The first 4 months of Israel’s COVID-19 outbreak witnessed a promising outlook in the Arab ethnic minority,14 with infection rates 3 times lower, and mortality 10 times lower than the Jewish population. Possible explanations include the viral spread initially “imported” via travelers returning from abroad, which did not reach most of the Arab towns and villages during March and April 2020. High compliance with public health measures was seen during the first wave within the Arab minority.
The second wave saw a dramatic change, with a sudden increase in both morbidity and mortality in the Arab population, rising to equal and then surpass numbers in the Jewish population. These steeply rising trends, particularly in the Northern region, were among the factors that contributed to the healthcare system reaching its capacity and suggest that the government did not sufficiently equip this minority group with the resources to deal with the pandemic.16
The high proportion of severely ill and intubated patients in the Arab population, despite the relatively younger mean age, are likely due to an overrepresentation of comorbidities in this group, including more prevalent obesity, diabetes, hypertension and smoking.21 These data from the second wave mirror reports from other countries where ethnic minorities have suffered disproportionately from COVID, for example in the US, where Black patients have been overrepresented in those hospitalized compared to White patients.22
Why would a population group, that displayed surprisingly low infection rates during the first months of the pandemic, demonstrate such a reversal shortly after? Several factors may have contributed to the change in the COVID landscape among the Arab minority between the first and second waves in Israel.
Long-standing socioeconomic inequalities
Most of the Arab population live in ethnically homogenous localities, characterized by less developed physical infrastructures, separate and less well funded educational system, that contributes to lower achievements, higher unemployment and less skilled and lower income jobs; crowded living, frequently in intergenerational composition that may accelerate the infection of the older, more vulnerable population.10 The first wave was characterized by fear of the unknown and high compliance. During the second wave, with far higher incidence of new cases, fear of losing one's job and being unable to provide for one's family might have contributed to lower compliance with social distancing measures - continued working, refusal to close businesses – resulting in high infection rates. This may be even more true in the Arab population, with a high percentage of men employed in manual jobs (45% in construction, manufacturing or agriculture) which do not allow work-from-home conditions.23
It is likely that COVID-19 hits harder and spreads faster where inequalities have weakened the social fabric and capital, and where the economic effects of lockdown measures may be the most severe.24 A recently published comment suggests that COVID-19 is not a pandemic, but rather a syndemic –involving biological and social interactions, where the infection meets non-communicable diseases that cluster in the weakest segments of the population.25
Lack of trust in Arab society
The Arab minority in Israel differs culturally and religiously from the Jewish majority, suffers from stigmatization, and deprivation, resulting in poorer health outcomes. The Statnet Poll (2014) showed a genuine feeling of discrimination among the Arab community: 39% of respondents believe there is discrimination in Israeli institutions, and 53% believe there is only partial equality.26 Trust in governmental institutions is lower than for the general population,27 although trust in the health system was found in a survey to be higher among Arab compared to Jewish respondents.28 An already low level of confidence in the authorities may have been exacerbated by swift changes in policy and the limited resources given to local authorities by government to support them; trust in the system may have hit an all-time low, contributing to low adherence to COVID restrictions. Furthermore, witnessing many ultra-Orthodox Jewish communities continuing religious ceremonies and prayers with large gatherings, might have eroded the trust of the Arab community even further.
