How to fight polio with cultural sensitivity

(Editorial Observer)

Polio has reemerged in New York. The virus was identified in late July in an unvaccinated Rockland County man and has since been detected in wastewater samples in at least two counties. It is too early to tell whether a limited outbreak — or worse, a full-blown epidemic — is brewing, but experts have been concerned about the virus spreading in communities with low vaccination rates. The man who tested positive is part of an Orthodox Jewish community in which vaccine hesitancy tends to run high. Only 60% of Rockland County 2-year-olds have been fully vaccinated against polio, compared with 80% in most of the rest of the state.

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Unless health officials get those percentages up quickly, a virus that has been all but eradicated may become entrenched. That would be heartbreaking, but it would not come as a surprise. Measles descended on the same communities in 2019, COVID-19 ravaged them disproportionately in 2020, and before either of those, mumps and whooping cough were known to pop up at regular intervals. The increasing regularity of these crises has begun to make them feel inevitable: The vaccines are there. The people don’t want them. What are officials supposed to do?

A large, rigorous vaccination campaign feels like an especially tall order now, with public health agencies tapped from the COVID pandemic and even the most receptive groups weary of public health messaging. But in the long shadow of frustration and neglect, an unsung collective has been gathering strength: advocates and health workers from Orthodox Jewish communities. “The last few years have been very intense,” said Nesha Abramson, outreach director at Community Counter, a nonprofit focused on public health advocacy in Orthodox communities. (Abramson is Haredi and lives in Crown Heights in Brooklyn.) “But we’ve learned a ton about what works and what doesn’t.” Here’s what she and others like her want health officials to know.

Cultural sensitivity is crucial; shame and stigma don’t work. Orthodox Jewish communities are hardly monolithic. Some are ultra conservative. Others use the internet. They are ethnically diverse, too, and in some cases just as politically divided as the rest of the country. Such nuances have a way of getting lost during public health crises, though. And that is a missed opportunity: One of the best avenues for addressing vaccine hesitancy in a given community is through pro-vaccine people who already live in the community. “Haredi communities have a high proportion of moms with graduate degrees,” Abramson said “They believe in science and already do so much outreach on their own. But there’s no broader effort to support them.”

What most Orthodox communities have in common is the intergenerational trauma that comes with long histories of displacement and oppression. “Look at the pandemic through that lens,” Abramson said. “You have a lot of grandparents that are Holocaust survivors, and this affirms all of their worst fears. They lost multiple family members in rapid succession, they weren’t allowed to say goodbye, and the details of what happened weren’t necessarily explained to them.”

Amid their grief and bewilderment, they were also harassed and vilified. “I had one man tell me that he was pretty lucky because he had only been spit on a few times, only shoved to the ground once and, beyond that, only called names,” said an official who worked closely with Orthodox Jewish communities during former Mayor Bill de Blasio’s administration. “Imagine how bad it has to be for getting spit on to be considered pretty lucky.” Those experiences were compounded by health officials who often fumbled in their dialogues with ultra-Orthodox groups and by politicians who singled them out frequently — and often unfairly — for criticism.

Painting these communities with too broad strokes and then dousing them in shame and stigma did nothing to quell previous outbreaks. Officials should remember that as they tackle polio.

Religion is not the true barrier to vaccination. A steady beat of vaccine-preventable disease outbreaks has created the impression that public health and ultra-Orthodox Judaism are uniquely incompatible. But that’s not true. In the second half of the previous century, these communities achieved a public health victory for the ages. Through sustained, grassroots community outreach, they turned genetic carrier testing into a cultural norm — long before that happened in other communities. As a result, Tay-Sachs, a rare but fatal genetic disorder that occurs disproportionately among Ashkenazi Jews, was all but eliminated.

There is no reason a similar success can’t be achieved with vaccination, but health officials must start fighting the right battles. “Vaccine hesitancy is not rooted in Orthodox religion,” Abramson said. “It’s fueled by people who come from outside the community to spread lies and sow fear.”

The measles outbreak of 2019, for example, coincided with a flood of anti-vaccination propaganda aimed at Orthodox and ultra-Orthodox families. Somali communities have been similarly targeted, as have other isolated groups in which vaccine resistance is growing. The goal of these machinations is not just to turn people away from vaccines, Abramson said, but also to sell them something else. “You go into the pharmacies in some communities and see all these anti-vax products,” she said. “There’s a huge profit motive. But during the mealsles outbreak, that was largely overlooked while people blamed Orthodox communities.”

At the height of the COVID-19 pandemic, journalists, politicians and health officials in New York focused on Orthodox religious zeal. Less was made of the dense housing in some communities; their jobs, which often made social distancing impossible; or the fatigue they faced after large COVID waves hit early. “Ultra-Orthodox communities were struggling with all of the same challenges plaguing other high-risk groups,” said Charles King, CEO of Housing Works, a New York City-based organization that advocates housing and health care for people living with HIV/AIDS . “But instead of that, we kept hearing about the need to close synagogues and cancel religious events.”

Women are key. “The perception among officials has been that rabbis are the community gatekeepers because they are the ones that drive voting,” King said. “But men aren’t the ones making the health care decisions for their families. Women are.” And when it comes to medical advice, women are not going to their rabbis. They are going to their doulas and kallah teachers. And they are talking to other mothers.

Abramson and other Haredi women have learned through their battles with whooping cough, measles and COVID-19 how to use these networks to promote public health and persuade the vaccine hesitant. They have started roundtable discussion movements in living rooms and kitchens. They have installed themselves in pediatricians’ offices. They have answered questions and given advice. Above all, though, they have listened. “So many people just want to talk,” Abramson said. “And they will tell you things that have nothing to do with vaccination that explain why they are afraid of vaccination.” You can use that information to drive vaccination rates up, she said.

Abramson and her colleagues have tried to build on these lessons. She has applied for grants to create information campaigns for WhatsApp, a messaging app used by many Haredi mothers. She has also worked with local groups to get funding for training and other similar initiatives. But those efforts have been to little avail.

“Most of the money went to citywide organizations in the form of large block grants,” King said. “Those groups have more political experience, but they don’t have the same hyperlocal connections that a group of mothers would have and that you need to actually influence people’s behavior.” Politicians and health officials may want to rethink that strategy.

This article originally appeared in The New York Times.

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