Not only did the polio campaign result from Israel’s unique policy of standardized monitoring of sewage for traces of polio viruses [
20], we also argue that both the campaign and the public reaction to it are rooted in Israeli idiosyncrasy. Indeed, public reaction to vaccination cannot be understood without addressing the complex political landscape of Israeli society. And while the local landscape is an important factor when addressing vaccine refusals in every society [
4,
7], the particularities of Israeli society shaped the local patterns of acceptance and refusal on the one hand, and of the campaign methods on the other.
Fostering trust in the system, as in any public health campaigns, became the prime goal of the polio vaccination campaign. Trust is often achieved as a result of a transparent and consistent policy. In this case, the reintroduction of a vaccine that was excluded from routine immunization protocols only a decade ago, required clear answers. However, this move—although clear to policy-makers and public health experts—resulted in suspicion among non-health professionals.
The campaign leaders sought a way of persuading the public to act for the benefit of others and needed therefore to conceptualize these others in a language that would induce compliance. However, the meaning and use of terms such as the “Public” or “Society”, have been constantly changing in the context of rapid process of privatization in healthcare in Israel. In order to cope with growing healthcare expenditures and heightened budget constraints, many countries (including Israel) have adopted various models of public-private partnerships. Privatization of healthcare can be reflected in various ways: modes of financing, service delivery and changing modes of operation adapted more to for-profit schemes [
10]. Privatization of healthcare in Israel did not occur in a void. Starting from a more collectivistic perspective that was prevalent in the 1950s, widespread American influences have eroded “the public” or “society” to the point where political schemes are structured as the dichotomy of the individual vs. the state ([
22]; on the relationship between individualism and privatization in healthcare see also: [
9]). Noting these changes in Israeli society, a public health physician offered his observations on the impact they had in recent decades:
“Something very basic has changed in Israel…. The health system turned from paternalistic to less paternalistic, but specifically in Israel there was a major change in my mind, in people’s commitment to the community, to the state. Solidarity that might have been more focused on the state than on the community in the past, has gone down and now it’s more the issue of “me”, individualism, how does it benefit me. And once that’s the case, everything the state wants from you, you check if it’s worthwhile for you personally. You immediately check everything, everything makes you suspicious”.
Social forces emphasizing individualism as well as a massive push toward the privatization of health services had shaped the public reaction to the campaign. Individual citizens experienced these processes of privatization not just as the state’s disengagement from their health, and the health of their children, but also ultimately as a professional failure on part of the health system. This failure to provide services had eroded the trust between the state and its citizens. The same public health physician explained the context in which these failures occurred:
“I think the real story is how health services for school children were privatized. In recent years the state had privatized these services to bodies who, even though they received more money than the public system would have spent, were unable to perform the tasks, and did much less in terms of health promotion [in school children]…. And now when parents get a letter [about children’s health] from someone, who is a for-profit company being paid by the ministry of health, parents can be suspicious.”
Commenting on the effects of privatization of health services on citizens’ trust in the state, a senior ministry of health public health physician commented:
“The public is skeptic when it comes to the interests of the establishment. With empty slogans, they [the representatives of the state] are putting their hands deeper and deeper into our pockets. Yes, we are the ministry of health, and we see ourselves as the good guys, but the public sees us as part of the establishment. They don’t see us as the good guys. We are seen as just another government office, giving a government order. And people object to that, they are skeptical about that.”
The above quotes reflect the social implications of these shifts to individualism and privatization: even when it comes to one’s health, that was once the responsibility of the state, the individual feels that he or she are no longer receiving the same kind of support from the state. And from that perspective, personal survival becomes the name of the game.
In this state of affairs, self-interest becomes the main orientation of practice. Far from group solidarity, self-interest begets mainly suspicion and mistrust. And while many expressed suspicions regarding the nature and necessity of the vaccination campaign, concerns were negotiated through various mechanisms. Addressing this suspicion, a senior Ministry of Health public health physician explained:
“There were questions (about the OPV vaccine), and it’s a bit weird that there were questions, because until 2005 it was given as routine [immunization] and there were no questions… The (changes in) policy confused people. But more than that, the public is not getting smarter, it’s getting pickier and skeptic… first the establishment is not seen as reliable… and the public is skeptic about the establishment’s agenda”.
Following an explanation of how trust in government ministries and officials, has dwindled due to the sense that the government’s agenda is less reliable, the same senior ministry of health public health physician has said (referring to the vaccination coverage rates known at the time of the interview):
“And yet, at the end a voluntary coverage of over 60% of the children is an indication that the ministry of health’s messages were received as trustworthy… I think it’s a show of trust at the ministry of health”.
