How has tiny Israel beat out bigger countries on COVID-19 vaccinations, securing a steady stream of vials and inoculating a larger share of its citizenry than any other nation?
Israel paid a premium, locked in an early supply of Pfizer-BioNTech vaccines and struck a unique deal: vaccines for data.
The nation of some 9 million promised Pfizer a swift vaccine rollout, along with data from Israel's centralized trove of medical statistics to study "whether herd immunity is achieved after reaching a certain percentage of vaccination coverage in Israel," according to their agreement.
"We said to Pfizer ... that the moment they give us the vaccine, we'll be able to vaccinate at the speed they've never heard of," Israel's health minister Yuli Edelstein tells NPR.
Israel's small size and technologically advanced public health system offer an attractive model for Pfizer to demonstrate the impact of the vaccine on an entire population. Pfizer has not signed a similar agreement with any other country, company spokesperson Jerica Pitts says.
The vaccines-for-data trade-off has sparked impassioned debate in Israel among data privacy experts, biotech researchers and the country's own medical ethics board, weighing the potential benefits of mining the population for vaccine insights against the potential abuse of millions of personal medical records.
"We need to understand that [Israel's agreement with Pfizer] is going to be one of the, I would say, widest medical experiments on humans at the 21st century," says the Israel Democracy Institute's Tehilla Shwartz Altshuler, a data privacy advocate and a leading voice questioning the Pfizer data deal.
Some Israeli commentators have accused Shwartz Altshuler of seeking to spoil a successful national campaign that the government has branded with the hashtag "VacciNation." She and many other Israeli experts tend to concur that quick access to the vaccine is Israel's most important priority.
Israel is already reporting promising initial results of the vaccination campaign. The Health Ministry said Thursday that out of a group of 715,425 Israelis fully vaccinated, only 317 — 0.04% — got infected with the virus at least one week after their second shot, and 16 were hospitalized with serious symptoms.
Israeli HMOs have reported a decrease in infection rates among those vaccinated with one shot of the Pfizer vaccine, and a drop in the country's serious COVID-19 infections for older age categories a couple of weeks after Israel started its national vaccination drive.
"I think that it's really very special that Israel's been recognized by Pfizer as a country that the whole world can learn from," says Diane Levin-Zamir, director of health education at Israel's largest HMO, Clalit Health Services. "There's good research coming out and we're being very transparent about the data."
Vaccines and politics
Most Israelis are celebrating their record-setting vaccination drive. "To be the first place in the world, it's a good feeling," says Yoni Boigenman, an Israeli getting a first shot of the Pfizer-BioNTech vaccine at Jerusalem's main sports stadium, which has been converted into a hive of needles and nurses 14 hours every day.
Close to a third of the population has received at least one shot of the Pfizer-BioNTech COVID-19 vaccine and about 17% received both shots, far beyond any other country. Israel aims to be the first to vaccinate most of its citizenry against COVID-19 before elections are held March 23.
The vaccine drive is central to Prime Minister Benjamin Netanyahu's reelection campaign. The first Israeli to receive a shot, Netanyahu mounted his syringe in a glass box, the needle angled upward like a rocket ship, with a plaque riffing off the words of U.S. astronaut Neil Armstrong: "One small shot for a man, a giant step for everyone's health."
Israel has waved away human rights groups' assertions that the country is obliged to provide vaccines to Palestinians in the Israeli-occupied West Bank and the Gaza Strip; Israel says the Palestinian Authority holds that responsibility.
Still, Israel has decided to send 5,000 COVID-19 vaccines to Palestinian medical workers in the West Bank, with an initial shipment this week, Defense Minister Benny Gantz's office tells NPR. Palestinian officials signed late deals with vaccine manufacturers and still await shipments to begin vaccinating the public.
Some Israeli medical experts warn that widespread immunity cannot be achieved so long as millions of Palestinians are not vaccinated. Palestinian officials say they do not expect to vaccinate the majority of their population until at least the end of the year.
