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 lives 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 like with Katrina or to big wars or to an earthquake or stuff like this—I’ll stress the most important one three times: preparedness, preparedness, and preparedness. The most important thing is to prepare. And this also involves being prepared mentally, because that makes it much easier to react in an emergency situation. We at IIBR and I myself personally were able to switch our focus very quickly when the pandemic occurred because we were mentally prepared.
And a very important part of preparedness is to write good SOPs, standard operating procedures. And I don’t think SOPs should be that detailed because some of the challenges are generic. Sometimes you cannot cover everything in SOPs, but you have to have an SOP, for pandemics, for a big war, or maybe for an earthquake. For short events, but not so much for a long-haul pandemic situation, checklists are very important just like they are for airline pilots. Few in Israel have managed more mass-casualty events, mostly terror-related, than me. Even on the 30th or the 40th that I managed, I would always open my wallet, I had a small card with the initial checklist, and I operated by that checklist so that I wouldn’t forget anything important.
Another important part of preparation is drills and exercises. They are very efficient uses of resources. A tabletop drill is not very expensive. Sometimes you try to do a full-scale drill, but one of the things that you should be very cautious about is the lessons that you learn from them. You have to remember that it was a drill, and you can never simulate reality well enough. Let me give you one example. Usually in the drills, there are dummies that simulate the casualties. In reality, the casualty would weigh at least 170, 180 pounds, but the dummy will weigh maybe 20, 30 pounds. Or if the simulation involves intubation use, in the drill you [go], “Ok, I did intubation. Check.” But in real life, not everyone will know how to perform it properly. But still I think drills are very efficient.
Another thing that you should do very often after drills is to draw conclusions that SOPs should be updated from time to time. It wasn’t rare that during an inspection of one of the hospitals in Israel, I would see some 20-year-old phone numbers with their five or six digits, and certainly they were not up-to-date digits. Phone numbers change. Medicine changes. Preparedness changes. You have to update.
Another important thing is to have certain stockpiles. You can never stockpile everything, but there should be some minimal generic stockpiles of antibiotics, vaccines if you have them, personal protective equipment, ventilators, just things to begin with. This is very relevant to the COVID pandemic because we all saw the interruptions in the supply chain. So you cannot always trust that things will come in via ship or airplane.
Another thing that is important—and this didn’t work well in Israel because of fluctuations in which ministry was taking the lead—the chain of command should be very clear. Just like in a terror event, the chain of command should be very clear during a pandemic.
Perhaps the most important lesson specific to the pandemic—was the issue of media communication and transparency. Of course today, this also involves social media as well as TV and newspapers. What would have been massively helpful is for a skilled and popular official to have appeared on the 8:00 o’clock news in the morning, 8:00 PM at night, and for people to have known that this was the formal message of the government of Israel or the United States or any other country. Then in between, other people could have said whatever they wanted, but it would have been clear that this was the official message. And this was missing, and I think that not just in Israel but in many other countries, you saw declining trust during this period. There was a dynamic where one official appeared and then other officials appeared soon after to say much the same thing, and those in the media of course had to fill up the time in between. So they brought medical analysts on, and some people talked a lot about things that they didn’t understand and didn’t know. You’d find a cardiologist talking about immunology; you’d find rehabilitation people talk about an area outside their expertise, and sometimes political reporters started to compare vaccines. I don’t think it was managed well.
Another thing that is crucial in any such event—and I think it should be done more than once, especially in a public health emergency that has lasted now more than two years—is the debriefing or what in the United States is called the ‘after action review.’ I think the debriefing is very important. So if it’s a terror attack, you do the debriefing as soon as possible after the terror attack, and you should do it quickly because cognitive processes tend to change reality, not because you want to lie, but because you perceive the reality as you think it should have been and not like it really was. You say, “I put the chest drain in in two minutes,” and if someone was recording, it turns out you did it in 10 minutes. So certainly with a terror attack, you did a debriefing very quickly, as soon as you possibly can with the most relevant participants.
In a case like this [the pandemic], I think there should be periodical debriefing. I don’t think it should be scheduled by calendar or anything like this, but after a major decision, after the first lock-down, after the first round of vaccination, there should be debriefings. And I don’t think there was a very organized effort to do debriefings. People learned lessons, but I feel not enough.