Trust in the state and its institutions, or lack thereof, during the campaign was also framed in terms of the broader conversation on privatization processes, especially that of the national healthcare system, and their role in dismantling the sense of social solidarity. In an opinion piece published in the daily newspaper “Haaretz”, Ravit Hecht, one of the newspaper’s columnists, wrote:
“A live vaccine is based on the principle of social responsibility and solidarity…. These values go against the existing socio-economic system…Once the state prefers to pull its hands from the life of the individual—in employment, welfare, education, retirement etc.—it lost control of his life, and following that his trust and willingness to enlist for social projects” [
15]
According to Hecht’s analysis, that was published at the height of the campaign and addressed the concerns over low vaccination adherence by the upper socio-economic classes, low adherence and lack of parents’ trust in the state and the ministry of health should be understood in a broader political context in which solidarity and social responsibility are no longer valued assets. The same state is now working to enlist these sentiments as part of the polio campaign. Summing up her argument on solidarity and social responsibility Hecht concludes: “They (Israelis) learned to count only on themselves. So why is it (the government) messing with their heads now with social responsibility?”
Issues of trust in the State and its institutions were of an even more complex nature when it came to the Bedouin communities that are marginalized by the state and its institutions, and are thus more suspicious of government policies. The initial outbreak was reported within Bedouin communities in the Negev. As a result, polio control efforts were first rolled out within these communities, and only later extended to the rest of the country in the form of a full vaccination campaign. Bedouin communities’ limited access to health services [
13], especially in unrecognized Bedouin villages, and their tense relationship with the Israeli state, made trust an even more important issue during the polio campaign in Bedouin communities. Even outside the context of a government-ran polio vaccination campaign, health services offered by the state raise suspicion among the Bedouin population. A Bedouin nurse working in the south of Israel recounted some of the clashes she experienced in her routine work:
“I often go with the outreach vehicle, in the heat, in the remote areas (gablaot), during Ramadan, and I experience violence. Our drivers experience violence. People say “we don’t want you here, what are you doing here? What do you want? Don’t come here, how many times have we told you not come here.” And then I try to convince them. Sometimes they are convinced, sometimes they aren’t convinced. It depends on who you are talking to, if they are willing to let you in or not.”
The distrust among the Bedouins that is often associated with government sponsored health services extended to the polio campaign. Recounting the events of the polio campaign the same nurse talked about of her interactions with parents:
“Parents came to ask me if this is the disease they are talking about on TV. They asked if the Jews are also being vaccinated, or just the Bedouins… because some people were spreading rumors that they (the government) want to kill Bedouins. They said “really, vaccinating the Jews?” and I said “I vaccinated [Jewish] children, what’s wrong with you? The same vaccine you have here, the same one there, no reason for fear”…. I have their trust, I’ve been there for 13 years”.
In this case, the trust that was necessary for the campaign was not in the state and its institutions, that are not considered trustworthy, but in a nurse who has shown her commitment to the community for more than a decade. In many ways, the campaign proved that even trust is being individualized and in some cases no longer resides in the state, but in specific trustworthy individuals working for it. In these cases, the personal, trustworthy professional, has replaced the trust in the State.
This shift of trust from the State to individual health professionals was also evident in the Israeli Ministry of Health’s strategy of convening all relevant health institutions (e.g. Sick Funds, hospitals) and professional societies (e.g. Pediatrics, Family Physicians, Public Health) in order to convey a unified message. The Ministry sought to gain the trust of the professions so that all health professionals will convey the same message to the public, and not just those working for the ministry of health. Gaining the trust of the health professions first, was also one of the lessons learnt from a previous pandemic influenza campaign. The medical community’s ability to speak in one voice, and thus regain the public’s trust as individual professionals and as a profession (and not merely as the representatives of the State), was seen as an important strength of the campaign. This unity of message was able to harness the media to the campaign, as another pediatrician explained:
“The media was unable to find any leading medical figure to come out against the campaign…. And once they (the media) saw that this is the situation, I think it was easier for them to back the campaign. And as a rule, the media was supportive.”
However, the trust in this case, both the public’s and the media’s, was not primarily in the State and its institutions, but rather in individual physicians and nurses, and in the intimate relationships they had with the public.
