Arroyo is an amateur kickboxer, lanky and athletic. He hurried down the street, talking by phone with the hospital’s infection-control nurse and mapping out a plan. At home he changed out of the octopus costume and logged on to the hospital’s electronic medical records to check what time, exactly, the girl with measles had entered the ER. He called the other doctors who had been on duty to see if they remembered any pregnant mothers or immunocompromised children who would have been especially at risk.He also called the hospital’s IT department to help backtrack through medical charts. His team generated names of 55 children who had potentially been exposed to the disease, then asked the New York City Department of Health to cross-reference it with vaccination records. For the MMR vaccine (against measles, mumps, and rubella) to be effective, the immune system has to be mature enough to produce antibodies to the virus. Young babies’ immune systems are not sufficiently developed, so children generally receive an MMR vaccine at 1 year old and another at age 4 or 5; those who had come through the hospital but had not completed both doses were considered at risk.On the Maimonides list were a 12-month-old, a 10-month-old, and three babies younger than 6 months, including one who was just 17 days old. All were vulnerable, and Arroyo realized he was already running out of time. To prevent infection, the children needed to receive MMR shots within 72 hours, and young babies would have to be given immunoglobulin, a form of temporary protection, within six days. The infection-control nurse began making calls to those babies’ parents.
- Megan MolteniHow Measles Hacks the Body—and Harms Its Victims for Years
Measles Had Been Eliminated. Now It’s Nearly a Daily Threat
- Joanna PearlsteinCalifornia’s Vaccination Rate Slips as Medical Exemptions Rise
The hospital team began making calls again. Children returned for shots, and their parents were instructed to keep them home for 28 days. The nurse who greeted patients near the registration desk kept watch for those with fever and a rash who needed immediate isolation, and Arroyo rushed repeatedly to the intake area to look at worrisome rashes.
As the fall wore on, the cases kept coming.Chany has spent most of her life in Borough Park, not far from Maimonides. She has a youthful face, with bright green eyes and a tentative smile. When we met at a café near her home, she was wearing a wig, as married women in her ultra-Orthodox community do, and was modestly dressed in a black skirt and long sleeves, with a black-and-white-striped duster on top. We’d been talking by phone for more than a month about the course her life had taken, from compliant patient to activist. She greeted me with a hug but then seemed to become wary.When Chany married and began having children in the 1990s, she took them to a pediatric practice and saw no reason to question the physicians’ recommendations. Her first three children received their vaccines on schedule. “I was open to the doctors, like a nice little girl,” she said. “Whatever they said, I did.”Yet as her children grew, Chany noticed problems, which she believes “should have been a red flag.” The first child had recurrent ear infections. When the third child was about a year and a half, Chany’s father said to her, “I don’t think he hears.” The boy was later diagnosed as being on the autism spectrum.Chany, whose last name WIRED agreed not to publish, had heard the idea that vaccines could cause injuries, but she hadn’t given it much thought. Now a glimmer of doubt entered her mind. When her fourth child was old enough to receive an MMR, she expressed her nervousness about vaccines to the doctor. She says he brushed her off, saying only that the shot was safe and effective. Chany felt dismissed, then disappointed with herself for allowing the child to be vaccinated. “Why can’t I tell him I don’t want this right now?” she thought. “Why can’t I stand up for myself?”Chany had hoped to go to college and become a speech therapist. By the time her husband finished his degree, though, she was consumed with the demands of a growing family. Now she turned what time and energy she had toward reading up on immunization. Searching online for books, she landed on one by Sherri Tenpenny, an Ohio physician who claimed that vaccines are linked to autism. One antivax source led to another. Chany began printing out lists of vaccine ingredients from the CDC, browsing the internet, and watching videos. She was drawn to videos by Andrew Moulden, a Canadian neuroscientist who claimed that vaccines cause autism by triggering oxygen deprivation or “mini strokes” in the brain. “His information really opened it up for me,” Chany says.She now felt certain that her third child’s speech and hearing delays had worsened after he started getting vaccines. She reached out to a well-known vaccine skeptic named Mayer Eisenstein. Unlike her own pediatrician, Eisenstein listened sympathetically to her concerns and even gave her his cell phone number. By the time Chany’s fifth child was due to receive shots, she was firm in her convictions. She believed vaccination had caused her children’s disabilities. “I realized it was my mistake,” she says. “And if I made a mistake, I’m going to have to fix it.”Chany decided to create a forum for women in her community. “No one likes to be alone,” she says. “If your child just got a vaccine and now he doesn’t speak anymore, your doctor’s not going to answer that.” Since some Hasidic sects frown on internet use, ultra-Orthodox women often receive community news, inspirational talks, and other information by way of the phone. Chany worked with others who set up a hotline called Akeres Habayis, or Woman of the House, so that she could use it to share information. “Mothers can feel when something’s wrong with a child,” she told me, “and you should listen to their feelings and not disrespect them.”