"It's a gold mine"
Nearly every Israeli citizen and resident belongs to one of four public HMOs, a health care system rooted in the national trade union of Israel's early years. Every Israeli's full medical history – from physician visits to hospitalizations – is accessible to any health provider at the click of a mouse, a repository of digital records going back 30 years.
"It's a gold mine," says Ziv Ofek, who helped launch Israel's public health database, which he asserts is unparalleled by any other country.
Unrelated to the Pfizer study in Israel, Ofek's medical data company, MDClone, is helping assemble a separate Israeli coronavirus patient database, with privacy protections. Israeli researchers are already tapping it for insights, such as findings that suggest a higher likelihood of dying from COVID-19 among those with fatty liver disease.
The data offers potential for vaccine research, too.
"Is there any progression of other diseases? ... Does it impact your hypertension?" Ofek says. "All you need to do is just to be able to load the fact that you've been vaccinated, and then you can run new studies."
The Israeli Health Ministry initially kept the terms of the Pfizer agreement confidential, but on Jan. 17 published part of the English-language contract, dated Jan. 6, to reassure the public about data use. Instead, the fine print has raised further questions.
Israel's medical data experts want to know exactly what Israel is giving Pfizer, and whether the data being studied amounts to a clinical trial without the express consent of the millions of Israelis rushing to get vaccinated.
In interviews, Israeli officials insist they are only giving Pfizer anonymous statistics already provided to the public, such as the number of weekly cases and hospitalizations.
Pfizer said in a statement that it "will not receive any identifiable individual health information. The [Israeli Ministry of Health] will only share aggregated epidemiological data."
But the contract says Israel will give Pfizer unspecified "subgroup analyses and vaccine effectiveness analyses, as agreed by the Parties," leaving open the possibility that more personalized categories of data could be delivered.
"Can you have a real research based on ... statistical numbers? This is not research," Ofek says. Israeli health officials "claim they don't give patient-level data, only statistics. There's a big question whether it's the whole truth, part of the truth or no truth at all."
Privacy and medical data experts say buckets of data scrubbed of patients' personal details can still be traced back to identify people if the sample is small enough, revealing sensitive medical details such as who is HIV-positive. If Israel transfers such private data to Pfizer, there are concerns it could get hacked and disseminated by third parties.
"Your insurance company will know all your medical history. Your employer will know it. The political campaigner who would like to convince you to vote for someone would know everything about your medical history, not to say about people who would like to marry your children," warns Shwartz Altshuler, describing what she calls a small concern.
The contract also allows Pfizer or Israel to "provide input, make factual corrections" and delay publication of their studies of the vaccine's effectiveness, which some Israeli medical data and privacy experts say could allow either party – each with vested commercial and political interests in the vaccine's success – to hide or delay publication of failures. A Pfizer spokesperson did not respond to NPR's query on this matter.
The head of Israel's medical ethics review board, Dr. Eitan Friedman, says the review board has requested further clarification on the agreement. The government has not officially responded to the board's request to review the agreement, he says.
If Pfizer and Israel are studying response to the vaccine by subgroups of Israelis' demographic profiles and medical conditions, it should qualify as a clinical study requiring his board's approval, says Friedman.
"There needs to be total transparency. No one party can override the real data. We need to know the truth," he says.
The data study and fast vaccine rollout have fed some suspicions. Skepticism about the vaccine is prevalent among Palestinian citizens and residents of Israel.
"I heard so many rumors about this. Some say ... they want to see the experience on the people here, if it's a good vaccine or not. That's why I'm a little confused about it," says Nuha Sharif, a Palestinian resident of Jerusalem who nevertheless came to the Jerusalem sports arena to get her shot.
She has Israeli health insurance and received the vaccination for free, unlike Palestinians in the West Bank and Gaza who are still waiting for vaccine manufacturers to deliver vials to the Palestinian territories.
Some Israelis getting shots at the arena say they are not worried about their data.
"If it can help the world to get out of it, I don't care," Noam Ben Dror says. "I don't think it's a big secret, my personal data."
Sami Sockol contributed reporting from Jerusalem.