The paradox of success—balancing individual risks and collective benefits
In this state of affairs, where suspicion towards state institutions is on the rise and self-interest became much stronger, success in eradicating diseases becomes a challenge for health policy makers. In addition, public cooperation in vaccination and eradication campaigns is hindered by the paradox of success, namely that successful eradication campaigns change the profile of diseases, and thus make them less threatening to the population, and the campaigns to combat them less crucial. A public health physician, who has been working in both the public health sector and academia, explained in an interview:
“We all knew that if there will be a case of polio it would be much easier to vaccinate afterwards. That’s the paradox of motives. If you are able to prevent [a disease] for years, you are able to prevent it now, identify an event very early on before there is actually a case, it is very hard to convince people to get vaccinated…. If you are successful [in eradication] you are shooting yourself in the leg”.
Beyond the paradox of successful eradication, and the difficulties it created, public cooperation was also phrased in terms of the risks of an outbreak versus the risk associated with the vaccine. And while health professionals and the public phrased those risks in different terms, the need to address the balance of risk was prominent among both parents and health professionals. A public health physician, who was involved in the decision to initiate the campaign, addressed this complex problematic perception of risk:
“I think the perception of real risk for me, and maybe even the director of the ministry of health and the minister, did not reach broader circles. I don’t know about physicians and nurses maybe yes, but not the public and that is a very dangerous thing… if we look at the media, there is the perception of relatively high risk associated with the vaccine, which is not justified, and way beyond the real risk…. It means that in a broader sense, people have an exaggerated perception of the risks associated with the vaccine, versus a perception of limited risk associated with the disease.”
Launching a national vaccination campaign under these circumstances of conflicting perceptions of risk and benefit, and with no confirmed cases of polio in the population, required a unique set-up. And yet, while varying perceptions of risk were a major factor, interviewees addressed the sense of urgency that accompanied the vaccination campaign, and many of them described it in terms of a military operation. A mayor of a southern Israeli town that was at the center of the campaign described the atmosphere in his town:
“I used everything [to get the word out], media, text messages, mosques, local media and journalists. The ministry of health published ads and distributed flyers to people… we met with physicians in town and we had like a war, like the military sets up for a new war, a war room and all those things. We had one enemy called polio, so we have to overcome it”.
The war metaphor repeated in many of the interviews, and for some was also part of the explanation for the campaign’s success. A public health physician explained:
“We know how to react well. And so if there’s an “operation” (mivtza), then the public knows how to react…. The public is used to it, the state is used to it, to know how to function during an operation in general, and vaccination campaigns are part of it…. The Israelis are very good at being recruited”.
The war and military recruiting metaphors are also interesting as they bring to the fore an apparent contradiction between the growing individualism and the central role of the military in Israeli society, proving that there are still domains where a more communal perspective reigns in Israeli society (on the changing roles of the military in Israeli society see the work of Yagil Levy [
19]).
While the atmosphere of emergency was prominent in the ministry’s action, and in some community leader’s responses, the call to vaccinate all children under the age of 8 years was not accepted by all. Moreover, the public reaction to the campaign was based on multiple layers of objection, refusal, and active suspicion directed at the state and its policies. Metaphors of military operations, state mechanisms, and duties not only evoke the familiar toolkit of Israeli citizenship as shaped by militarism, but also the rigid dichotomy between the state’s apparatus of coercions, and the citizens who feels threaten by uncertainty and thus foster practices of individual self-interest. In the context of this study, we wish to suggest how far these sentiments were from what was in fact needed from the public.
Furthermore, the military metaphor of public mobilization seems anachronistic in the face of the privatization process prevalent in Israeli society, as the threatening whip of the State loses its power in the era of massive liberalization. As a result, policy makers had to find another strategy to convince the public to cooperate with the goals of the campaign. For the first time in its history of vaccination campaigns, the Ministry of Health consulted a private public relations firm. The result was the campaign: “Two drops and the family is protected”, described below.
The family in the campaign
Faced with the challenge of promoting an environmental vaccination campaign when there were no confirmed cases of polio in the population, and following the policy decision to initiate a campaign that was environmental in its nature, and not directed at the protection of children who were already vaccinated with IPV, the ministry of health had to craft a complex message. Solidarity was not understood as a strong motivator. Accordingly, and drawing from the family-oriented structure of Israeli society, a decision was made to craft a message targeting families. Kaliner et al [
18] explained the decision:
Many parents felt that OPV was a ‘social’ vaccine that builds on herd immunity and compensates for the small percentage of the population that has not received IPV, and felt that administering OPV to their IPV-vaccinated children is merely altruistic. Mindful of that, the message to the public was that the vaccine will protect their family members and close friends and not just the individual or the ‘environment’ or ‘society’ ([
18]
:3).