In 2000 the US said measles was gone—defeated!—within its borders. Except, not quite. Cases still broke out sporadically. Now the country is in the midst of its worst outbreak in more than 20 years. From January 1 to June 13 of this year, 1,044 people, mostly children, in 28 states have been sickened with the disease. So how was measles declared eliminated, and does the current outbreak mean it’s back for good? The answer is more complicated than you might think. —Megan Molteni
What does elimination mean?
The word elimination sounds absolute. But when it comes to measles, it does not mean the US has zero cases. It means no current strains are native to the US. But the virus can still be carried in from another country.
In another illustration, a woman stands with her arm around a small boy. “My son regressed into autism after his MMR vaccine. Now he’s in his own world and can’t communicate,” she says. “But at least we had no problem enrolling him in school.”The tone of bitterness and regret in the handbook mirrored Chany’s feelings. So, too, did the call to mothers to feel empowered. There was an email address people could write to, and Chany would respond. The pamphlet also provided the number for a “Peach Hotline,” which connected callers to Akeres Habayis. Through the hotline they solicited volunteers, and Chany told those who contacted her how to distribute the pamphlet in their neighborhoods. “It’s a grassroots movement,” she says. “It’s literally person to person.”In early 2014, an ultra-Orthodox woman named Zahava, who lives in Williamsburg, found a copy of the Peach pamphlet on her doorstep. For more than 70 years, Williamsburg has been home to Hasidic Jews, many descended from Eastern Europeans who settled there after surviving the Holocaust. Hasidim tend to live in close communities, living by tenets set forth in Jewish texts. Zahava, who agreed to speak as long as her full name wasn’t used, is devout and lives in a large apartment building, where children play together and extended families gather for meals. Others in her building received the Peach pamphlet too, and friends and neighbors pored over the sensational claims, especially those about autism.Roughly 40,000 copies of the pamphlet appeared in kosher grocery stores and by apartment doors in Williamsburg and Borough Park, as well as in ultra-Orthodox communities in upstate New York and New Jersey. Zahava, who has delicate features, pale skin, and light eyes, read the pamphlet just months after giving birth to her first son. She felt terrified. The pamphlet played on the anxiety that she and other new parents often feel about bringing babies into a world of pesticides, plastics, and pollutants, and it seemed to offer a simple explanation for virtually any physical or developmental anomaly. “It doesn’t take much to put fear into a mother,” Zahava says. “And once the fear is there, it is very hard to get out of it and go to the logic.”Zahava did her shopping at an upscale kosher market and had the groceries delivered to her home. One day, inside her order was another copy of the pamphlet. It came again with subsequent food deliveries, filling her with dread about vaccinating her infant son. Each time she took her boy for a checkup or sick visit, she bombarded Dov Landa, the physician assistant who treated her child, with questions. She felt reassured by his well-informed answers and his concern for her son, but the self-doubt would creep back in.One day at the grocery store, Zahava saw a pile of the pamphlets and felt her distress well up again. After asking the cashier if she could have them, she walked out with the stack and dropped it into the nearest trash can. Eventually, after her husband consulted with a rabbi, who assured them that the shots were safe, Zahava brought her son to Landa for his vaccinations.In 2015, Zahava had another child, a boy who had an easy temperament but kept getting high fevers and ear infections. “Every time we went to the doctor there was something else going on with him,” she said. His recurring sicknesses meant his immunizations had to be delayed. Just before his second birthday, in 2017, he was diagnosed with a rare form of cancer. After nine months of chemotherapy, Zahava’s son went into remission. But with a compromised immune system that wouldn’t respond to vaccines, he couldn’t receive his shots.In October 2018, just a month after her son got the green light to start preschool, Zahava’s husband heard about a measles outbreak on a Yiddish news hotline. A traveler who had contracted the disease in Israel, during the Jewish holiday of Sukkot, had brought it back to Brooklyn. The couple called Landa, who suggested that they keep their son home for a little while.
