As a neurologist whose patients return to see him year after year, Dr. Robert Brown Jr., of Mayo Clinic, hears about plenty besides strokes and aneurysms. His older patients pull up smartphone photos of grandkids and great-grandkids; his farmer patients talk of rough winters, rainy spells, fluctuations in the price of corn. While investigating memory loss and personality change, he hears about dogs, football games, vacations, and funerals.
But in November, someone he’d met in the clinic sent him a question he wasn’t expecting. The man was in Rockland County, N.Y., a leader in the ultra-Orthodox Jewish community. He was concerned about a measles outbreak there, and was wondering how to address parents’ hesitations about vaccines.
The question is an important one, puzzled over by pediatricians and psychologists alike, and it’s taken on a new urgency in 2019, when the number of confirmed measles cases in the United States — 764, as of last week — is the highest it’s been in 25 years. How that question arrived in Brown’s inbox, it turns out, might just help inform the answer.
When the illness began to spread in the last seven months, it brought tension with it, as contagion often does. About two-thirds of the cases were occurring within outbreaks in New York: one in Brooklyn, the other in Rockland County, both places with substantial ultra-Orthodox Jewish communities. Apparently, measles took off when some travelers returned stateside from Israel, and its spread was aided by an anti-vaccine tract circulating among some religious families. But some in these communities felt that, because of a small minority within their ranks, attention was unfairly focused on the group as a whole.
As Aron Wieder, a Rockland County legislator, put it, “The misrepresentation of the Orthodox community as not being vaccinated — it’s spreading like the measles disease.”
But there was a twist. The characteristics of ultra-Orthodox Jewish communities that might potentially make them vulnerable to the spread of vaccine hesitancy — being tight-knit, distrustful of outside authority — are the same ones that members have used to encourage other families to vaccinate.
An ultra-Orthodox oncology nurse in Brooklyn heard, from her cousin in New Jersey, that some neighbors weren’t vaccinating their kids. So she started texting with parents, refuting misinformation, explaining the science and safety of immunization, and, eventually, lugging reams of research to meetings in homes around the tri-state area.
Rabbis have stated that vaccines are kosher and urged their congregations to protect themselves and their children by getting immunized.
The email that Brown received was a similar effort from within the community — but the interventions that ensued weren’t just meant for families. They were also designed to help doctors.
The request started with none other than Grand Rabbi David Twersky, a spiritual leader — the rebbe — of the Skver Hasidic sect. Descended from a long line of revered religious teachers, Twersky guides his ultra-Orthodox community from New Square, a patch of former farmland 20 minutes west of the Hudson River.
“There are thousands and thousands of people over the years who are going to the rebbe for blessings — or if they have a problem, to ask advice,” explained Victor Ostreicher, a businessman who’d grown up close to the rabbi.
The questions that these visitors ask can be about almost anything. But in October, when the measles outbreak began, more and more of them had to do with vaccines. “Some people were scared,” Ostreicher went on: So-and-so had told them they shouldn’t vaccinate, somebody else told them they should, and some doctor had said something that raised questions in their minds. They wanted to know what the rebbe advised.
“Not that the rebbe had the question if vaccinations should be given,” Ostreicher said. “He was 100% sure.” But Rabbi Twersky thought it might be useful to have a document from some medical authority that he could show visitors, to help convince them that immunizations would not only protect their children, but also that the injections were safe.
Over the years, when congregants came to him with serious health problems, he often recommended that they go to the Mayo Clinic, in Rochester, Minn. And Ostreicher — a founder of Rockland County’s Refuah Health Center, where many members of the community get health care — has often accompanied them as a patient advocate. In the last seven years, he estimates, he’s made the trip around 10 times.
“Mr. Ostreicher is our founder and our board treasurer, he’s also in many businesses, and has an ability to interact with and navigate very difficult things,” explained Chanie Sternberg, president and CEO of Refuah. “Going to Mayo is two sides of one coin: It’s helping the patient understand the system, and helping the doctor understand the patient.”
While volunteering in this way, Ostreicher had encountered a number of practitioners specializing in a bunch of organs, but he’d become especially friendly with Brown. That wasn’t entirely a coincidence. Brown makes a point of getting to know the friends and family who come to his patients’ appointments. He enjoys it, and it can be a useful diagnostic tool; the hangers-on are often best-equipped to tell him about what he calls “those transient symptoms that … may not come across in a 90-minute neurological observation.”
So, when Grand Rabbi Twersky asked for a letter stressing the importance of vaccines, Ostreicher reached out to Brown, who in turn got in touch with his Mayo Clinic colleague, pediatrician and vaccine researcher Dr. Robert Jacobson, who sat down to write. He wrote about the hospitalizations that happen in a quarter of measles cases, about the brain swellings that can occur, about the chances of death. He wrote about how the measles-mumps-rubella shot prevents the disease.
“Here at Mayo Clinic we not only make sure all of our children get this vaccine on a timely basis,” he wrote, “but we make sure all of our medical staff get the vaccine as well.”
Then he pressed send.
The Grand Rabbi wasn’t the only authority in Rockland County who wanted some backup.