The narrow focus on one’s family, instead of a broader environmental message, or an altruistic message based on the welfare of a broad group of others, was apparent in the strategy employed by the ministry of health. The tension between a broad environmental message and a narrow focus on one’s family, and the benefit of honing the message towards a family oriented one, were clarified to the medical and public health community, and other professional groups, as the campaign was rolling out. A senior pediatrician who was involved in the design and execution of the campaign explained:
“Environmental vaccine was the wrong term to use here, the right term to use, and ultimately the more emotionally appropriate one, was protecting the
family
, and not the environment. The environment is on the moon, it’s all the people resisting vaccinations, it’s all sorts of people I’m not interested in. In reality, everyone asks himself or herself “whom am I interested in?”. What I’m interested in is my family, the father, the grandfather, the grandmother, the mother—all the adults in the family. Maybe it wasn’t clear in the beginning [of the campaign].”
The shift from a broad environmental message was not accidental, but a thought through decision reached with the help of a public relations firm contracted by the Ministry of Health. Commenting on the choice to use the family as the center of the campaign, one of the leading public health physicians in the county had said:
“We were brainstorming with the PR firm which was behind the copywriting for the campaign, and came up with “2 drops and the family is protected”. This was the message we tried to convey, not the broad environmental message, not solidarity. Maybe 20-30 years ago when social solidarity in the cultural context was greater, this would have been the right thing to say—come get vaccinated like you join the Army. Get vaccinated and protect the homeland. But somehow we didn’t think such a message would work. So we tried to narrow the message, both when I did [media] interviews and the message itself, the focus was on the family.”
The environmental message, turned family oriented, was very straightforward, as the most prominent tagline of the campaign stated: “Only two drops and the family is protected from the danger of polio”. Seen on every publication issued by the ministry of health, as well as on the ministry’s website, the message was clear—the polio campaign protects families—the family unit turned to be the relevant “circle of solidarity”. A senior ministry of health public health physician traced this vigorous family-oriented strategy when addressing campaign messaging in the media:
In the media for example, the ones to deliver the messages were the pediatricians, and not the Ministry of Health staff who were seen as more detached and belonging to the state, and as such affiliated with the government’s guidelines and agendas. Pediatricians are seen as closer to field and maybe more reliable.
According to this public health physician, the decision to use pediatricians instead of public health physicians was intentional due to their relationship with the families in "the field”. And so, while public health physicians might be the specialists when vaccination campaigns are concerned, pediatricians were the ones who have an established relationship with families, and thus were seen as representing families’ interests, instead of the interests of the state.
The Israeli focus on the safety of the family as a motive for vaccination becomes more evident when comparing the Israeli messaging with polio messages in other countries. While the theme of “two drops” is prevalent in polio eradication campaigns worldwide, the addition “and the family is protected from the danger of Polio” is an Israeli twist.
We see in this twist a crucial factor in understanding the tension between individualism and social solidarity. “The family” is an idiom which has its direct meaning in the sense of one’s particular family, but could also be substituted as a metaphor for Israeli society at large, where “soldiers are our children” and where “family” is a synonym for “community”. In fact, scholars have long indicated the central role of family in the sociological and political landscape of Israeli society [
12,
16]. The permissive uses of reproductive technologies and genetic counseling in Israel indicate the central place of raising a family in the life courses of Israelis [
1,
14]. The fact that marital laws in Israel are governed by religious laws indicates an effort to conserve the family as a fundamental unit in the Israeli sociological make-up. Furthermore, just as one cannot escape the family into which he or she is born, one cannot escape his or her religious identity as born to a Jewish mother. The conflation of religious identity, familial belonging and collective status in Israel is perhaps the central determinant of one’s identity. The family, therefore, stands—in Israel social polity—as the key factor in shaping Israeli collective life.
The ministry of health’s emphasis on the family aimed to the very heart of the Israeli sociological imagination. Its slogan introduced two key consensual items: “The Family” and “Protection”. Whereas “Protection” refers to the ever-present sense of threat in Israeli society, “The Family”, we argue here—stands for community. In other words, “The Family” remains a reference unit for society in an era of individualism. In a culture where society loses much of its political meaning, the family is introduced as a partial substitute for a society. Bonds of solidarity within Israeli society could only be tied by presenting it through the prism of the family in contemporary Israeli society. By doing so, the ministry of health sought public compliance, which cannot be reduced to the level of individualistic utilitarian motives.
Ultimately, the campaign achieved a 75% compliance rate. Although we have no actual data indicating that the remaining 25% refusal is due to individualism, we do see the use of the family metaphor as a key element in building a rather wide consensus regarding the importance of the campaign.