Vaccines protect individuals, but they also protect the most vulnerable people in communities through a process called herd immunity. If enough people are immunized, there simply aren’t enough susceptible individuals for a virus to spread easily throughout a group. The virus runs out of steam ramming the doors of impenetrable fortresses before it can reach those who are too young to be vaccinated or whose immune systems are weak. Communities come in various sizes—whole countries, but also small pockets of people who live near each other or who have a strong group identity. To achieve herd immunity against measles, about 95 percent of a community needs to be immunized. And so its success depends on a high degree of cooperation; even a small number of holdouts can precipitate a crisis.That is what happened in Brooklyn—slowly, then all at once. Five years ago, the average vaccination rate at Jewish schools in Williamsburg, Borough Park, and Bushwick was 97.8 percent. Today it’s 96.2. About 9 percent of private schools in Brooklyn have vaccination rates of less than 90 percent. At one yeshiva in the Borough Park neighborhood, almost 97 percent of students were immunized against measles in 2012; today, the rate at that same school has fallen to 72.7 percent.The loss of herd immunity made it almost inevitable that measles would spread rapidly once it was introduced in Williamsburg and Borough Park, where extended families live in close quarters and gather frequently at synagogues and community halls. Measles cases worldwide were rising, with over 170,000 reported in 2017. And in October 2018, measles arrived in Brooklyn not once but at least six times. At least one child carrying the disease arrived from Israel, and other travelers brought it back to the US from Ukraine, where the border war with Russia had disrupted public health efforts. In Indonesia, Madagascar, and the Philippines, poverty and lack of health care access contributed to measles outbreaks. In the UK and a number of other European countries, the misinformation was largely responsible for heightened vulnerability.Misinformation has been spreading for years on tech platforms, thriving within what researchers call “small world” networks—clusters of people who are highly interconnected and tend to reinforce each other’s views. Instagram, Facebook, and YouTube had done little to limit the spread of propaganda, but as measles flared across the country, and pressure from lawmakers and journalists mounted, they succumbed and took modest steps. Facebook, for instance, announced it would stop letting antivaccine information be promoted through ads or recommendations, though plenty of well-known agitators remain active. On Amazon, books skeptical of vaccines still dominate search results.In Brooklyn’s ultra-Orthodox communities, the Peach name was adopted by other groups of vaccine-skeptical parents. In 2018, as the disease surged through yeshivas and play groups, Chany’s forum continued getting phone calls. Women with sick children dialed in to Akeres Habayis and traded remedies they used to take care of their kids at home. Some were hesitant to go to pediatricians and be reported to the department of health, Chany says. “Measles is not polio,” she adds, “and it’s not smallpox. It’s not the bubonic plague either.”
But measles can have serious, long-term consequences, such as immune-system suppression and cognitive impairment, even for healthy children. And to someone like Zahava, with a vulnerable child, it was every bit as frightening as the plague. When another Peach pamphlet appeared on Zahava’s doorstep in 2018, her frustration mounted. She heard a rumor that a child in her son’s preschool class had measles. Zahava called the mother, explaining that if her son contracted the virus it could lead to pneumonia, brain swelling, and even death. She needed to know if the woman’s child had the disease before she sent him back to school. “I told her I needed to protect my child,” Zahava says. “And she said, ‘So maybe give him some vitamins to boost his immune system.’ I told her that wasn’t going to help at this point … She went on about how vaccines cause cancer and autism and everything in between. I’m like, ‘This is totally not where I wanted the conversation to go. Can we start again? Does your child have measles or not?’ ”Zahava knew that the vast majority of parents in Williamsburg still immunized their children. But the minority seemed the loudest. At a bris for her nephew, a woman was “talking herself blue in the face about how bad vaccines are.” Zahava noticed three other women—one with a baby, one pregnant, and one newly married—listening, rapt. Later, she regretted not speaking up. When her sister-in-law told her about an Orthodox nurse named Blima Marcus who was leading workshops on vaccines, Zahava decided to invite her to Williamsburg.In December about 10 Hasidic women, mostly in their twenties and thirties, sat in tiny orange chairs in a kindergarten classroom in a local school. Marcus, who stood at the front of the room, is an oncology nurse who devotes part of her time to counseling religious families on end-of-life care. When she became aware of how much misinformation was making the rounds in her community, she gave herself a crash course in the science of vaccines. She spends hours a week talking to mothers, taking pains to listen to their concerns.
