‘Israel is unprepared,’ ex-COVID czar warns amid rising delta infections

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Moshe Bar Siman Tov, are there days when you regret leaving such an influential position in the government?

Definitely not. Just the thought of it makes me uncomfortable. I participated in the state budget ritual for so many years on both sides, both in the Finance Ministry and at the Health Ministry.

But don’t you have an urge to take part in the decision-making when it comes to COVID-19, for example?

No, I don’t. I’m over it. I’m really not sorry I’m not in government, participating in budget debates or anything else for that matter.

When you were appointed director general of the Health Ministry (in 2015), you made personal sacrifices. You left a position in the United States with your family and enlisted for public service. What has changed?

Honestly, before the outbreak of the pandemic there were other government roles I wanted to fill, but the coronavirus crisis forced me into a situation that left me totally over-saturated.

Why?

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Because it was so fraught, busy, endless – but that didn’t come from a bad place. I experienced everything, all aspects, with such intensity. I was at the center of it all, and now I want to try something different. This isn’t a decision for life: I assume I will find myself in the public sector again at some point.

Do you feel sorry for whoever is working there?

No, but there is something terribly daunting about entering the public sector in this country. Even if we put aside the low remuneration, which can be compensated for by interesting work, the environment in that sector can be toxic. People are coming at you constantly from all directions.

Israeli Health Ministry director general Moshe Bar Siman Tov in 2020, after he resigned from his post.
Eyal Toueg

You mean like what recently happened to Dr. Sharon Alroy-Preis, the Health Ministry’s head of public health services, who the media said was “acting like she’s crazy?”

That is the latest example. I do not know Sharon; I’ve met her twice. Suddenly a person is thrown into the colosseum because of forces they do not even understand. I was targeted too. You can’t even begin to understand how it happens that one morning a woman like Sharon finds herself subjected to such an aggressive campaign [by anti-vaxxers, after she spoke out in favor of COVID-19 restrictions and vaccinating children].

Who is to blame for this?

These are probably the rules of the game. I don’t have an explanation or know what should be done, but people are constantly looking for the next person to stick under the guillotine. They shame others in public instead of talking about what we should do, what our strategy is. In Sharon’s case it was immediate and extremely ugly. No one deserves to go through that, to have their intentions questioned. And besides, there is a general director, there is a minister. She does not make decisions.

Demonstrators gathered outside her home, calling her a “Nazi murderer.””

“Nazi” comments were on the fringes, but the discourse against her has penetrated the mainstream.

It never used to be like this. What happened? COVID-19? Benjamin Netanyahu’s rule?

COVID-19 has taken everything to an extreme. We don’t conduct a dialogue about ideas and we have no strategy as a country, and Israel is one of the countries with the fastest pace of change. In a decade, another 2 million people will live here, and we have no strategy for dealing with that. There is no road map that says: Here is where we are headed. So, when there is no discussion of ideas, the discussion focuses on people.

Our society is also very heterogeneous. In addition, there is a large dimension of uncertainty. I would interview people and tell them to come work for the government, and they would say: You are asking me to come, but what will happen when you leave? The game can change at any time. A new minister arrives, a new CEO, the agenda changes.

A young Israeli woman being vaccinated against COVID-19, in June. “The coronavirus will not be defeated by any one thing, nor is it a matter of a short-term concentrated effort.”
Avishag Shaar-Yashuv

A lesson in humility

On the other hand, criticism of public officials is important.

Substantive criticism of policies, not comments like “crazy.” And if you are going to criticize, then do it directly and not behind the back, anonymously. At the bottom of everything there is a connection to strategy: We are frantically looking for a magic solution to COVID-19, and it can teach us many things.

What, for example?

Humility, and the fact that life is complicated and requires complex solutions. All the time people say: “This is the solution for COVID-19, let’s do it and we can get back to normal.” First it’s tests, or breaking the chain of transmission, and then its masks or vaccines. The coronavirus will not be defeated by any one thing, nor is it a matter of a short-term concentrated effort. In many ways the pandemic has suited Israel’s relative advantages – strong community-based health services, a flexible and adaptive system with the ability to cope with burdens.

And yet?

But if you look at the strategy – there isn’t any. We are unable to internalize that there is a complexity here that demands a profound change in our lifestyles. After all, what will happen on September 1 (when the school year starts)?

What will happen?

The same thing that happened on September 1, 2020 [schools opened but were shuttered due to a lockdown about two weeks later]. Either that or a miracle. We expect things to be fine, but at the moment we are not really prepared. It is likely that the virus will continue to spread. Instead of seeing how to prevent contact between the sick and the healthy, people say: “Let’s shorten quarantine times.” But this will lead to the opposite phenomenon, more students in isolation, because we are negotiating with a virus that is not considerate, nor can it be deterred.