One vital lesson learned, which I refer to in my book, is that Israel—and this also applies for the United States—must create its own vaccine manufacture capabilities. I think that the capability to manufacture vaccines is a strategic capability. It’s like the ability to bake bread, to manufacture ammunition, and things like this. I think this is strategic. You cannot depend on other people. I think that Israel has to have a formal capacity to plan and manufacture vaccines for future events. And then on a daily basis, it can manufacture routine vaccines like for flu or for hepatitis or things like this.
CTC: You played a central role in the original development of Israel’s BriLife COVID-19 vaccine. Could you describe the efforts to develop this vaccine and the lessons learned for developing medical countermeasures for future pandemics? Can you explain the promise that this vaccine and the technology behind it holds, including as a booster, for inoculations in the developing world and for potential future pandemics?
Shapira: How it all started was very strange. It was Saturday night. I was watching a movie at the cinema, and then I saw that I had five phone calls from an unknown number. My phone was silent but still it was vibrating. On the fifth call, I thought, I don’t know, maybe a war started or something like this. I went out to take the call, and they invited me the next day—February 2, 2020—to join the Prime Minister to present the option for manufacturing vaccines or therapeutic antibodies.
Before the meeting, I sat with a group of scientists to discuss the best approach. There are a few approaches for developing vaccines. There is one that today sounds very natural, but it’s certainly not natural: the messenger RNA vaccine like by Pfizer or Moderna. This is one approach. Then there is the approach of a protein-based vaccine, and that’s another good and relatively modern approach. And there is the traditional approach by attenuated or by dead viruses. So these were the options. We hesitated. We hesitated for a few hours, and we made a decision to pursue two main options. One of those was to pursue a protein-based vaccine. We thought the messenger RNA vaccine was too modern, and while we thought it might be the future, we thought it was too risky.
The second option we decided to pursue would later become known as the BriLife vaccine. It’s a vaccine based on a virus platform that affects only animals, the VSV [vesicular stomatitis virus]. This method was used to develop a vaccine against Ebola.a We chose this way because when we started, there had been a history of about 300,000 people vaccinated against Ebola with this vaccine in the preceding three years —so we thought it held promise. And what we did is that we took the VSV virus, which is the animal virus, and with some genetic engineering, we shaped it. The VSV has its own spike, and on this virus, we transplanted the spikes of the SARS-CoV-2, which is the virus that causes COVID-19. And this is the vaccine. We tested it on four animal models. It was also a challenge to get hamsters, and we thought that hamsters would be a good model. We evaluated it on mice, and also on what is called transgenic mice, that is mice with the relevant genes of people, and you can see the real disease in [such] mice, because otherwise mice are not affected that much by COVID. Then we tested it on rabbits and bigger animals. We did it on swine.
So we evaluated it. We saw that it’s effective. We saw that it’s safe. And we were ready by the beginning of July 2020. The scientists were very rapid. The bureaucracy was slow. And we were affected a lot by bureaucracy, and this really delayed us. We have only started phase three trials. We could have been ready much earlier. And I think it’s a shame. I think it’s a very good vaccine. We evaluated on all variants, including Omicron, and we saw that it’s more effective than the others against the variants. It’s less effective against the original virus, but it’s more effective for the variants than the competitors. At the very least, I think that it should be a perfect candidate for boosters because I think mixing and matching different types of vaccines is a wise idea when it comes to boosting.
I should emphasize that our budget was [small], if you compare it to the mega pharmaceutical companies in terms of budget and number of people, with our core relevant team comprising about 80 scientists. And our budget was a little less than $60 million. And if you look at the mega companies, there were 3,000 people working on the vaccines and the budget was about $3 trillion. So it’s a huge difference. So I still feel that it’s a huge scientific and R&D achievement, which I’m very proud of. I perceive myself as the father of this vaccine, and I think it’s very important capability. First of all, I think it will be used. And even if it will never be used, it’s very important that we went through the whole process so it will be easier and faster next time. I don’t think it was a waste of resources.
CTC: There’s this attribute with this particular BriLife vaccine “in which the spike protein of the vaccine appears to evolve in a manner consistent with the evolution of the SARS-CoV-2 virus in nature.”3 Can you explain that further?
