As the world begins to emerge from a horrific pandemic, armed with high-efficacy vaccines and a roadmap of lessons learned, it has become abundantly clear that dangerous infections are here to stay, and it is up to health care leaders and citizens to remain prepared and vigilant in preventing another deadly and disruptive COVID-19.
Border closings, innovation efforts, and robust testing in Israel and other countries, are examples of what worked in preventing and addressing the spread of SARS-CoV-2, whereas incidences of slow testing and contact tracing early in the pandemic failed to control the virus in the U.S. Shutting down schools also led to several other public health concerns, and the next big hurdle in the fight is vaccine hesitancy.
If there is one thing the world has learned over the last year, it is the crucial need for the development of a global health system that can address disparities in testing and in treating those with COVID-19, particularly by providing help to underserved communities. During the last day of the virtual 39th Annual J.P. Morgan Healthcare Conference, two health care leaders discussed the efforts and mistakes experienced, as well as the path forward toward herd immunity and the unknown outbreaks to come.
Israel’s success in control and vaccination
The response to the pandemic in Israel is one that seems to stand above many industrialized nations. The country was one of the first to shut down its borders under much criticism at the time. While it turned out to be the right approach, a surge in the fall months, when people became complacent “hit us in the face,” said Eyal Zimlichman, chief medical officer and chief innovation officer at Sheba Medical Center. Currently, the country is in its third surge, but it is countering that with available vaccines.
“We have about 80% of the population over 60 vaccinated, at least on the first vaccine out of two” shots, and the numbers are starting to go down, he said.
Sheba Medical Center is the largest hospital in Israel with 2,000 beds. Owned by the government, it received 14 patients infected with the virus that were on the Diamond Princess cruise ship off the coast of Japan, enabling it to open the first underground COVID-19 intensive care unit with more than 200 beds.
“As we talk about opening the economy, about opening culture and so on, we’re playing a huge role,” Zimlichman said. “And when we talk about that role, it’s really driven through innovation, thinking differently, being more, I would say, courageous to try new things.”
Sheba Medical Center launched its ARC (Accelerate, Redesign, Collaborate) Innovation Center in November 2019 to help connect Israeli digital health care startups with the hospital. The center is led by Zimlichman, who said COVID-19 put ARC to the test, providing a perfect storm for innovation. With a goal date of 2030, it is working backward to solve many problems experienced globally by the pandemic. A new ARC center is forming in Chicago through a partnership with Kaleidoscope Health Ventures to provide international companies with a U.S. foothold, to address health disparity issues, to incubate innovators, to collaborate on data science, and to provide a gateway for global investment.
U.S. death rate triple that of Israel
Representing 4% of the world’s population and about 19% of the world’s deaths from COVID-19, the U.S. has not fared nearly as well as Israel.
“A big reason for that is we failed to get testing to be accurate, quick, frequent and broadly available,” said Rajiv Shah, president of The Rockefeller Foundation.
According to the World Health Organization, as of Jan. 15, 2021, the U.S. has had 22.87 million confirmed cases and 381,522 deaths of COVID-19. This corresponds with 91.5 million cases and 2 million deaths globally.
Israel’s confirmed cases are at 493,501 and deaths are at 3,687. To put that in perspective, the deaths in Israel are about 426 per 1 million population, whereas deaths in the U.S. are nearly three times as much, at about 1,152 per 1 million population.
In February and March of 2020, problems with testing led to a slow response and a complete lockdown that cost the American economy $300 billion to $400 billion a month, Shah said. It also posed deep problems of inequity in which essential workers continued to expose themselves, while others remained safe but struggled financially. The Rockefeller Foundation worked with all levels of government to support testing, contact tracing, isolation and the acceleration of therapeutics and vaccines.
By the beginning of May 2020 testing was up to 400,000 to 500,000 tests a week and it is expected to reach more than 300 million tests for the month of February 2021, Shah said. Sports teams and some schools have managed to successfully complete seasons and semesters by using testing to remove those infected, including asymptomatic individuals, from the chain of transmission. It is a tried-and-true method that should be used across the board, Shah said.
