omicron surge in mid-January, just 3,500 people were hospitalized with serious cases of COVID. To put that in perspective, cases on the worst day of the current surge were 10 times higher than on the worst day of all the previous surges. And on the worst day for Omicron deaths—Feb. 1—121 Israelis died. This in a country with just 9.2 million people.
“Omicron hits everyone, whether vaccinated or not,” Gili Regev-Yochay, a Harvard epidemiologist, told The Daily Beast. But hospitalizations and deaths haven’t risen nearly as much as cases. That disconnect—“decoupling,” epidemiologists call it—helps explain Israel’s seemingly counterintuitive response to the current COVID surge.
The country did… nothing. That response, or lack of one, could signal a new attitude toward COVID in Israel and similar countries.
The vast majority of Israeli cases have been mild, owing to a combination of vaccine-induced immunity and the tendency of Omicron to stay in the head—and manifest as a bad cold—rather than attack the lungs like previous COVID-19 variants. Deaths in the current wave are concentrated in that quarter of the Israeli population that isn’t vaccinated. The death rate for the unvaxxed has been 10 times higher than the death rate for the vaxxed, the Israeli health ministry reported.
Through it all, there has been no widespread panic. Not from the government. Nor health experts. Nor the general public. The Israeli government added no major new domestic restrictions during the Omicron surge. “There was no need for lockdown or school closures,” Leshem Eyal, director of the Center for Travel Medicine and Tropical Diseases at Tel Aviv University School of Medicine, told The Daily Beast. “Commerce and culture remained open and the country functions normally.”
The country that had become among the strictest on COVID is now moving swiftly in the opposite direction.
The implication is clear. As the pandemic enters its third year, Israel is closer than ever to striking a sort of truce with the novel coronavirus. Many Israelis seem increasingly comfortable with the modest risk milder lineages such as Omicron might pose to the vaccinated. There’s little to no political will for new limits on crowds and businesses. If anything, people want fewer limits, even if that means higher risk for the unvaccinated.
There’s a word for this society-wide acceptance of a contagious disease. “Endemicity.” Once a country or community has all the tools it thinks it needs to reduce the threat a disease poses to an acceptable level, the disease becomes endemic and people get on with their lives.
There’s obvious risk in declaring COVID endemic at this point. But Omicron for all its transmissibility isn’t as lethal as earlier lineages—nor does it significantly reduce the effectiveness of a boosted vaccine. A lineage that does evade the vaccines might change a lot of minds, and fast. But for now, it looks like Israel is getting ready to add COVID to the long list of diseases Israelis consider a daily risk, but an acceptable one. Chicken pox. West Nile fever. The flu.
And inasmuch as Israel is usually ahead of the global curve when it comes to public-health policy, Israelis thinking of COVID as endemic could be a harbinger of a similar approach in other wealthy countries with easy access to vaccines. Indeed, there are signs Americans are beginning to accept the somewhat greater risk that the SARS-CoV-2 poses in their own, less-vaccinated country.
It might seem paradoxical that one of the countries that took the novel coronavirus the most seriously is also one of the first to accept that the virus might never fully go away. In reality, strict measures—aggressive vaccination, in particular—made it possible to move quickly toward endemicity today.
Israel locked down hard during the initial wave of infections in the spring of 2020. There were tight restrictions on indoor and outdoor gatherings. Businesses closed. Some schools did, too. For 10 weeks, Israelis barely moved.The government only partially lifted the restrictions as infections dipped. But each time there was a fresh surge in cases–driven, in many cases, by new and more dangerous lineages—the government ordered another lockdown.
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But the lockdowns got a lot looser once vaccines were widely available, from early 2021. In February that year, authorities created a so-called “green pass”—a proof of vaccination or recent infection that gave the holder greater access to more businesses. The green pass helped keep businesses open. Widespread testing, contact tracing and targeted quarantining of freshly infected students and staff helped keep schools open. But it was vaccines that were the key to Israel’s comparatively blessed 2021, and which laid the groundwork for the current rollback of restrictions.
Israelis vaccinated fast. In a little over two months in early 2021, two-thirds of Israelis got jabbed, most of them with two doses of messenger-RNA vaccine. The vax-rate plateaued, but at a high overall level compared to many other rich, industrialized countries including the United States.
Today, 73 percent of Israelis have gotten at least one shot of the vaccine. Sixty-six percent are “fully vaccinated,” usually with two doses of mRNA. Most impressively, more than half of Israelis have gotten a booster shot. And Israel was the first country to offer a second booster—in other words, a fourth dose of mRNA—to the elderly and immunocompromised, starting in January.
Compare that to the U.S., where 76 percent of residents have gotten one shot, but just 64 percent are fully vaxxed and an unimpressive 43 percent are boosted. The U.S. Food and Drug Administration hasn’t authorized anyone to get a second booster.
To be clear, not every health expert is on board with the idea of “vaccinating the vaccinated” with a second booster. “Vaccinating the vaccinated may divert attention and resources from other proven measures such as reaching out to the poorer populations who did not receive the three doses, [thus] increasing inequalities,” Hagai Levine, an epidemiologist at the Hebrew University-Hadassah Medical Center in Jerusalem, told The Daily Beast.
But fourth doses may have helped protect the most vulnerable Israelis when Omicron struck. Israelis, if they got sick with Omicron, usually got only a little sick. A small part of the population suffered far out of proportion to everyone else. “Data show clearly that the burden of severe disease and death in this wave is largely among the unvaccinated,” Naor Bar-Zeev, a pediatric infectious disease physician at Johns Hopkins University, told The Daily Beast.
Yes, Omicron has driven up cases by a lot. But a huge increase in infections resulted in small increases in the worst outcomes. “The peak of death in this wave is much more blunted than in previous waves, despite an astronomical rise in infections,” Bar-Zeev said.
Decoupling is an important signpost on the road to endemicity. In a society that’s managing a once-devastating disease, a surge in infections comes at acceptable cost. Many Israelis have decided that a few hundred deaths out of two million cases is a price they’re willing to pay to keep schools and businesses open.
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That popular acceptance has policy implications. Though Israel is still in the thick of the current surge—the government counted 31,000 fresh infections on Sunday—the trend looks to be moving downward. Quickly citing the decline in cases, the Israeli government last week signaled it would cut the number and types of businesses requiring the green pass for entrance.
America isn’t far behind. Many of the biggest U.S. states that still had COVID-related restrictions on businesses began lifting them in early February. A new strategy is emerging in the U.S., one where COVID response is a mostly local responsibility. The majority of the country would be wide open most of the time.
Strictly local and temporary measures are consistent with a move toward endemicity. The flu is endemic, after all, but schools occasionally close amid flu outbreaks. “Without knowing more about possible mutations, we are still in a pandemic that requires constant revision and innovation of management strategies,” Jennifer Reich, a sociologist at the University of Colorado Denver specializing in vaccination, told The Daily Beast.
There’s a not-insignificant chance that some dangerous new SARS-CoV-2 variant will come along, one that crashes right through the wall of vaccine-induced immunity that makes a degree of normalcy possible. That could make the current move toward endemicity look short-sighted—if it happens. And even if that lineage never appears, and most of us can safely get on with our lives post-Omicron. But there will still be COVID deaths on the margins. The unvaccinated. The immunocompromised. The elderly.
We should never forget the cost of this possible new normal, in Israel or somewhere else, Reich said. “Over the next few years, we should watch how discussions of ‘learning to live with the virus’ erase the lives that might be lost along the way.”
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