“Let’s ask Ben Shapiro to come speak,” the nurse practitioner said. “He’s popular.” “Or we can mention the ten plagues, since Passover is coming up,” offered a pediatrician. They were talking about countering anti-vaccine propaganda among ultra-Orthodox Jews, and they were brainstorming with a hint of desperation.
Trying not to obstruct women in strollers and men on the way from morning prayer, I had made it to this conference room in Borough Park, to collaborate with a group of clinicians discussing the health needs of Chasidim. They had been convened by the New York City Department of Health, who had a crisis on its hands. This crisis is now affecting Baltimore and Maryland.
More people have contracted measles in the past three and a half months than they had in all of 2018; this now constitutes the second-worst outbreak since 2000, when measles had been eliminated. A public health emergency was declared in New York this past Tuesday; more than 260 people have been infected in the Chasidic neighborhood of Williamsburg — the majority of nationwide cases in this spike. (Four measles cases have been confirmed to date in Baltimore, probably attributable to the New York outbreak.)
These facts were known to those in the room that April day. But no one had any perfect solution. So after our brainstorm, we followed the playbook that doctors and public health officials have always used. If “they” (the public) just knew more, they would make the right decisions. If they could be filled with proper facts and reliable information, they would vaccinate their children, for crying out loud. How could they not vaccinate their children?
There is something to this line of thought. Indeed, anti-vax propaganda has been spreading throughout Chasidic communities. Just a few months ago, a high-placed rebbetzin (rabbi’s wife) was recorded telling a rapt audience of hundreds how God didn’t want people to vaccinate. There’s an anonymous group called PEACH circulating brightly colored, cheerily written poppycock which enrages every physician bone in my body. The natural reaction is to wag fingers. Even the statements coming out from the city have the tone of an irritated schoolmarm: do better, behave, and the disease won’t spread. An editorial this week in the Satmar Chasidic organ Der Yid excoriated the anti-vax parents as “senseless and heartless.”
It’s the same playbook used by the health establishment in relating to so many groups, with a consistent record of failure. Chasidim are held to be at fault for not vaccinating just as African Americans are blamed for crack cocaine, poor white people for opioid addiction, and women for chronic pain. It is always easier to blame the patient, or the affected population, than correct the underlying issues. It’s easier to tell people what to do than understand why they won’t do it or why they are suffering, alienated, and mistrustful.
Human behavior is inconveniently complicated. Providing knowledge is not enough to change action. Everyone has biases, scientists no less than others; knowing who to listen to and how to interpret advice is a core human activity, even for people different from us. We have to understand how people make decisions and whom they trust. We know whom many people don’t trust: doctors, government, administrators.
When life is in danger, many argue, the government has the right to coerce compliance with health measures. This underlies measures taken by New York City Mayor Bill de Blasio with his emergency this week, and similar measures taken by the New York State Health Commissioner. Other states, as well, are limiting ways in which parents can plead exemption from vaccination requirements for schoolchildren.
I am sympathetic to these measures, as a parent and a physician. Public health measures often are implemented top-down, not bottom-up. But, by the same token, they are only successful once they become part of the culture, natural, almost automatic, like brushing your teeth or wearing seat belts. As was pointed out this week by health law experts in Wired, government power only goes so far; its legitimacy is not unbounded. Government monopoly on force doesn’t mean its force is always the best approach.
So, it turns out, what those doctors were doing in that Borough Park conference room might have been the right thing after all: empowering Chasidim themselves to right their own errors, making sure Chasidic leaders and activists make decisions for the lasting benefit of their own community. Where mistrust of the system leads to abandonment of good health practices, the system needs to earn back trust, by letting people find their way. Almost as long as there have been doctors, people have objected to their advice. Public health officials need to listen to these objections. There is no persuasion without understanding.
Zackary Berger is an internal medicine physician. He blogs at his self-titled site, Zackary Sholem Berger, and is the author of Talking to Your Doctor: A Patient’s Guide to Communication in the Exam Room and Beyond.
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