“In America, there are 55 million school kids that have been forced to experience nearly all of the last year learning from home, and frankly, it has been a disaster,” Shah said. “It has led to significant learning loss, particularly for lower income families and children in those families. We’ve seen an increase in child abuse that has gone unreported because schools are their safe-haven” and without the schools distributing food, “we saw an increase in child hunger in our country.”
“It’s important for a variety of social reasons, not the least of which is the learning of children, to get those schools open again,” Shah said.
Hesitancy hurdles and vaccine rollouts
Now, with both the Pfizer Inc./Biontech SE mRNA vaccine Comirnaty (BNT-162b2) and Moderna Inc.’s mRNA-1273 both available under emergency use authorization, some U.S. efforts will shift to administer the vaccines, reaching into vulnerable communities.
“African American communities have had a very high percentage of people self-report real hesitancy around the desire to access the vaccine and that’s going to be the next big hurdle in the United States,” Shah said.
The Trump administration’s Operation Warp Speed, as well as international programs and private company efforts, all contributed to the fast development and high-efficacy performance of vaccines, proving many experts wrong.
“Most experts were saying we would be at this point six months later and we got there six months sooner,” Shah said. “That’s a tremendous accomplishment.”
But to help those overcome vaccine hesitancy or concerns over safety and necessity will require a huge outreach from local leaders, people known personally who are trusted, as opposed to distant medical authorities. It also will require the logistics and financials to provide free or low-cost access to the vaccines. The mindset must shift from wanting not only to protect oneself, but also to protect a neighbor and to “see it as a form of national duty or national service,” Shah said.
Although the U.S. had a goal of administering 20 million inoculations by the end of 2020, only about a quarter were done.
“Now we see a new Biden administration team setting a goal of 100 million inoculations within 100 days,” Shah said. “I believe that is an achievable goal, but it is only achievable if we get every company, every local authority, together to come up with creative ways to dramatically expand access on the ground in community after community.”
Israel, on the other hand, expects to vaccinate its entire population by March.
Protecting the globe from future pandemics
Zimlichman said three factors play into the country’s ability to achieve that goal. Israel operates through four HMOs that work directly with the government and it has one central data health care record for all citizens and residents. Thirdly, Zimlichman believes Israel has a “sense of urgency” that he has not seen in other countries.
“That’s really what we need in the United States,” said Shah.
Southeast Asia, which dealt with SARS in the early 2000s, responded well in the early parts of the COVID-19 response because of prior institutional collaborations and memories of what was previously faced. South Korea had a public/private council that formed alliances between diagnostic companies and public health authorities.
In the U.S., “we have so many different layers of governance and government,” Shah said, “and we have a $4-plus-trillion health care system, but spends the bulk of its resources on the very end of life, intensive-care type of costs in an in-patient setting. And that’s the antithesis of a system that is focused on broad data-driven public health.”
In 2014, the death and suffering caused by the Ebola crisis in West Africa reverberated globally and resulted in four reviews of the response, providing a roadmap to make sure the mistakes do not reoccur.
“The core elements of those roadmaps were never put in place,” Shah said. “And so the Zika crisis came and became an endemic disease. COVID-19 has now come and I believe over time will become endemic in some form. The reality is these types of pandemic threats and epidemics ought to be preventable and we have the knowledge and the roadmap on how to do it.”
The first thing needed is a broad, global data surveillance system that can see outbreaks early and provide information on when they are spreading and how they are spreading, to identify the spreaders and to remove them from being transmissible. Secondly, Shah said, strong preparedness plans tied to funding mechanisms need to be in place to provide personal protective equipment and to train personnel. Third, the U.S. needs “the global capacity to do what Israel did” by accelerating the response. And finally, the country needs investment in global health systems.
“It might be that Israel does a great job and America turns it around and catches up and that other industrial nations succeed,” Shah said, “but if there are 400 million people in parts of Africa not getting tested and carrying COVID-19 variants that are mutating and run the risk of becoming COVID-20 or 21 or 22 or 23, and becoming the next big, global threat, that’s a threat to all of us. So reinvesting in global health systems, particularly in those nations with the least resources, and seeing that as part of our common security, our common interest, and frankly, our common humanity, is something we have to start to do with much more seriousness, if we’re really going to avoid the next major pandemic.”