That day, one of her first questions to the women in the classroom was whether she needed to bother addressing whether vaccines cause autism. Given the settled science, she didn’t want to spend time unnecessarily. To her surprise, she says, “The women were like, ‘Of course we need to discuss autism!’”Marcus explained how Andrew Wakefield’s study had breathed life into the antivax movement . But the study was tiny and deeply flawed. “In over 20 years of research, that study has never, ever been reproduced,” Marcus told the women. Meanwhile, numerous papers, examining the medical records of hundreds of thousands of children, have found no association between the MMR vaccine and symptoms of autism. She told the women how, in 1993, Japan suspended the use of MMR vaccines because of concern about the mumps portion of the vaccine then being used in that country. But during the time in which the vaccine’s use dropped to zero, autism rates kept rising. When Marcus showed the women a graph of the two trends moving in opposite directions, several of them gasped. “That was it for most people in the room,” Marcus says.In her no-nonsense manner, Marcus refuted other myths about immunization. Some women had heard that vaccines contain aluminum that can cause harm to children; Marcus explained that aluminum is used to boost the body’s response to immunization, and most of it is cleared from the system within days. Minuscule quantities of even scary-sounding substances are unlikely to cause harm, she said, invoking the old saying “The dose makes the poison.”
Zahava’s sister-in-law was there and felt a rush of relief. Hearing misinformation day after day, she says, makes it easy to second-guess yourself and think, “‘One second, am I the crazy one?’ The nurse actually had answers to all this nonsense.”
In late March, flyers appeared on lampposts around Williamsburg and Borough Park: “Once and for all, Clarity!” The flyer featured an image of a massive syringe in a doctor’s hand, with the words “Vaccines save lives!” It then showed the same syringe emerging from the barrel of a gun, countering “Vaccines are dangerous!” Similar announcements ran, in Yiddish and English, in free local newspapers.The text of the flyer provided phone numbers for a call-in discussion with doctors, lawyers, rabbis, and politicians on March 31 at 8:30 pm. In Williamsburg, robocalls urged families to listen in. Zahava says she received five reminders on her landline in the days leading up to the event. No one seemed to know who was organizing the call. Dov Landa, who treats Zahava’s children and about 10,000 others in New York, had seen the announcements on a WhatsApp chat group and speculated throughout the day with colleagues.Landa estimates that only 1 percent of his patients are staunchly opposed to vaccines, while perhaps 20 percent are sincerely confused, awash in fearful misinformation. “They’ve heard the message so many times, even the moderates start to believe that maybe there’s something to it,” he says. His approach is to talk to parents about vaccine safety, one on one, again and again. He rarely leaves the office before 10 pm and often finds himself texting answers to questions about the MMR vaccine in the middle of the night. He was up at 2 am recently convincing a reluctant father to bring his daughter in for a second shot, which the family had delayed for years. Landa, who is a member of the Lubavitch Orthodox sect, passes out a pamphlet that Blima Marcus wrote with a group of other Orthodox nurses about the virtues of vaccines. He reminds parents that many rabbis have strongly supported routine shots. This form of persuasion is “painfully slow,” he says, but he believes that in the long run it is the most effective way to change minds.