The doctors and nurses at Refuah had already been doing everything they could to stop the outbreak. “We’ve been working in lockstep with the Department of Health to offer vaccinations to anyone willing to receive them. We did robocalls, banners, town hall meetings. Word of mouth is a big one,” said Dr. Corinna Manini, the center’s chief medical officer. “We have automated ways for people to call in 24/7 and determine their measles vaccination status.”
But they still had questions about how best to deal with patients hesitant to get vaccines.
They’re hardly the only ones. “Physicians sometimes feel overwhelmed about these vaccine-hesitant parents,” said Eve Dubé, a medical anthropologist who studies vaccine hesitancy at the Québec National Institute of Public Health, in Canada. “They feel their own expertise is being criticized. For physicians to be told, ‘I don’t trust what you’re saying’ — that can be very emotional.”
So, as the Grand Rabbi began circulating Jacobson’s letter, and as the measles outbreak continued, the leaders at Refuah decided to fly the doctor in from Minnesota. “It was important for our providers to hear from someone who had done the research — what works and what doesn’t work,” said Sternberg, the president and CEO.
The training was planned for March 25 — one day before the Rockland County executive declared a month-long state of emergency, in which all unvaccinated children were banned from indoor public spaces such as houses of worship, malls, and schools. So many Refuah practitioners wanted to listen to Jacobson they couldn’t all fit in the conference room, and he had to give his talk twice.
He began the way he would in his own practice: with the presumption that parents will vaccinate their children. “Say, ‘Your child’s due for the MMR vaccine, I’ll have the nurse come in and do it,’ … with the assumption, you came to see me, this is what we do as part of the visit,” he explained in an interview this month. It’s the same thing he does for other routine procedures. “I don’t get into a long discussion about the benefits and risks of a stethoscope exam. I just say, ‘Now I’m going to take a listen to your heart.’”
It was a technique that had worked in a 2013 study, when researchers filmed 111 discussions in which physicians brought up vaccines and found that those who asked parents about vaccines were more likely to face hesitancy than those who assumed the shots would take place.
But there will be some parents who continue to express worry. As tempting as it might be to simply hand them some pamphlets to read, Jacobson explained, this is the moment for the physician to start asking questions. “You step back, and you say, ‘So I understand you don’t want to do the MMR vaccine. Can you tell me why?” he said. “This is really important because clinicians who might just jump into it and start giving advice on the vaccine without knowing what the parent’s concern is may completely miss the boat and have really failed to connect with the parent.”
After all, he said, the parent and the pediatrician are after the same thing: To protect the child. Only once that sense of trust and shared purpose is established — one built on hearing out the parent’s questions and concerns — only then might the practitioner have a chance at changing someone’s mind with evidence and advice. “The clinician’s effectiveness will be in that room and in that relationship of caring one on one,” he said.
It’s hard to say, once Jacobson flew back to Minnesota and the Refuah practitioners dispersed back to their exam rooms, whether his words had a direct effect on the local measles numbers themselves. After all, the training coincided with other public health measures. Last week, the Rockland County executive announced that “19,661 safe and effective MMR vaccinations have been given since the outbreak began; clearly illustrating that the combined outreach and education efforts have had a significant effect.”
Yet there’s long been a fraught relationship between the county administration and the area’s ultra-Orthodox communities. Though the reasons might be different from place to place, similar sentiments are felt in various communities across the U.S. and abroad. As Dubé put it, “We’re in an era of lower trust — in elites, in medical authorities, in experts. … It’s larger than just vaccines.”
In her work as an anthropologist, interviewing mothers of new babies, Dubé has heard it again and again, how beliefs are rooted in relationships, with concerns about vaccines spreading from friend to friend, family member to family member, beloved leader to congregant.
We listen to the people we know. Often, they have more power than statistics in a flyer or advisories on a website. So this long chain in defense of immunization — from rebbe to community leader, community leader to trusted doctor, trusted doctor to expert colleague, expert colleague to practitioners in the rebbe’s own backyard — might be less circuitous than it sounds.
We certainly wont be hiring any Ultra-Orthodox in our company, a measles outbreak could devastate a company and potentially open it up to major lawsuits (like if a child in daycare dies if infected).
Don’t want to vaccinate and prevent decease and protect your children and be a responsible human towards other humans? Affraid of the minimal chance of negative effect? Then be consistent so also don’t take any medication, don’t have surgeries, don’t have blood / plasma transfusions. Zippo. Why even visit a doctor – ever? Those that take care of themselves and the human population will outlast non-vaxxers big-time. The resulting survival of the fittest will prove Darwin right – again.
What a wonderful idea: to have a trusted member of the community explain how vaccines work to protect against measles and its complications.
A beautifully written column.
How many of these Jewish people in Rockland were vaccinated? Not that many less than the rest of the population. How many of the 764 cases were vaccinated? No answer. How many were from MMR viral shedding? No answer. How many deaths? Answer: None How many deaths from the MMR vaccine? Answer: 108 documented. Probably more due to under reporting on VAERS.