Shapira: The messenger RNA vaccines are like a still picture of what happened in January 2020. They were based on a sequence—for example, with Pfizer—it was based on the sequence from January 12, 2020. Because our vaccine is based on a live virus, it is more dynamic. So the live virus can change, it can mutate itself, and it can make the approach to receptors in the body better than just a synthetic reprint of an old-fashioned virus. Therefore, I think that our vaccine is more effective to the virus than the original one, the messenger RNA one. The messenger RNA vaccines are less effective against variants like Omicron in which there are so many mutations from the wild form that it’s almost a different virus. Because ours is live, and it adapts better.
CTC: The BriLife [COVID-19] vaccine was originally licensed to NRx Pharmaceuticals and as you have noted was in clinical trials.4 After NRx made a commercial decision to no longer pursue the project, in April 2022, the Israeli defense ministry stated that IIBR was examining other alternatives to develop and commercialize the vaccine.5 What is your perspective on what the pathway forward for this vaccine should and could be?
Shapira: I finished my contract at the IIBR in June 2021, so I am not updated with the commercial decisions, but I know that it will be a great waste not to make this scientific achievement available for human care.
I’d like to mention one aspect of our efforts, which was very frustrating to me. We were the first in the world to produce the best therapeutic antibodies for the virus—monoclonal antibodies. To explain the concept, I always give a military comparison. Polyclonal is like a bomb, and there is a lot of collateral damage. If it’s monoclonal, it’s like a targeted missile.
Here is the frustrating bit: While in Israel we are capable of producing 15 million units of the vaccine for the citizens of Israel and the Palestinian Authority, there are no capabilities in Israel to manufacture antibodies under GMP, good manufacturing practice. And there are very few places in the world we can do it. We were negotiating with two places; then we were pressed to choose one of them, and then it didn’t advance and it remained just an academic achievement.
Besides these efforts, we worked on evaluating mask protections, we created models for the spread of the virus, we were among the earliest places that could do proper PCR for this [virus] in Israel, and we evaluated antigen kits.
CTC: In CTC Sentinel, we think about threats and all the manifestations of those—via state actors, non-state actors. To that end, this question is about synthetic biology, which has increasingly come to the fore in national security conversations. For our readers, can you briefly describe what synthetic biology is, and outline the benefits and risks associated with its use? How has, if at all, COVID altered your perspective on the application of synthetic biology? Secondly, how would you describe the risk of a non-state actor using synthetic biology or other advanced scientific tools for malintent, and how likely or unlikely is that kind of a scenario?
Shapira: I think that synthetic biology provides mostly promises and opportunities. The definition of synthetic biology is a little bit vague because there is genetic engineering and there is synthetic biology and there is overlap between the two. Usually they say that ‘genetic engineering is doing more of the same and synthetic biology is doing new things.’
So I will talk first of all about the promises. I think that synthetic biology holds promises for medicine: better tailor-made medicine, manufacturing organs for transplant, enhancing genetic therapy, and we see things today in agriculture—for example, substitutes for meat, many of them are based on methods of synthetic biology. There are promises in manufacturing: less persistent types of polymers, plastics, all these kind of things. You can manufacture substitutes for fuels. There are uses in computers, the memory of computers. Because DNA is a type of code, it’s a four-letter code, it holds promise for storing an enormous amount of information. They say that in one spoonful of DNA, you can store all the knowledge acquired in the world in one year. And it’s much more long-lasting than CDs and flash drives. You can still find the DNA of very ancient creatures. So it’s mostly promises. But like with every other promise, there are also dangers. It’s a double-edged sword. And for each good utility, you can describe others. It’s something that you have to keep in mind. You have to try to do the good and try to avoid the bad.
I’m really not aware of the source of COVID; I really don’t know what it is, but I think that one of the lessons dealing with such a dangerous microorganism is the need for responsible science. And with responsible science, I’m talking about two things: first of all, to have safe facilities, safe laboratories; to have a very well-trained staff, to do periodical obligatory training for your staff and to evaluate them. And the second thing is responsible publication. This is very hard because with all the sciences, it’s ‘publish or perish.’ You want to publish and want to publish in good journals, but some of the publications and some of the experimentations are dangerous. There was a famous case a few years ago about how someone was able to create an old pox from the past that he purchased through the internet.b This is one example. Another example is that people played with the avian flu. Avian flu is a very frightening disease, but one of the good things about avian flu is that it’s not that contagious between people. There were two articles by researchers outlining how they made this flu contagious in two ways: one through genetic engineering and one through another form.c So one of the things that is important is responsible science.
