Some three weeks ago (November 21), the Tel Aviv Conference Center hosted “The First International Conference on Informed Consent.” Now, informed consent is a good thing. It is also mandated by Israeli practice, American law, and by most developed countries. Academics and practitioners, both legal and medical, routinely hold meetings and confabs and write articles on how to upgrade or improve the process. So, what’s with the “First International Conference,” and why was it geared to the lay audience? And why in Israel?
Turns out this was no ordinary informed consent conference. In fact, it wasn’t even about informed consent at all – at least as commonly understood in the medico-legal communities. In actuality, this was an anti-vaxx conference: an anti-vaxx conference specially targeted to the Israeli audience.
So, how would one know? The program wasn’t posted on the Conference Center’s website. Nor was the event widely publicized, at least not in the Anglo press. Even so, over 1,000 persons attended. (This isn’t based on the organizer’s estimates. I was there). Turns out, there is a dedicated and active anti-vaxx movement here in Israel, with over 43,000 subscribers on one (Hebrew) Facebook page alone. (The program is available at one of their websites: And this isn’t the only anti-vaxx website reaching Israelis; the Children’s Health Defense page is another.
So now, Israel has two measles-related epidemics on its event-horizon: over 4,000 cases were diagnosed in the past year (compared to 30 the year before) and a burgeoning anti-vaxx movement has been seeded and is thriving. Israel is, in fact, the only developed country able to boast a World Health Organization (WHO)-designated measles epidemic — the sixth worst epidemic in the world.
Is there a relationship between the benign-sounding anti-vaxx groups and the recent epidemic? Who knows? The Ministry of Health has yet to determine the driving force of the scourge. In fact, the Ministry of Health hadn’t done very much to stem the epidemic at all, either in terms of curtailing the disease, increasing vaccination rates in epidemic-prone communities, or stemming or countering misinformation propounded by the virulent anti-vaxx movement. Proposed legislation to impose stricter responsibilities on parents and schools has been tabled due to the legislative limbo accompanying the interim governments. And with the ministry’s budget frozen due to the election crisis, there is little reason to be optimistic that next year will be better.
We aren’t even sure how the index case(s) transported the disease into this country, other than some vacuous claim by the Ministry of Health that the measles epidemic was “imported.”
(By way of comparison, in investigating the epidemic in the Hasidic community in Rockland County, NY, the Department of Health identified three importers (all the index cases came from Israel), their ages, the dates of entry to the US, the places they frequented, and possible routes of exposure).
So, why should we care how measles is spread in Israel? People say measles is not a particularly threatening disease; some claim (based purely on emotionally driven stories –without scientific data) that adverse events from the vaccine are more worrisome.
Perhaps. That is, until you consider that, as of last Friday (December 6, 2019), 63 deaths were reported in Samoa (more than doubling in two weeks) – out of 4,300 reported cases. In Israel, only three people died from the disease — out of 4,000 cases. Only.
Perhaps because cases of whooping cough (which is unquestionably a fatal disease) increased by 150% this year in Israel, markedly tracking decreasing vaccination rates, and the increasing anti-vaxx sentiment in Israel, which appears to be potently spreading throughout the country, stoked by false information deftly presented.
Perhaps because Israelis travel back and forth to America, exposing Americans, who in turn expose Trans-Atlantic flight attendants, who in turn put the rest of us at risk.
Perhaps because Israelis visiting the US are now routinely denied visitation rights to relatives in American hospitals because of fear of contagion from Israeli carriers.
Perhaps because if we don’t clamp down on the anti-vaxx community here in Israel, we will be facing a greater epidemic in the future – and more cases mean more hospitalizations, deaths, and money spent that we can’t afford to waste, diverted from other health concerns to address the seriously ill measles-patients.
And while adverse reactions have indeed been reported from the measles vaccine, no deaths have been reported from the vaccine when properly administered. Utilizing a risk-benefit analysis, without vaccination, just about everyone who is exposed gets sick (measles being one of the most infectious diseases on Earth — three to six times worse than smallpox, for example). Without vaccination, somewhere between 1/100 and 1/1000 die — depending on the country and the duration of the outbreak. Millions of dollars are spent on hospitalizations (for example from encephalitis, meningitis, and pneumonia) that would otherwise be avoided and deployed elsewhere. Thousands of hours of health-provider and public health team time are diverted from other serious conditions.
Why is the Jewish community at special risk?
Truth be told, this year’s epidemics in the US did reach non-religious, and even non-Jewish communities, but the two heaviest hit areas were three Haredi enclaves: the Squarer population in Rockland County, and Hasidim in Williamsburg and Borough Park in New York City – jointly contributing 1,000 cases to the total disease-load, or more than half the US cases. These three epidemics were all triggered by Israeli visitors who arrived in NY in time for the high holidays and spent enough time in shul, sitting close enough and long enough to enable easy spread of the disease to others.
In Israel, cases were reported in trendy Tel Aviv and Haifa, but hot spots were localized in Jerusalem, Safad, Beith Shemesh and B’nei Brak, Haredi areas notorious for non-vaccination. (The Arab community, by contrast, boasts an extremely high vaccination rate.) Again, how the disease was brought to Israel is an interesting, and open, question.
Perhaps it had to do with the Jewish custom to visit the Ukraine – the worst epidemic epicenter in the world with over 50,000 cases reported in 2019. (The Ukraine also boasted the highest disease rate for 2018, and there is no reason to suspect any less for 2020). The Ukraine is also home to the tomb of Rabbi Nachman of Brazlov in Uman, where upwards of 50,000 Jews from around the world visit shortly before Rosh Hashana. And it is the seat of the Skverer Hasidic dynasty, who later settled in Williamsburg and Rockland County. From there, infection is sure to spread over the course of Chol HaMoed Sukkot to families and friends from different areas.