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Sign up for the Backchannel newsletter and never miss the best of WIRED.None of those messages were aired in the March 31 event. Instead of presenting scientific information, the call featured vaccine skeptics or outright critics. It was organized by a group called PACT—Parents Advocating for Children Together. Chany says Peach isn’t connected to PACT but told me “it’s the same idea.” In the past few years, among the ultra-Orthodox, the antivax movement has become a larger, loosely organized confederation: “If someone wants to do an event, they just do it,” she says. “There’s no central organization.” Chany supported PACT by donating through the group’s GoFundMe page and called in to listen. “It was good,” she says. “It woke people up.”During the call, Del Bigtree, who produced the movie Vaxxed with Andrew Wakefield and others, conducted an interview with Lawrence Palevsky, who describes himself as a holistic pediatrician. In sober cadence, Palevsky said “medical scientists are even using measles virus as a way to cure cancer. So of course people want to know the next question: If the measles virus is being used to help people resolve their cancer, is it possible that having the measles is a protector against getting cancer later on in life?”
Zahava, who had tuned in almost as a test of resolve, felt stricken. At 11:30 that night she texted Blima Marcus: “Do you inject people with measles to cure cancer?”
Marcus replied, “Inject measles to cure cancer? What?” Marcus told Zahava that measles actually weakens the immune system for two to three years.
“And if so, measles prevents cancer,” Zahava replied, still with a glimmer of doubt.
“No,” Marcus assured her. “It doesn’t.”For several days, Landa’s patients also inundated him with questions about the call. One mother unfolded the insert to the MMR vaccine in front of patients in the hallway and worried aloud about its contents. By that time, the New York City Department of Health was reporting a total of 317 measles cases in the city since the start of the outbreak. But Landa estimated that the true number was many times higher because some patients were avoiding doctors. Measles is “literally all over the street,” he told me. (By mid-June the official tally had risen to 596.)That same week, a 4-month-old baby with a fever and hacking cough came into Landa’s office. The boy didn’t have the characteristic measles rash, but he was breathing rapidly, struggling for air. When Landa sent him to a hospital emergency room, he tested positive for measles. The boy’s breathing continued to decline, and he was put on life support with a mask clamped over his face and pressurized oxygen pumped into his lungs. He had developed pneumonia and had to get intravenous antibiotics. Within a few days, a fierce red rash covered his body. After almost a week in intensive care, the boy was discharged to recuperate at home, the long-term effects of the disease still uncertain.Before the advent of vaccines, nearly every child contracted measles before the age of 15. The disease reached epidemic proportions every two to three years, sweeping through communities in the late winter and spring. School absences rose, with feverish, coughing kids sequestered at home for weeks. With each wave, thousands of children were hospitalized with pneumonia or brain swelling, which could cause permanent brain damage, seizures, and even death. Because measles depletes the immune system, once children recovered they were more susceptible to ear infections, bronchitis, and pneumonia. One study, published in the journal Science, found that before vaccines, measles was indirectly responsible for as many as half of all deaths caused by childhood infectious disease.
After the measles vaccine was licensed in 1963, the number of cases plummeted and the epidemic cycles ceased. Not only did vaccination represent a feat of medical science, it reflected a widespread understanding that self-protection and social protection are inevitably intertwined. The ultra-Orthodox live by this communal commandment. Landa points out that they come together to provide food for the elderly, organize visits to the sick, staff volunteer ambulance services, and make sure even those who can’t afford it get access to high-quality care. Getting vaccinated, he says, fits this duty to protect others in the community who cannot protect themselves. Yet fear of vaccines has challenged that group solidarity.
When I asked Chany about the benefits of herd immunity, she would not acknowledge that communities as a whole gain protection from vaccines. The plight of children with compromised immune systems, like Zahava’s son, did give her pause. “That’s a tough one. I was in touch with somebody whose child had cancer and is on chemo, and her other son got measles,” she said. But she didn’t linger on the discomfort. “I don’t know what ended up happening, but I didn’t hear of anybody dying … There are a lot of viruses out there that are worse than measles, so just focusing on measles as the thing that’s going to kill someone who is immunocompromised doesn’t make sense.” (So far no deaths have been confirmed in the current US outbreak.)In early May, Zahava and I met in front of her apartment building, where a few neighbors chatted by the curb. By that time, New York City had declared a public health emergency , requiring that anyone over 6 months old living or working in Williamsburg be vaccinated with the MMR within 48 hours unless they could document a medical exemption or immunity to the disease. She wore a loose blue cap over her hair and pushed her younger son in a stroller. A few blond curls were visible around his face as Zahava adjusted the sunshade, speaking to him gently in Yiddish.
