A View from the CT Foxhole: Shmuel Shapira, Former Director General, Israel Institute for Biological Research.

• Author: Cruickshank, Paul

Professor Shmuel Shapira, M.D., MPH, served as the Director General of the Israel Institute for Biological Research (IIBR), Israel between 2013 and 2021. He is the founder and head of the Department of Military Medicine of the Hebrew University Faculty of Medicine and IDF Medical Corps. He is also a Senior Research Fellow at the International Institute for Counter-Terrorism (ICT) at Reichman University in Israel.

Professor Shapira previously served as Deputy Director General of the Hadassah Medical Organization and as the Director of the Hebrew University Hadassah School of Public Health. He is a Full Colonel (Res.) in the Israel Defense Forces (IDF) and served as the IDF Head of Trauma Branch. He is an authority on terror, trauma, emergency medicine and military medicine, and instructs medical students, physicians, EMS, medical leaders, and rescue teams on terror medicine, management of mass casualty's events, military medicine, advanced trauma life support, and risk management. He has published more than 110 articles and is the editor of Essentials of Terror Medicine, Best Practice for Medical Management of Terror Incidents and Medical Response to Terror Threats. He is the author of The Pandemic Circus (Yediot Books, Rishon LeZion 2021).

CTC: Between 2013 and 2021, you served as the Director General of the Israel Institute for Biological Research (IIBR), a unit affiliated with the government of Israel that researches all areas of defense against chemical and biological threats, including the operation of national laboratories for detection and identification of such threats. Could you explain the purpose and work of IIBR, and the degree to which the pandemic has changed mindsets about biological threats?

Shapira: Like you said, last year, I finished my term as the head of this very important and unique institute. It's an R&D institute focusing on preparedness for chemical threats and biological threats. It's very unique because it's an academic institute but with very practical objectives. So, you have always to find the right balance.

Obviously, the pandemic was the challenge of a lifetime, and if it had happened after my term, I would have deeply regretted it, though it was very tense, a lot of pressure. It certainly didn't add much to my health and well-being, but it was fascinating. I felt like it was everything that I had been preparing for all my life, because I studied medicine, I had a military career, I was in the Navy. I had a lot of exposure to mass-casualty events and disasters. I've been in delegations abroad. I was in a delegation in Rwanda, which was a real biological disaster. It started with tribal conflict, but then you see how the cover of civilization is thin and will break up if there is disaster. There were really big, bad epidemics of cholera, pneumonia, and meningitis.

And so everything in my career had prepared me for this challenge. Very soon after the start of my term [in 2013], I decided that one of our main focuses should be preparedness for a potential future pandemic. We built generic capabilities to produce a vaccine and built up our diagnosis capabilities. We were prepared as much as we could be for such a surprising event.

CTC: Tell us a bit more about the IIBR specifically and how that organization responded to the pandemic.

Shapira: Like in any good organization, the strength of the IIBR is the people. A very big part of this is the exceptional percent of our people who are PhDs in four different main areas: biologists, chemists, physicists, and mathematicians. Therefore, we're doing really cutting-edge research in the fields that we are interested in. We have many publications in the open literature, in the best scientific literatures like Science and Nature. We give presentations--in the last two years, certainly because of COVID, less often--but we have been giving presentations at international conferences. We very often have guests and good collaborations with peers from the United States; peers from France, from the Louis Pasteur Institute; peers from Germany, from the Robert Koch Institute and the Paul-Ehrlich Institute.

So we have a lot of collaborations, including of course with universities in Israel, and the main thing we do is we develop modes of medical response. First, you study the pathogen, or you study the agent; then you develop preventive measures, you create a protocol for response, a protocol for self-defense, for public defense; and then therapy and vaccination if it's feasible.

CTC: You have this extraordinary concentration of scientific knowledge at IIBR, and you and your colleagues have dedicated your fives to protecting against biological threats. Do you feel there was a big change in mindset--more widely within Israel at the policy-making level, at the government level, at the population level--about biological threats as a result of the pandemic?

Shapira: I think that the pandemic certainly will make a change, but sometimes we in Israel are short-distance runners. We see something, we respond, we panic, we take very extreme measures, but then after a while, especially given the perception the pandemic is subsiding (which I hope will be true), we focus on other obligations, budget obligations, and things like this. I wrote a book whose title, if you translate it to English The Pandemic Circus (2021, Hebrew)," (1) makes clear it is critical of the overall response of Israel to the pandemic. I think there were many good attempts to respond, but there was a failure to mount a consistent joined-up response.

The book draws on the lessons learned from terror medicine, a new field of medicine I helped develop at the international level. More than a decade ago, I jointly edited "Essentials of Terror Medicine" with two American co-authors. (2) Terror medicine is coping with terror in two ways: in the clinical way, but also in an organizational way. If there is another pandemic, I hope people can open the book and try not to reinvent the wheel.

As a matter of fact, I think that the risk of a pandemic is going up. I think that with globalization, with the chopping down of huge forests and everything like this, the intermixing of people and wild animals, the chances of pandemic are increasing. With bacteria that are antibiotic-resistant, with all this, I think it's probable that we will see the next big pandemic before a century will pass.

CTC: What in your view have been the strengths and weaknesses of the Israeli response to the pandemic? And then what for you are the key lessons that should be learned from the pandemic in protecting Israel and other countries against biological threats moving forward?

Shapira: One of the strengths of Israel is that there is a very strong culture of preparedness for emergencies because of its experience with military conflicts and terror attacks. So, there is something in the Israeli culture that lends itself to this, but I don't think that we used this strength enough. I think that we could have done better than we did.

One source of strength when it came to the pandemic is that the management of the hospital and medical system in Israel is top-down. There is an emergency division in the Ministry of Health, and everything goes down from there, and almost all the hospitals in Israel are public hospitals; there are very few private hospitals. And therefore you can enforce the hospital policy, where you can come in and give the hospitals their accreditation. One of the things that is checked is the emergency preparedness and equipment. Among the organizations in Israel that really deserve medals are the sick funds (HMOs), which provide primary and some of the secondary care. In Israel, there is obligatory medical insurance, and it's run by the sick funds, which are a bit like Kaiser Permanente. And all the citizens in Israel are insured by them, and they responded very well during the pandemic to protect the health of the community. So I think that we have a good system here to cope with this kind of challenge. But one of the things that I regret and one of the things that I am critical about in my book is that we didn't use our strength enough. We could have done better with what we have; we have a good basic system.

Another point about Israel--and this is something in the Israeli culture, and I've referred to this already--is that we are short-distance runners. We sprint very well. We run, but then after a while, we lose our interest and focus. In situations like the Six-Day War in Israel, we're the best in the world. We respond in an emergency when we must, and we do it well. But if something lasts longer, it's harder. We are not that persistent.

If we talk about the lessons--and part of the lessons are not unique to COVID; some of the lessons are very generic to other disasters, to floods...