But then what? How did the three Israeli index cases to US the transform into a phalanx of over 1,000 cases in the three neighboring areas? And how is it that the reasons or Frum Moms opposing vaccination are remarkably similar in the US and in Israel?
Could it be that there is one spigot/one source of information feeding information targeted to these groups? And if so, does it matter?
So, what do we do?
The dangers of the anti-vaxx movement and the consequent rising failure to vaccinate are becoming well-recognized internationally. In Samoa, an anti-vaxx activist was recently arrested. In the US, vaccination is compulsory, but exemptions existed in the form of religious and philosophical opposition. Those exemptions are now being eliminated.
Attempts to determine the root of community reluctance to vaccinate are ongoing. Tracing of cases is routine. But none of these responses exist here.
Actually, legal efforts to compel vaccination and initiatives to simplify the vaccine process have largely failed to recruit potential vaccinees, or fell short of projected expectations. Perhaps in the future, legal efforts might prove effective. For now, the best approach seems to be persuasion.
One effective initiative (and antidote to the anti-vaxxers) was employed by the Rockland County Health Department and was based on the disturbing discovery that anti-vaxx literature, rallies and events were being targeted especially and directly to the Hasidic community. In response, the county procured and provided literature championing vaccination — also targeted to the Hasidic community. It worked.
So, how would we craft a persuasive pro-vaccination message in Israel? And if misinformation is gurgling from one spigot, is there some way, legally, to shut it off? I will deal with the first question below — under the rubric of Know Your Enemy; the second will remain for a future column. For now, it’s food for thought.
Targeting the literature: Sophisticated Message to High Class Clientele
Here are my take-aways from the Tel-Aviv Conference: The event was not specifically geared to the Haredi audience. It was, however, very mommy-friendly. The main hall was filled to capacity. In addition, the talks (mostly from US and UK speakers) were broadcast to an overflow room with lots of floor space for tots to totter — and free food. That room was filled with about another 200-or-so moms.
Interestingly, one determinant suggested for the anti-vaxx sentiment in the Haredi and Hasidic community was lower socio-economic status and lack of education. Certainly, this conclusion did not apply to the attendees at the Tel Aviv Conference. Counter-anti-vaxx responses need to keep this in mind.
At a pop of 260 NIS per person, the audience was certainly not impoverished. The women I spoke with were educated, nicely dressed and well-groomed. Many wore Haredi-type head-coverings, although denied they were Haredi. Israeli all, they all spoke fluent English. Some had degrees in education, psychology, and sociology. Most of this cohort came with suckling infants. Interesting, that they had no problem schlepping to Tel Aviv with baby in tow, making it hard to believe they couldn’t shlep children to the local Tipat Chalav. (One excuse Health Authorities give for the lower vaccination rates in the Haredi communities is that with all the children, getting vaccinated is too much of a hassle. It defies logic to believe that complimentary baby care can’t be arranged if needed under these circumstances, or that vaccine clinics can’t be set up in places these moms frequent normally).
Astoundingly, the same reasons for opposing vaccination surface in the US and in Israel within the Haredi/Hasidic audience. In speaking to several moms at the Tel Aviv conference, they first gave the expected responses for rejecting vaccination (precisely as reported in the press, both American and Israeli.) In a sense, it seemed that they had been programmed or primed to give these answers: we’re too busy with all our children; we are not anti-vaxx – just delaying the vaccines; we don’t trust Big Pharma’s vaccine industry.
When I asked why they were attending the conference, after paying obeisance to the “official” reasons, the women elaborated – they didn’t trust their doctors who summarily passed off the vaccine without explanation, and they wanted control over their children’s well-being (perhaps one of the few venues these women have to be empowered as the final arbiter). It seems for once these women were being validated and not passed over. But as they spoke, their reasoning became more insidious: the information given by the anti-vaxx speakers was more believable than the pro-vaccine message. In other words, the techno-babble given by the anti-vaxx community just sounded too good, too true.
And truly, the messages were brilliantly crafted. Without post-graduate degrees in public health (which I have), it would be virtually impossible for a lay-person to deconstruct the errors. Indeed, my husband, a PhD in economics and son of a surgeon, was taken in. The presenters were cagey. There was little reliance on the now-debunked autism theory in the formal talks. Instead, slick visuals with graphs brazenly (and invalidly) commingling outcomes and events were put forward, not as correlative, but as causal. Interspersed references to anti-anti-vaxxers as Goebbels-like provided the necessary hysteria-mongering. The woeful take of a mother whose children were apparently adversely affected by vaccines rounded off the professionally orchestrated persuasion efforts – all geared with Mom-in-Mind. And while the presentations were mostly in English, simultaneous Hebrew translations were provided. Accuracy? Well, smallpox was mistranslated as chicken pox, for one thing.
Given the surge in cases of preventable diseases in the last few years in Israel, something must be done. Would mandatory vaccination laws help? Well, it couldn’t hurt – but given the paralysis in the Israeli government, I wouldn’t hold my breath. Would fining recalcitrant parents motivate? It might, but would be too long in coming. Would targeted anti-propaganda efforts help? No question.
Israel boasts a host of pro-health NGOs. Here’s an initiative they can pursue – without waiting for government intervention.
David Goodsell [CC BY 4.0 (https://creativecommons.org/licenses/by/4.0)]