As we walked to the corner, three or four school buses jockeyed for position, turning onto the main thoroughfare. Zahava’s son, still unimmunized because of his cancer, was required to remain at home, while students who came down with measles and recovered could return to school. “That’s the cutest part of the joke,” she said with a flash of sarcasm.
Zahava was tired of keeping her son cooped up and away from other children. There are only so many craft projects she can come up with. He needed to be fit for new shoes, but she worried someone with measles might be in the store, so she went without him. “I do what I can, and the rest is all in God’s hands,” she said.
Alexander Arroyo, the Maimonides doctor, also lives in one of the zip codes defined as a measles hot zone. His daughter turns 1 year old in August, and he has worried from the beginning of the outbreak that she’ll catch the disease before her scheduled MMR. “Yesterday alone I had four babies come in who were exposed in a pediatrician’s office and needed immunoglobulin,” he told me.
Arroyo’s wife, who is also a physician, suggested that they give their daughter the MMR early, and he agreed. He brought a dose home from the hospital and put it in the refrigerator, “right by the margarine.” For days, however, work was so hectic that he didn’t have a moment to sit her down. Then one Saturday night in May, another infant, around the same age as his own child, came into the ER, dehydrated and feverish with measles. “OK,” he thought. “I’m done.”
As soon as his shift was over, he hurried home and gave his daughter the vaccine.
Measles Hot SpotsPublic health officials aspire to have 95 percent of people immunized against measles. At that level, you achieve herd immunity—that is, even those who can’t get shots will be protected by a wall of immunized neighbors. But in more than half of US states, student vaccination rates are lower than that. Some aren’t immunized for medical reasons, and nearly all states permit skipping shots for personal or religious beliefs. The result is that adults who aren’t fully protected and babies who are too young for their vaccines are vulnerable. A recent paper in The Lancet Infectious Diseases identified 25 US counties most at risk for a measles resurgence, as seen on this map. The researchers based their conclusions not only on immunization rates and exemptions but also population size and—critically—proximity to an international airport. Last year, 82 infected people brought measles into the country, according to the CDC. The Lancet study’s takeaway: Even well-protected states like California and Texas could suffer outbreaks. —Joanna PearlsteinWASHINGTONMeasles cases in 2019*: 81(Personal-belief exemption rate: 3.7%)The year’s first outbreak started in January, triggered by a child who traveled from Ukraine to Clark County, Washington, which has an abysmal 84.5 percent vaccination rate. In May the governor signed a bill eliminating the personal-belief exemption for the MMR (measles, mumps, and rubella) vaccine.ILLINOISMeasles cases in 2019: 9(Personal-belief exemption rate: 0.9%)In May, a week after scientists named Cook County, Illinois, as the region most at risk of a measles outbreak, a traveler proved the point: A person with measles left a trail of possible exposures through O’Hare International (the sixth-busiest airport in the world), on public transit, and at a university campus.CALIFORNIAMeasles cases in 2019: 53(Personal-belief exemption rate: 0%)Six months after a measles outbreak in Disneyland in 2014, California eliminated the exemption that let parents opt out for personal beliefs; it had accounted for 2.5 percent of kindergartners. Medical exemptions, however, have been on the rise.NEW YORKMeasles cases in 2019: 897(Personal-belief exemption rate: 0.8%)New York has one of the country’s highest vaccination rates, but you wouldn’t know it based on the number of measles cases. That’s because in some communities, rates are dramatically lower. In six Brooklyn zip codes, immunization rates are under 92.5 percent.
*As of June 21Amanda Schaffer (@abschaffer) is a science writer in Brooklyn. She wrote about a rogue herpes vaccine trial in issue 26.05.This article appears in the July/August issue. Subscribe now .
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