There are seven religious minorities in Israel comprising 37.5% of the population. In Israel, the ultra-Orthodox Jewish community, and the Arab population (Muslim and Christian) are the most prominent and well-defined minority groups (20, 21). According to the Israeli Central Bureau of Statistics 2018, there are three population groups: Jews, who constitute 75% of the population; Arab Israelis, who account for 21% of the population, and others, 4% of the population which include non-Arab Christians, Buddhists, Hindus, Samaritans, and Bahá'ís. In 2015, the Arab Israeli population reached 1.8 M and is comprised of 84% Muslims, 8% Druze, and 8% Christians. Bedouins account for 16% of the Muslim population (22). These religious minorities are collectivist, and the identity of the group transcends that of the individual (23). The ultra-Orthodox and Muslim minorities have large families, live in close-knit communities, have death rituals that distinguish them from other marginalized groups, have a complicated relationship with the government and their behavior is guided by their spiritual leaders (24).

Compliance with physical distancing across religious minorities has been shown to be relatively poorer compared to the majority group (23, 25, 26). The Jewish ultra-Orthodox minority comprises 12.6 of the population but 40–60% of all coronavirus patients were Jewish ultra-Orthodox; similarly, the Arab population comprises 21% of the population but 33% of all coronavirus patients were Arab (27). The social representation theory stresses the need to design culturally adapted messages to reflect the shared reality of each marginalized group (28). Throughout COVID-19, however, although risk perception has cultural roots, messages calling for physical distancing were not culturally adapted, leading to poor compliance with guidelines (29, 30).

The COVID-19 pandemic, a public health emergency, affected many countries worldwide and necessitated measures to contain the virus. Like other countries, Israel implemented measures of preservation of hygiene, mandatory mask wearing, and maintaining physical distancing (27, 31, 32). Physical distancing refers to maintaining physical separation to reduce close contact between people (33). Practices of physical distancing included self-isolation, quarantine, preventing assemblies of people in community settings, and closures of schools, gyms, bars, and restaurants (34, 35). Physical distancing remained the primary intervention throughout the five waves of the pandemic (36, 37). Health authorities invested efforts to implement the physical distancing policy by education, persuasion, legislation, incentives, and coercion, which offended members of certain religious minorities (33, 38). These measures to contain the virus prevented communal traditions, including religious practices, death rituals, and funerals (34, 35). Coercion infringed human rights, and lead to higher stress, distress, family conflicts, and loneliness (39).

Although collective religious practices foster connectedness and resilience, there were no platforms to foster spirituality throughout the adversity faced by minorities (40–42). Furthermore, minority members claimed that activities in synagogues and mosques, which are critical for spirituality, for social support of bereaved, for family conflict resolution, for marriages, divorces, funerals, and for individual counseling, were banned under the guidelines, without any discussion with spiritual leaders about safe alternatives that had been applied in previous pandemics (41). Other public places (i.e., parks, bars) were allowed, from the third wave of the pandemic, to open whereas places of worship remained closed, leading to disappointment and anger at health authorities and the disengagement of minority members and their leadership from the fight against COVID-19.

Due to their poor compliance with guidelines, members of religious minorities, who had to cope with linguistic, employment-related, and socioeconomic challenges, became more vulnerable as it was harder for them to understand and apply public health measures (43). Members of religious minorities faced heightened discrimination by the majority group (23). The involvement of the police to enforce the health guidelines created fear and a sense of humiliation (41). Reports in the mass media depicted members of religious minorities as lacking respect for the physical distancing measures and jeopardizing public health (44).

Media reports kept exposing the lack of compliance of the Jewish ultra-Orthodox population with the law mandating hospitalization in public hospitals in cases of severe COVID-19. To avoid having their followers die in solitude, in overflowing, understaffed hospitals, the leadership of the ultra-Orthodox established underground hospitals which were an innovative implementation of patient-centered care in a health crisis (45). Several months later, the health authorities themselves adapted the policy enabling hospitalization in the community of patients with moderate COVID-19.