Another issue of concern is do-it-yourself biology or backyard biology, also known as bio hacking: Things that could only have been done 10-12 years ago in the leading academic centers, you can now do in your garage; the equipment got much cheaper, much more efficient. The disposables and reagents, et cetera are very easy to get. It does not require huge knowledge. You don’t have to be a super scientist.
All these things are very difficult to regulate in a democratic society. And I know that some of the leading journals create some review committees, but they very rarely stop publication. They might postpone the publication two to three months, but then at the end, they almost always publish.
CTC: When we’re thinking about preparedness for the next pandemic, having the ability to quickly develop vaccines is going to be a huge part of it. It took about a year from the COVID-19 outbreak for vaccines against the virus to be approved and deployed. And although a vaccine has never been rolled out at such speed, many died around the world before they could get a shot. In March 2022, Moderna announced it was planning to begin human trials for vaccines against 15 threatening viruses and other pathogens by 2025, to speed up vaccination timelines in case of future pandemics. It was reported that “the new effort aims to complete preliminary dose and safety testing for vaccines against numerous threatening viruses preemptively. That way, if [any] of these viruses or a close relative causes a major epidemic, Moderna will have a prototype vaccine on hand and might be able to begin large human efficacy trials very quickly.”6 Given the need to prepare for the next pandemic, which could be natural, accidental, or deliberate in origin, how important are efforts to speed up vaccine deployment, and what role should governments play in encouraging them?
Shapira: First of all, I think that you should remember the quote ‘the biggest bio terrorist is Mother Nature.’ So this is something that we have to be ready for. There are millions of viruses, though not all of them are dangerous to people.
All I know about the Moderna vaccine initiative [to develop vaccines to protect against potential future pandemics] is the same information in the press that you just quoted. I think that it will be very difficult to focus on all viruses. One thing that is needed is international collaboration to try to make progress on this front. Even for a superpower like the United States, it will be difficult to do it by yourself. But I think that rather than developing vaccines against specific viruses, the target should be to have some more generic protection: a vaccine that will enhance your immune system to cope against viruses—not to let them go into the cell, not to let them replicate, or even not to let them penetrate through the mucosa of the upper airways or the bronchi or things like this. I think this should be the direction.
Another thing that people tend to forget—and I think it’s very important, and it’s related to the need to develop vaccines that offer more generic protection—we are advancing very quickly to a world without antibiotics. I’m named after my grandfather who I didn’t know who died in around his 40s from pneumonia. And I think that we are in danger of getting back to this period again, that people will go to hospital for some minor surgery and they will die of these types of infections.
So, I think to try to chase every bacterium and every virus is futile. You cannot chase them, so we should find more generic protection, something that will enhance the immune system, something that will block the penetration of bacteria. I’m not talking about basic, obvious things like washing your hands and things like this, that goes without saying. But if I had more resources and was younger, I would aim to develop some generic protection against viruses such as SARS-CoV-2 and H1N1.
The agility of response is going to be crucial moving forward. I think that COVID-19 taught us that things can be done quickly. U.S. and British regulators switched quickly to a mode of emergency and made shortcuts when they felt that the shortcuts weren’t endangering. So I think this is one of the things that should be done: You should understand where you can have a shortcut and cut the bureaucracy. But we need to be more ambitious than that. My vision for the future is a laboratory like an IIBR, NIH, or CDC that will confirm that a new vaccine works against a virus, and then will email the information to physicians, who’ll have a printer with the bases, print it, and give it to their patients, and that’s it.
To return to a previous point, I’m really concerned about where we are with antibiotics; we are very close to a very dangerous situation. There are very many bacterial-resistant infections in hospitals. And it’s a major problem, certainly in the Western world. Diseases that we thought that we would never see again—for example, tuberculosis—we see them again and they are much more resistant. And so I think we need to develop more general protection than antibiotics and vaccines currently offer. The need is to develop what in essence is biological protection gear for the body against biological threats.
CTC: Can you talk a little bit more about the concerns about antibiotic-resistant bacteria?
Shapira: So far, we have talked mostly about a pandemic by viruses, but the Black Death plague was much more disastrous and was caused by bacteria. So pandemics can also be caused by bacteria.