Recommendations by a group of behavioral scientists in the UK, for the success of messages to help reduce COVID transmission, included “clear and specific guidance” as a key tenet,29 alongside “stand together” messages which build on group identity and solidarity – particularly important for reaching marginalized groups. Growing debates and fractures in Israeli society eroded its resistance.30,31 The first COVID-19 campaign by the MOH in Arabic was not launched until the end of April and was not entirely culturally adapted.17 Efforts were made to bring the voice of Arab society as early as the first COVID-19 wave to the national COVID situation room. However, Arabs were under-represented among senior decision-makers on the COVID committee, limiting the reach and relevance of the committee’s message.17 The under-representation of Arabs in the Ministry of Health, where decisions are made (3% of the Ministry’s workforce, while Arabs constitute 18% of all healthcare system workers) undermines their health in routine times and even more so during a health crisis.32
Socio-cultural and religious characteristics
Early in the pandemic, during the month of Ramadan, religious leaders conveyed messages to the public to refrain from large gatherings of family and friends and all the mosques, including Al Aqsa - the most holy mosque in the country- were closed with no exceptions. The Arab community indeed refrained from large gatherings during Ramadan and seemed to comply with other public health measures of social distancing, as well.9 At the beginning of August, another important holiday in the Muslim calendar (Eid al-Adha) occurred, where families typically gather in large numbers to celebrate. In contrast to the first wave when religious leaders united in their message to stay home, during Eid al-Adha the mosques, including Al Aqsa mosque, remained open. The Arab religious and political leadership, witnessing that many synagogues were left open while they ordered their community to close all mosques during Ramadan, changed their attitude to a more pragmatic approach.
July and August are typically the most popular time for weddings in the Arab community, where wedding gatherings, which take place over several days, regularly include 1000 guests.33 In Arab culture, weddings are an integral part of community life and an opportunity to honor those who attended one’s own wedding; non–attendance might be interpreted as an insult to the families of the bride and groom. Though official guidelines did not allow such large gatherings, restrictions were not sufficiently enforced and many weddings were allowed to take place in private homes (after wedding halls were closed), with local authorities turning a blind eye. Several mayors were documented participating in such huge, crowded gatherings, where the two meter-rule of social distancing was not maintained and face masks were usually not worn. This documentation of senior officials’ non-compliance created a negative example for the entire community. Many infections occurred at weddings due to lack of social distancing, and non-compliance with face masks.34 In Bukataa, a village of 6658 residents in the Northern region of the country, a large wedding contributed to a tremendous increase of COVID-19 infections, from 2 initial patients before, to 80 confirmed cases diagnosed one week after the weeding. At another wedding in the North of the country, 15 members of staff from a regional hospital were infected. In addition to weddings, birth ceremonies or “aqiqah” that usually take place 3–6 months after birth of a child, with dozens of guests, continued to be held during this period.
Insufficient enforcement
Enforcement of restrictions in the general population, but particularly in Arab towns, has been less than optimal. It has long been argued that the police are less present and less enforce the law in Arab, compared with Jewish localities.35 However, this did not change significantly between the first and second waves. This leads us to consider that changes in behavior stemmed from changes in internal motivation to comply.
Maintenance of health behaviors
It is well researched that short-term behavior changes are easier to make, and harder to maintain in the long-term.36,37 This applies to weight loss, smoking cessation, uptake of physical activity, and can equally apply to the changes required during the pandemic, including social distancing, hygiene and mask-wearing. These health behaviors are generally more prevalent in the Jewish population, with higher rate of smoking and obesity and lower physical activity in the Arab population.38 In the initial phase, adherence to restrictions was higher, with people refraining from gatherings. As time progressed adherence naturally decreased. In the brief respite between the two waves (June 2020), restrictions were gradually removed and behavior could return to almost normal routines. The fact that Israel tackled the first wave with great success (albeit with a huge economic toll) led the public to perceive the threat has been "inflated", creating a sense of omnipotence that might have made people complacent and even indifferent to the pandemic. And indeed, when the low number of new infections was soon followed by the escalation of cases and reintroduction of restrictions, people lulled into a false sense of security by the preemptive celebration may have been less receptive to the renewal of efforts to prevent transmission.
Adherence to social distancing measures faces a myriad of obstacles, both social, practical and motivational, which are even more marked in disadvantaged populations.39 These populations find it less feasible to use digital platforms to work from home, use public transportation more often to travel to work and might be more overwhelmed by economic losses. When struggling to earn a living, most people would take fewer precautions to protect their health. 40–42