Moreover, the disempowerment of the religious minority spiritual leaders responsible for the sustainability of their communities during the five waves of the pandemic caused a breach of trust between these communities and the health authorities and inhibited the support of religious leaders for public health measures (41). COVID-19 guidelines inhibited the practice of death rituals and created multi-level clashes between values and beliefs and guidelines, inhibiting effective processing of grief and effective functioning following loss. Muslims, in particular, experienced disenfranchised grief at the individual and community levels, jeopardizing wellbeing and leading to distrust of authorities and policymakers, deeper polarization in the society, lower utilization of health services, poor mental health, and worsening of chronic illnesses (41).

Core activities of public health include community education, outbreak investigation and communicable disease control, risk factor and disease surveillance, screening, development and implementation of public health interventions, evaluation, and research. Since the 1970s, public health has been emphasizing the partnership approach, which aims at community engagement, health promotion, and inter-sectoral partnerships (1). The partnership and collaboration approach throughout COVID-19 in Israel, however, was deficient.

Health authorities and policy makers were perceived by members and leaders of religious minorities as failing to recognize the loss of community; as devaluing the spiritual leaders of religious minorities who are responsible for the continuation of community and excluding them from decision making; as unaware of potential adaptations to religious values and beliefs that were possible in previous pandemics; failing to provide resources to help community members plan for practical needs after death; failing to improve wellbeing and resilience through grief counseling and self-care for elders during this challenging time; failing to create and make accessible communication platforms that alleviate anxiety and process collective loss in order to restore social identity (24, 41, 41, 45, 46). These experiences resulted in distrust, disappointment, and anger at health authorities, rejection of the vaccine, poor compliance with guidelines, ineffective grief, deeper polarization from the majority population, and poor utilization of health services.

Health authorities have a role in promoting the substantive inclusion of marginalized groups in healthcare decision-making (51). Health authorities must be strategic and proactive in reaching out to specific groups, to identify and address their needs, to disseminate transparent and accurate public health information, and shape actionable options to enhance public trust in health authorities and policymakers (49). Actively listening to leaders of religious minorities can facilitate collaborations with the communities which will reduce tensions through the process of reclaiming trust in authorities and policy makers. A collaborative approach may lead to open conversations that elucidate the challenges that religious minorities experience and the effects on equity and public health principles, especially in universal health systems.

There are implications for policy makers and authorities at three levels: Leadership, community levels, and collaborators. At the leadership level, to establish trust of leaders and their communities, in authorities, health authorities must validate the leadership of minorities by approaching it, initiating dialogues, providing transparent empirical data, and understanding disparities in approach and objections. Authorities and policymakers should avoid top-down imposition of solutions using a one-size-fits-all model (55). At the community level, authorities are called upon to understand the sources of objection and distrust and use culturally appropriate channels to communicate. Regarding collaborators, this author proposes to engage clinicians from religious minorities and collaborate with them to initiate community-based efforts to understand their needs, concerns, and possible solutions.

To succeed in promoting inclusiveness, authorities, and policy makers should apply the VOICE model in several steps. First explore their Values regarding inclusiveness in universal health systems. Second, be Open: the knowledge does not lie only with policymakers. Reflect and ask what we learned during COVID-19. Although there is a universal health system that aspires to eliminate inequities, state policies in practice reduced inclusiveness and enhanced perceived and actual inequities between the majority population and religious minorities. Third, Inquire about needs, concerns, objections of minorities. Fourth, Communicate and Collaborate to develop possible culturally adapted alternatives to the policies to preserve public health on the one hand and to respond in a way that includes religious minorities, on the other. Fifth, Explore alternatives over time. Figure 1 presents the VOICE model.

Looking forward, health authorities may intervene to ensure inclusiveness in health services for all members of society. Ensuring inclusive health responses is important in addressing health inequities in the short and long term (56). This author proposes six interventions to foster inclusiveness: (a) Create future inclusiveness through leadership education making sure that the health authority boards that make policy decisions reflect the diversity of the population. (b) Train the next generations of leaders by inclusive communication, public engagement, involved networks, as well as recruiting agents from each minority and setting up advisory groups. With time these measures will help the leaders of religious minorities to gain influence on shaping policies and help reclaim trust in policy makers health authorities. (c) Employ measures to prevent the infringement of civil rights of minorities and assess it as an important measure for health quality (d) Reward practices of inclusiveness to direct conduct toward this goal. (e) Critically appraise practice by evaluating and measuring trust, polarization, and utilization of health services.