How many cases did we have in the 1950’s when I grew up? Hundreds of thousands with the mortality rate falling without a vaccine by 95% by 1963 due to better hygiene and sanitation, improved nutrition, quarantines, etc. Measles was essentially wiped out BEFORE there was an MMR vaccine. THAT was true “herd immunity.” We all have 100% lifetime immunity to it as a result of having it or being exposed to it. The MMR cannot give lifetime immunity and therefore there is no such thing as herd immunity currently. Vitamin A can cure measles.
We have plenty of studies showing the MMR contributes to autism and many other neurodevelopmental problems in children. Don’t believe that? Read the VACCINE INSERT………it’s right there in black and white published by Merck. Read the medical research not paid for by Pharma.
No double blind placebo controlled studies of the MMR proving it works or is safe. No safety studies published in the last 30 years despite the 1986 NIVCA mandating those studies be done EVERY YEAR since then and reported to Congress with deaths due to the vaccine itself and none from the disease.
We also know that having measles and mumps significantly reduces the risk of heart attacks, strokes and several cancers later in life.
Vaccine hesitancy? I would call it vaccine rejection due it being unnecessary, unsafe until proven otherwise and too many benefits from having the disease which was a childhood right of passage in my childhood years.. Ditto Chickenpox and Mumps.
The scare tactics and unnecessary fear mongering are not working. Browbeating and legislative mandates will not work. It is decision to be made by the physician and parents via informed consent. If the parent decides against a vaccine, so be it. That’s why we live in a supposedly “free country” that is becoming less free due financial forces behind the scene creating a false hysteria.
There are reams of studies disproving ANY link or causality between MMR and Autism. And the original study was retracted due to intentional fraud by then-Dr. Andrew Wakefield who lost his license to practice in the process and was only trying to sell his own alternative vaccine. Your scaremongering and science illiteracy places lives at risk.
And, yet…what do you say to my cousin who did vaccinate then days later the shot killed the little sweetheart? His brain was on fire and he couldn’t be saved. Wouldn’t it have been safer to just get the measles like I did? Or was his sacrifice for the “Greater Good” simply a consequence? I ask sincerely because it’s not misinformation to watch a toddler die from the shot. [Posts like this often don’t get approved, or get deleted because of censorship…so one wonders though…if transparency is the answer in medicine and with the wealth of evidence why the suppression?]. Maybe the good will be an educated public if ALL posts are allowed (anti-vaxxers are so few just sheer volume outscreams them).
There have been zero reports of fatalities from this year’s MMR vaccination. Measles is a serious and dangerous childhood illness that is preventable only with vaccination. Please stick with the science and avoid anonymous scare-mongering.
Kudos on this article and especially on this approach to addressing a serious and growing public health issue.
This illustrates the persuasive power of narrative and relationship. Education about the facts and the science is rarely persuasive to a typical human being, but many (most?) physicians and scientists do not understand this basic principle. Most people are not rational critical thinkers.
When people experience competing narratives, they go with their gut feeling and the relationships they have (or don’t) with the people providing the narrative. If one narrative is coming from someone in your community and the the other from an authority or institution, we can clearly see which one is often more compelling.
Excellent article and analysis of big picture on how to enlighten a human to follow thru. I will be brief on my situation so you can maybe pass that technique onto other doctors but for different medical problem-old age. I will be brief but you will get the point. My Mom (Elizabeth Schmidt) was 88 when she had a fall and had cork-screw fracture of left shin-she died 6 months latter. Was at St. Joseph hospital then to South Lyon Michigan for rehab where infection occurs. Back to hospital then different care center in then back to hospital (account infection) then back to another care center (Glacial Hills) in Ann Arbor MI where military doctor lady said your Mom can pull thru this. But the doctor had to go back to military for duties. So infection still there and Mom wants to go to birthday party for her sister-in law in Michigan. So everybody at care center said she is fine and take her there. Mom has emisis (threw up) while in Mushkegeon MI and goes to hospital then to care center there where nurse tells me why is your Mom here. Take her to Grand Rapids but I didn’t here this from me-she was a blessing but my cousin (who is nurse-2 year nurse-and local union nurse at Hackly hospital said we can watch your Mom because my cousin’s Mom was in same care facility. Yep u guessed it not much help from cousin or staff and Mom dies. She I feel gave up on health care process by the way she had Cadillac health care coverage thru Xerox Blue Crops/Blue shield. My take away from this (and to pass on to you) is don’t trust family even if nurse and go to the best facility for parent. I even called your Rochester MN location and Cleveland Clinic I dropped by and both said just get her here but my older brother felt she should have family around her. So my reason for passing this on is: report card at these facilities on how many people die vs are cured while at the facilities. I wish I understood science while in High School but went to business studies. Graduated Eastern Michigan University Dec. 1979 and worked for IBM 13 years then downsized then went to work for Amtrak as Conductor last 27 year’s. I share that to show I am not a dummy but I felt beat by the local care centers-hospital at St. Joseph in Ann Arbor was very good but my feeling is care centers get kick back from insurance companies to take patient down so the insurance company does not have to pay Cadillac benefits. Just a BIGGER picture than what “care” is all about. I truly wish I would have moved my Mom nut Thank you for your nice article Bob Schmidt.
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