But we have learned things, haven’t we?

The health care system has learned and applied things. It was the only public system that functioned, and so it remains. What is the education system doing to cope? We may be doing amazing things, but from what I see in the media, we are no more prepared than last time around.

A health worker collects a swab sample from a young girl, at a coronavirus testing center, in Tel Aviv, today.
Oded Balilty,AP

Maybe in fact the government has decided that there is nothing we can do, that drastic measures are too costly, so we have reached the conclusion to go with the flow and just live with it.

I agree that we should not take drastic steps, and certainly not shut down the education system, but rather ensure that schools operate safely.

What should be done differently?

One should learn how to prevent the spread in the education system, for example: embrace outdoor learning as much as possible, because the virus is much less contagious outdoors; limit recess times; separate classes; eat separately; enforce mask wearing, even though we know that this does not always prevent outbreaks.

Regarding Ben-Gurion International Airport, even though I travel abroad from time to time, I will accept a week’s isolation or at least undergo another test four days later. In short, there are things that can be done, but my feeling is that they aren’t really being implemented. And the fact that we start vacations in early September this year [because of the Jewish fall holidays] is not encouraging, because then comes October 1.

What is your position regarding vaccination against the coronavirus in schools?

I am in favor. Education Minister Yifat Shasha-Biton’s statement to the effect that it amounts to a crime is outrageous, and may cause damage that will take many, many years to repair.

Many, many years?

Yes, because there is a general consensus in Israel about the effectiveness of vaccines. More than 95 percent of the population is routinely inoculated. We always looked at other countries and said, “Thank God, we don’t have their craziness.” Health was not a political issue in Israel. In the United States everything is political, health there is extremely politicized, so their health care system is functioning terribly.

Suddenly politics has taken over the decision-making here too. Not in terms of importance and priorities, but vis-a-vis all the populist aspects of health. People say: “We are just asking questions.” But if the consequence is widespread questioning of vaccinations, and we begin to witness a gradual erosion in the immunization rate or parents who delay vaccination of their children – it will harm public health.

A health care worker and a patient at the Herzog Hospital, a geriatric-psychiatric hospital in Jerusalem, last month.
Ohad Zwigenberg

Health Ministry professionals are not the only ones with knowledge.

The health care system, unlike the defense establishment, is subject to constant scrutiny. From the outset of the pandemic there was not a single person without an opinion about how to manage it, and many came to work with us. The number of hours I spent on the phone with concerned citizens who got as far as the prime minister was enormous; there were days when most of my time was devoted to this. To people who were sure they had solutions to the pandemic and just needed to be heard.

‘No simple matter’

Those people didn’t have solutions?

No. This epidemic is no simple matter. We are used to thinking of ourselves as terribly sophisticated and the health care field has known insane breakthroughs – and suddenly a pandemic arrives, and we act like it was 1918.

Well, the vaccines are pretty dramatic, and they did not exist back then.

True, and we thought that with them we had resolved the issue. I, too, was convinced that it was all over, and now another wave is approaching. This is a blow to the national and personal ego, and it puts us in an unfamiliar and undesirable place. We are always convinced we understand everything. I have been following this virus for a year and nine months, and there is still more that’s unknown than is revealed. We are far from understanding it. We lack answers to basic questions.

For example?

To what extent is a vaccinated person infectious? We know that most people who have recovered aren’t reinfected. But what about a vaccinated person who gets infected – will they react like someone who hasn’t been vaccinated? Will they develop antibodies at a level that will prevent them from getting sick again? We do not fully understand the issue of contagion among children. And the virus is mutating, which is the most significant thing that we don’t grasp.

Travelers exit Ben Gurion Airport after landing in Israel, this week.
Tomer Appelbaum

And we aren’t adapting?

No. We make decisions based on a static situation; it’s like a snapshot of reality. But there is dynamism involved: The coronavirus is different today from what it was six months ago, even four months ago. Either the vaccine is less effective, or the virus is more resistant. What happens now? We don’t know. We speculate. Will the third vaccination be the answer? I’m in favor of it, but will it stop the pandemic?

Probably not.

More questions: Why are children suddenly dying in Indonesia (from the virus)? Why is there an outbreak in Florida? What is the reason for the recent decline in the number of infections in the U.K.? Is it the effectiveness of AstraZeneca or maybe it’s because of the long interval between doses in that country? They delayed administering the second dosage, so it may have come just in time to block the delta strain that had just arrived there, when the vaccine was most effective.

Those are two different hypotheses that explain the same phenomenon. People are saying that we can learn from the U.K. because the pandemic’s development here is 30 days behind them. But how can we learn from the them? Maybe they had different circumstances there?

Is it also possible that a new and more deadly variant will appear, or one for which the vaccine is not effective at all?