One big problem is that the development of antibiotics is very minimal because it’s not economical, even for the big pharmaceuticals. If you develop another fourth or fifth generation of cephalosporin, for example, which is one type of antibiotic, it’ll be a very short-term achievement because the bacteria are much faster at adapting and in one year, two years, most of the relevant bacteria will be resistant to it.
The other thing is let’s say that you develop at great expense and difficulty some ‘super gun’ antibiotic that is very, very strong. In that situation, physicians, if they act correctly, will put it on the shelf and use it only rarely when they have no other choice. But that creates no revenue stream to offset the expense for pharmaceutical companies. So it’s not economical for the companies. So we’re in some vicious circle that is very hard to break.
That’s why I think that we have to think outside the box. One of the ways, and it’s very developed especially in the country of Georgia, is phage therapy. Phages are viruses that destroy bacteria. Their capabilities are very, very high. There have been two cases in which they treat very resistant infections. So I think that we should really think outside of the box because we have almost consumed everything that is in the box. We have to think out of the box to find solutions that will last for 50 years, and not for [just] two years. Meanwhile, we shouldn’t neglect all the regular things: developing, improving and using antibiotics, vaccinations, and so on. But we should try to be more creative, too.
CTC: On the antibiotic-resistant bacteria front, what you’re saying is that the stakes for the planet are as high as for pandemics caused by viruses. That if things go wrong, this could create as disastrous a situation as a COVID-19 pandemic, unless the global community can get ahead of the game when it comes to this problem of antibiotic-resistant bacteria, correct?
Shapira: I think so. And it should be a non-political issue because all our interests are the same. You saw with COVID that it crossed borders like a fire. It started in China, and it very quickly was all over [the world]. Nobody managed to block it. All the attempts to do so failed, including even in New Zealand where they managed well for a while. Israel managed to delay the virus for two months, but afterwards, it flourished all over.
So I think there needs to be international cooperation in protecting against the full spectrum of biological threats, and I’m talking first of all about an intelligence attempt. I’m not talking about military intelligence. I’m talking about scientific intelligence to try to follow up on viruses, to see how they develop, how they mutate, to see where some viruses start to cross the borders between animals and human beings. It’s not a coincidence that all the Ebola outbreaks started in places in the middle of the jungle, when you cut trees, people are interfering with the animals, interfering with their environments. And this is the thing with globalization. Globalization is good, but it’s also a curse. You go in the airplane, and that’s it. You’re exposed. One hour, you’re in the New York and then 10-11 hours later, you’re in Tel Aviv Airport and you bring the infection.
The other thing to stress is that the costs created by the current pandemic are enormous,d with one economist likening it to the cost of buying everything in Manhattan 10 times over.
CTC: So, the message is that the world needs to invest big time in protecting against biological threats. And that investment will pale in comparison to what the costs might be of things going wrong.
Shapira: I think it would be a very cheap insurance policy compared to what we spent in the last two years.
CTC: You are a leading authority on terror medicine, the management of mass-casualty events, military medicine, advanced trauma life support, and risk management. In the case of treating victims of a potential future biological terrorist attack, what precepts need to guide authorities’ emergency response? How well prepared is Israel to provide this treatment in the case of such attacks, and what can other countries learn from Israeli capacity-building in this area? It has long been feared that chemical and biological attacks could produce an even greater psychological impact than the immediate loss of life. To avert panic, what needs to guide the communication strategy by authorities?
Shapira: I think that the main issue in any extreme event is as soon as possible to figure out how to best meet your needs given your available resources. This is the most important thing, and this is the way that prime ministers, chiefs of staff, people should think, ‘what are the needs?’ And the needs are mostly dictated by the number of casualties in an event. But there are also other details: economic considerations, the need to continue children’s education, the well-being of the population. The other thing is what resources you have. Certainly in certain extreme cases, you have to be ready to do triage. Not everyone can get the optimal treatment. You have to, yourself as a manager or as a leader, be ready to cope with such imbedded ethical issues.
Fortunately during this pandemic, as far as I know, it was only in Italy and for a short period that there was a real need for triage to decide who will be ventilated or will not be ventilated. But I think that the better you are prepared for it, the less extreme ethical conflicts you will live through when you experience the event and the shorter the chaotic phase will be.
