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.