There is no need to live by the worst-case scenario, but no scenario can be ruled out, and at the moment, we have a strategy aimed at a third dose and that is it, so it may not be relevant. The education system caused the flare-ups here during the previous two waves. And the vaccine is only relevant for those in the education system from the age of 12 and up.

What about the so-called green passport? Is there any point to it?

Use of the green passport (a digital document showing that someone has either been vaccinated, has recovered from the virus or recently tested negative for it) was based on an assumption that is no longer correct – it will not stop the pandemic. The assumption behind it was that vaccination prevents infection and contagion and therefore we can permit large gatherings in open or closed spaces. Plus, it was an incentive to get vaccinated. We now see that the justification for efforts to prevent infection has weakened, because vaccinated people become infected and can be contagious, so the only motivation we are left with is increasing vaccination rates.

There are many who claim that what you call “vaccination incentive” is coercion.

It is far from coercion. Enforcement is not practical, neither is grabbing people on the street and giving them a jab. It is unrealistic and unnecessary. But offering financial incentives? Absolutely. For example, if the state disperses a COVID-19 grant, it can condition it on the recipient getting vaccinated, and that would be perfectly justified, because the potential impact of an unvaccinated person surpasses themselves.

A medical worker takes swab samples from an Israeli woman at a mall in Haifa, northern Israel, this week.
rami shllush

Even though vaccinated people can also be contagious.

True, but their incidence of illness is less severe. Theoretically, if the whole world were vaccinated within a month, there would be no more COVID-19. Variants develop because there are populations in which the virus can run rampant. The higher the level of immunity, the lower the chance that the last outbreak would have occurred.

So, the vaccine was not effective?

Without the vaccine, we would have had more than 10,000 cases a day long ago and an unreasonable burden on the health care system, at a greater intensity than before. The vaccine is an important line of defense, but unfortunately it isn’t enough. We hoped it would allow us to get back to normal, and that did not happen.

COVID-19 has outlasted three health ministers and two prime ministers. How do you compare their performance?

I don’t hand out grades to ministers, but I can say that (former Health Minister) Yuli Edelstein did a good job. He inherited a difficult situation and handled it nicely.

And (former Health Minister) Yaakov Litzman?

I’ve talked enough about Litzman, I’m not talking about him.

And the current minister, Nitzan Horowitz?

I wish him success. It is too early to judge this government.

Minister of Education Yifat Shasha-Biton, in June. “Her statement to the effect that vaccinations in schools amounts to a crime may cause damage that will take many years to repair.”
Emil Salman

He says he will try to avoid a lockdown “at any cost” – what do you think about that?

I agree that another lockdown right now would be unbearable, also because it is pointless. But clearly, it’ll happen over and over again.

What should the government do tomorrow morning?

First of all, internalize that there is potential here for a long-term scenario with changing dynamics, and what we see now will be different in the future. We need to understand that there are aspects of our daily routine that need to change – in the realms of education and mass events. One needs to identify where the spread of the disease begins – enclosed spaces with a lot of people – and figure out how to minimize it. We should thus prioritize the school system and perhaps big events in enclosed spaces.

Enabling face-to-face classes for as long as possible should be the highest priority. If the price is that returning travelers have to isolate, then we should do that. Workplaces should maintain hybridity, allowing employees to work from home from time to time.

How long do you think we will live like this?

We cannot rule out the possibility that COVID-19 will be with us forever. Just as the flu entered the disease cycle, it is possible that the coronavirus will also become like a flu; we will retain an immunological memory and have seasonal outbreaks.

What do you think about the decision-making process regarding the third vaccination?

People proposed that epidemiology treatment team and vaccination committee meetings be open to the public. In my opinion, this is not a bad proposal. All meetings should be open and documented, just like when the health basket committee discussions were opened to journalists 10 years ago. It may lead to some people adopting more rigid positions, but they will get used to it. You can start with bringing journalists into the room, though it’s a calculated risk. Let people hear what’s being said. I mean what are we dealing with here – the Iranian nuclear program? But the impression is that the public will be open to a third round of vaccinations.

Would you recommend that your mother get vaccinated?

Nurses play with patients at the Herzog Hospital, a geriatric-psychiatric hospital in Jerusalem, last month.
Ohad Zwigenberg

Certainly, even though it was not easy for me personally after I got the second dose. I quickly developed fever and chills. I was comforted that this means my immune system responded well.

‘Shocking’ nutrition

You are perhaps the person most identified in Israel with the war against unhealthy foods. Do you support the proposed tax on soft drinks?

Bottom line, yes. We have to start with that, because in terms of obesity we have a disaster on our hands. Nutrition in Israel and around the world is shocking, and sugar and its derivatives are responsible for a major part of that. It is a major component of a sedentary lifestyle. But even a war on nutrition is a war involving a combined strategy employing several tools. We’ve started by labelling products, which made an impact, and now the sugar tax.