In each major disaster or major event, there is a sense of fear, and this has also been the case with the pandemic because you cannot see the virus. You sit in the plane and someone next to you takes off their mask, and he could give you the virus. You don’t see the threat. You don’t know if you touch the elevator button, if you’re getting contaminated. So I think the most important lesson is transparency to the public, and in future pandemics to tell them as soon as possible and as clearly as possible things like whether or not surfaces are contagious and different types of mask are effective, even if it is not pleasant to hear. You need to feel like people are talking to you in a way you can understand. And while experts may differ, there needs to be a clear official line from the likes of a Dr. Anthony Fauci. We saw with the first Gulf War when Israel was attacked from missiles from Iraq, the military spokesperson was talking once, twice, three times a day, and everybody really remembers it was a good model.
So, there is a need to educate the public about the threat. Knowledge is important. But so too is providing the public with active things they can do: get vaccinated, putting on masks, wash hands. I think these things decrease the fears.
CTC: Our aim in publishing this two-part series of special issues on the biological threat is to underline that biosecurity is a major national security concern. What is the big picture message that you want to get across to leaders and policymakers reading this?
Shapira: First of all, I think that as a leader—a civilian leader, a military leader—you have a responsibility to know about certain things, even if you’re not a biologist. You have to understand the main concept. I doubt that our major leaders are able to write a short chapter on what a pandemic is: What do you do in the first few days, first two or three weeks of a pandemic? Our leaders and politicians are expected to have knowledge about other subjects, for example the economy. Biological threats should be one of those things.
To wrap up the conversation, I would offer some initials: PPRR. The first P is prevention. The most important thing is prevention. Prevention is periodic vaccination, prevention is responsible science, prevention is knowledge, prevention is washing your hands, prevention is not giving antibiotics when they are not necessary. If you take antibiotics, finish the course of the antibiotics. This is prevention. The second P is preparedness. Be prepared.
Then the first R is response. If you are prepared and you have the knowledge, respond in the best way that you can. You can never be perfect. There will be always a short period of chaos but try to shorten this chaos; try to communicate. And the other part that I hope will be happening very soon is recovery. The world really underwent a major trauma. I’ve seen a few wars in Israel and many terror attacks, but this is a very traumatic incident for everyone. And I think recovery is necessary now. And part of recovery is also, God forbid, think of the next incident. There is a saying in Hebrew—I cannot translate it, but I’ll try to explain it—Shabbat is Saturday, so they say whoever works on the eve of Shabbat will rest on Shabbat. So if you prepare well, it will pay dividends. Preparedness is key. Don’t think it won’t happen. Look at it as if tomorrow, God forbid, an earthquake can happen and be ready for it. Don’t think ‘it won’t happen in my term.’ In your term, it’s your responsibility. CTC
[a] Editor’s Note: “The rVSV-ZEBOV vaccine uses a genetically engineered version of vesicular stomatitis virus (VSV), an animal virus that primarily affects cattle, to carry an Ebola virus gene insert. Experts at the Public Health Agency of Canada originally developed the vaccine, which is now licensed to Merck.” “Ebola Vaccines,” National Institute of Allergy and Infectious Diseases, last reviewed January 9, 2020.
[b] Editor’s Note: “In 2018, scientists announced they had created horsepox, a close cousin of smallpox, from chemically synthesized DNA fragments. This research highlighted some of the dangers of synthetic biology.” Filippa Lentzos, Gregory D. Koblentz, and Joseph Rodgers, “The Urgent Need for an Overhaul of Global Biorisk Management,” CTC Sentinel 15:4 (2022).
[c] Editor’s Note: “In 2011, scientists manipulated the bird flu virus to enable it to transmit between mammals, including humans. Before then, the virus had only been transmitted from birds to humans, with a fatality rate of 30-60 percent.” Ibid.
[d] Editor’s Note: The International Monetary Fund (IMF) expects the COVID-19 pandemic will cost the global economy more than $12.5 trillion through 2024. “IMF sees cost of COVID pandemic rising beyond $12.5 trillion estimate,” Reuters, January 20, 2022.
 Editor’s Note: Shmuel Shapira, Pandemic Circus (Tel Aviv: Yediot Books, Rishon LeZion, 2021).
 Editor’s Note: Shmuel C. Shapira, Jeffrey S. Hammond, and Leonard A. Cole (editors), Essentials of Terror Medicine (2009).
 Israeli Defence Ministry statement, as reported by Haaretz, April 19, 2022.