What if countries that excel at vaccinations still don’t achieve herd immunity?

In the race to herd immunity, Israel has three things that put it well ahead of other countries: a relatively small population, an ample supply of the Covid-19 vaccine, and a centralized health care system that coordinates the complicated logistics of distribution.

These advantages have put Israel at the top of the world vaccination chart, with over 30 percent of the population of 9.3 million having already received the required two doses. In the United States, by comparison, the number is about 4 percent.

But Israeli officials are finding out that the first stage of the vaccination campaign might be the easy part. They now face the daunting challenge of coaxing vaccine skeptics, younger Israelis, and members of more insular communities—chiefly ultra-Orthodox Jews and some Arab Israelis—to roll up their sleeves and get the shots. Without them, Israel is unlikely to defeat the coronavirus pandemic. The process has already been hampered by what many Israelis perceive as a politicizing of the vaccine campaign by Prime Minister Benjamin Netanyahu.

How Israel fares in this second stage will hold valuable lessons for other countries hoping to achieve herd immunity, a condition that many epidemiologists believe requires at least 70 percent of the population to have either been vaccinated or recovered from the disease. Failure to reach that number in Israel, with all its advantages, would bode ill for the rest of the world.

"Demand is for sure getting slower," said Ido Hadari, head of vaccine promotion and government affairs at Maccabi Healthcare Services, Israel's second-largest health care provider. "It's like getting more than halfway to the top of the mountain: It doesn't mean we aren't going to have to sweat to get to the peak. And we are sweating."

The Israeli rollout began early, driven in part by a doses-for-data agreement with Pfizer that would help the company study the impact of its own vaccine. Netanyahu received the inaugural injection in December 2020.

While the United States has struggled to get shots into arms as the public clamors for injections, Israeli health care providers conducted an orderly distribution. Within two months, the campaign helped ease the stress on hospitals by driving down the total number of patients in critical condition, and it lifted Israel out of its third lockdown. Around 90 percent of Israelis over the age of 60, the main target of the initial phase, have received at least a first dose,

But demand for the shots has dropped sharply in recent weeks. Television news programs have shown clips of empty vaccination centers. Though the vaccine is now available to all citizens over the age of 16, daily injections were down nearly 39 percent on February 13 from the peak in January, according to the Israeli Health Ministry. (Israel has not included most Palestinians in the West Bank and Gaza Strip in its vaccination effort, though it is broadly recognized as the occupying power in these territories, drawing condemnation from rights groups).

"I'm scared to death," said Etti Messika, a 58-year-old hairdresser in Tel Aviv—despite clinical data that shows very few people experience serious side effects. "I got all the vaccinations for my children, but I'm afraid there hasn't been enough time or trials for this vaccine. I'm afraid they approved it just because of the pandemic."

All told, Israel still needs to fully vaccinate another 2.7 million people, or 29 percent of the population. (Just under one-third of Israelis are not currently eligible to get the vaccine because they are too young.)

According to polling, many younger Israelis feel less vulnerable to Covid-19 and are taking a wait-and-see attitude. There also have been lower vaccination rates among Bedouin Arabs and ultra-Orthodox Jews, whom the government has a harder time reaching with public information campaigns. Israelis in rural blue-collar towns have responded in lower numbers as well.

Vaccine hesitancy persists even in some surprising places, including medical staff at some Israeli hospitals. As of February 10, the staff vaccination rate ranged from 43 to 80 percent across major Israeli hospitals.

Channel 13 News conducted a poll this past December that found that one-quarter of Israeli adults would refuse to get vaccinated altogether or wait at least a year, according to chief international affairs correspondent Nadav Eyal, who oversaw the poll. Because Israel has a relatively young population, convincing vaccine skeptics to get the injection is critical to achieving herd immunity.

"If you calculate it, we need about … 75 to 80 percent vaccination level, but we're not going to get it anyway because we have [a large population of] children here," Eyal said. "It's really important that everyone that can will get themselves vaccinated because of that."

With the country embroiled in yet another election campaign these days—Israelis go to the polls March 23—the vaccination process has seeped into politics as well. Netanyahu has made appearances at vaccination centers and taken credit for the supply deal with Pfizer. A chatbot on Netanyahu's Facebook page even encouraged visitors to share information about people who have not yet been vaccinated, prompting the social network to remove the post because it violated its privacy policy.

Netanyahu hopes the vaccines will help reopen Israel's economy, boosting his reelection chances. In an interview this week on Israel's 12 News, he said: "We are going to be the first ones to get out of this. … We are going to be the first in the world because of the millions of vaccines that we brought, and because of a fantastic health system that is distributing them."

But the mixing of politics and the pandemic has helped fuel anti-vaccination conspiracy theories. It has also stoked some resistance to the vaccination campaign among Netanyahu's political opponents on both the left and the right. Eli Avidar, a Knesset member from the ultranationalist Yisrael Beiteinu party and a prominent critic of the government's pandemic policy, declared at a town hall meeting Saturday that he's not getting vaccinated.

"It doesn't suit me. It's my decision. Every person has the liberty to make decisions about their body," he said. "This isn't North Korea."

Nadav Davidovitch, a member of an expert team advising Israel's government on Covid-19 and the head of Ben-Gurion University's school of public health, said vaccines have become a vehicle to attack the government.

"It reflects the tensions within Israeli society—mistrust among minorities and political instability," he said. "Some people think it's a conspiracy because of the involvement of Netanyahu. I think it's crazy, but I can understand."

The misinformation circulates even as data based on Israeli vaccinations demonstrates broad effectiveness. A study of 1.2 million people released Sunday by Israel's largest health care provider, Clalit Health Services, found a 94 percent decline in symptomatic Covid-19 infections and a 92 percent drop in serious illness among Israelis who had both doses of the Pfizer vaccine—a finding that corroborates the company's clinical trials. Scientists at Israel's Weizmann Institute found there's been a 50 percent drop in deaths and a 48 percent drop in seriously ill patients among Israelis over age 60 since mid-January.

Some officials are offering incentives for people to get vaccinated, including a reduction in municipal taxes in one Tel Aviv suburb. In the ultra-Orthodox city Bnei Brak, local officials are distributing meals ahead of the Sabbath to people willing to get the shot. Mobile vaccination sites have been set up near popular nature reserves, in part to target young hikers.

Israel's cabinet on Monday evening approved a "green passport" program restricting entry to gyms, cultural events, swimming pools, and hotels to people with vaccination certificates. Private companies might be allowed to restrict entry to their offices based on such certificates.

But such measures would surely face court challenges in Israel, and it's not clear how they would hold up to scrutiny. Legal and public health officials say governments in Israel and elsewhere will have to strike a balance between individual rights and the overall national interest of defeating the pandemic.

"I'm against compulsion, but on the other hand, you can't just give total freedom of choice," like allowing individuals to smoke in public places, said Davidovitch of Ben-Gurion University's school of public health.

"You can't just look at individual freedoms and forget that someone who isn't vaccinated is also infringing on other people's freedom. So we have to do something that is proportionate. There is no simple answer."

Joshua Mitnick is a journalist based in Tel Aviv. Twitter: @joshmitnick

Disclaimer: This article first appeared on Foreign Policy, and is published by special syndication arrangement