You said that you eventually supported the sugar tax but it wasn’t what you wanted ideally?

I very much support it, but it’s only fitting – and may still be possible – to amend the tax rules so that revenues from it will be channeled into the health care system. This is the right thing to do fro a moral point of view. It is a just tax, and to make it justified it must provide systemic revenue and not only be fiscal. In addition, I would be happy if the tax was levied separately, like with plastic bags at the supermarket or the deposit on drinking bottles: Don’t add it to the item’s retail price, otherwise there will be a gradual erosion over time.

So the tax needs to be refined. And in the future unhealthy foods should be heavily taxed. One of the things we wanted to do in the food committee, but didn’t know how, was to label ultra-processed food. This is a somewhat elusive definition, but we know such foods cause severe problems in terms of bone growth and development. Even if it contains protein and fat and you add vitamins, it will likely cause significant damage.

Why was it decided to focus on soft drinks?

Prof. Ronit Andwalt, head of the Health Ministry’s nutrition department, explained impressively that these are totally empty calories that are responsible for a significant portion of the added volume of sugar that we consume. And there really is no reason to drink sugary drinks. No reason at all. Sometimes we are hungry and have no time, so grab a sandwich or snack. But when thirsty people can drink water, they should not drink anything else. That’s why I understand the focus on these drinks; they are really a distillation of everything that is unhealthy in our diet.

If so, why tax diet sodas and natural juices as well? You didn’t label them as part of the food-labelling revolution.

Healthcare workers walk pass vending machines at Ben Gurion Airport, this month.
Tomer Appelbaum

My opinion is that one should drink water. It is true that we did not label diet sodas with red warning stickers, because we claimed that they aren’t as harmful as sugary drinks. But I would even ban the sale of some of these things to children. The basis for that would be that we do not have enough sense of urgency.

The thing I regret is that the taxation policy isn’t receiving sufficient attention in terms of public health. The war on unhealthy lifestyles is a difficult one, and the situation is extreme in many countries and has reached catastrophic levels. We are heading in that direction, but there is room to consider more extreme measures.

Like what?

We should ban advertisements for unhealthy foods that are aimed at children. When we initially decided to label unhealthy foods, I was very worried that something bad would happen until the reform came into force, almost two years later. I feared that the decision would be watered down, and also the government changed during this period – but fortunately this did not happen. When it comes to nutrition, I am extreme. I think the situation is extreme and requires extreme measures. We should treat it like cigarettes. One of the problems with food as opposed to cigarettes is that you can’t say “stop eating.”

But you can say: Do not drink Coca-Cola.

Yes, we can say do not drink sugary drinks. Neither Coca-Cola, orange soda and or Tropit beverages. But having said that, the war is bigger than a diet soda tax.

Cokes and other sweet soft drinks. “We aren’t winning the war on obesity and diabetes under normal conditions, and the price to be paid for losing this war is much higher.”
Rich Pedroncelli /AP

If you say “do not drink sugary drinks,” don’t you think we should shut down Coca-Cola tomorrow morning?

No, but we do need to change paradigms with regard to unhealthy foods. I would start by preventing the sale of some of them to children. We are not there yet in terms of the public mood, but we must get there. We haven’t banned the sale of cigarettes and are even going to legalize cannabis, so the context cannot be ignored, but restricting sales of certain items to young people is definitely a step to be considered.

It’s clear that we aren’t winning the war on obesity and diabetes under normal conditions, and the price to be paid for losing this war is much higher and exceeds the health care system by far. It is related to fertility. It is a multidimensional phenomenon in terms of the damage it causes, and sometimes you need to use unconventional tools to deal with such situations.

It took a massive effort to label foods. What has been its effect?

The main effect was reformulation – that is, reduction of sugar, salt, saturated fat and trans-fats from some products so they can be part of a healthier category. If we had applied labels on the day the law was passed, the number of products that would receive the red warning stickers would have been almost twice as high as on the day it went into effect (Jan. 1, 2020). The fact that companies have reformulated and removed harmful ingredients can be attributed to this.

You were the star during that period. What did that do to you?

I’m recovering. I gained weight and then I lost weight. Personally, I am taking my time. I want to do something that is mine, not be an employee.

Start a business? A start-up?

Yes, in the field of health innovation.

Is there already something concrete?

Nothing final, I am working on it and taking my time. I am a big believer in the phrase: “The path is wiser than they who tread it.”

But do you have an idea that will change the world?

By digital means. Health systems come very close to insufficiency on one hand and extreme inefficiency on the other – there is a huge waste in terms of unnecessary procedures. Instead, there is room for a technology-, data- and artificial intelligence-led revolution. That’s the idea.