Measles is an extremely infectious virus that can both kill and cripple children. Luckily, there are highly effective vaccines to prevent the disease. The World Health Organization recommends that 95 percent of the population be fully vaccinated against measles because it’s so contagious. This helps to ensure that vulnerable children and infants who cannot be vaccinated are protected.

Yet vaccination rates are falling globally. The result? A 20 percent increase in measles cases between 2022 and 2023, according to WHO and the U.S. Centers for Disease Control and Prevention. That adds up to more than 10 million cases. More than 107,000 people died from measles in 2023, mostly children.

The problem is worse in some communities, especially where connections to the outside world are limited. One example: the Charedi community in London. Often referred to as ultra-Orthodox Jews, the Charedi often run their own schools and daycare centers and can fall outside the usual public health health system. Vaccination rates have fallen below 70 percent in some of these communities, according to UK health officials.

It can be tricky to encourage people in isolated communities to get themselves and their children vaccinated. Sometimes it’s simply a matter of logistics, and sometimes it’s a matter of overcoming distrust, misinformation, and disinformation.

Dr. Ben Kasstan-Dabush has been studying this problem while at the London School of Hygiene and Tropical Medicine. One solution he found: Make use of people from within the community to communicate. “I worked with clinical and community partners to produce a short clinic clip that can be screened in primary care waiting rooms,” he says. “It features the voice of a Charedi Jewish healthcare professional and mum.”

Another success: coloring pages for kids that feature vaccination in a positive light and that use common Jewish names. Common-sense solutions include extending clinic hours so parents can attend outside working hours and religious holidays.

Now a lecturer of global health policy at the University of Edinburgh, Dr. Kasstan-Dabush is continuing to study how people respond to public health outreach attempts around vaccination. Listen as he chats with One World, One Health about some of the reasons kids might not get vaccinated on time and ways to make it easier.

View Transcript

Maggie Fox  00:00

Hello and welcome to One World, One Health where we chat with people working to solve the biggest problems facing our world. I am Maggie Fox. This podcast is brought to you by the One Health Trust with bite-sized insights into ways to help address challenges, such as infectious diseases, climate change, and pollution. We take a One Health approach that recognizes that we are all in this together and everything on this planet — the animals, plants, and people, and the climate and environment — are all linked.

Viruses connect us all. They don’t respect borders and the way they spread brings home how important it is to communicate well with people and to make sure that vaccines and other preventive measures are fairly distributed. One great example is measles. It’s probably the most infectious virus people will ever encounter. It spreads through the air and hangs in the air for at least two hours after an infected person has left a room. 9 out of 10 people who aren’t immune and who breathe in that virus will probably become infected themselves.

But there’s a highly effective vaccine, the Measles, Mumps, and Rubella or MMR vaccine, before measles vaccines were introduced in 1963, the virus killed 2.6 million people — most of them kids. It still kills more than 100,000 a year because of vaccination, it can also cause blindness, and brain damage, and make children vulnerable to other infections. You would think people would clamor for this vaccine, but there’s a lot of misinformation and disinformation, as well as simple logistical problems in getting the vaccines to all the places they’re needed. Some communities are more likely to either get passed over or to be targeted by anti-vaccine campaigns. So how do you reach them?

In this episode of One World, One Health we’re talking to Dr. Ben Kasstan-Dabush, lecturer of Global Health Policy at the University of Edinburgh, who has found some ways to reach into some of these communities in London.

Ben, thank you so much for joining us.

Ben Kasstan-Dabush  02:02

My pleasure.

Maggie Fox  02:04

Can you tell us, first, a little bit about the problem? Measles vaccination is down globally, but certain communities are more vulnerable, and the one in particular we want to talk about is this ultra-Orthodox Jewish community in London. What’s going on?

Ben Kasstan-Dabush  02:23

I mean, it’s a complex picture, right? And what we’ve seen in England over the last 10-plus years, is a decline in routine childhood immunization coverage. We’ve seen that, at a national level and there’s been a bigger picture of structural changes that have affected vaccine delivery programs, ‘ engagement with communities. It’s an era that has been characterized by austerity, reductions in public health spending, and investment in community health. So, I think we first have to get that landscape. I don’t think that has separated England from any other higher-income country in the last 10 years. I think it’s probably been a pattern.

So, these issues kind of affect the public health relationships with communities, who you introduced as “ultra-Orthodox Jewish families,”— Charedi. They are based in Israel, in the US or so, in London, in the UK. They tend to have much larger family sizes. So, for example, in my research, I’ve met with families where there are 6,7,8, 9, 10, 11, 12, and 13 children, so continuous childbearing until menopause, and that can, in some cases, raise practical challenges in physically getting to a vaccination clinic. It can mean that recommendations may have changed over the time of raising the first child to the last child. It might mean needing additional support, for example, those additional reminders to get to the vaccine clinic.

Then there are also practicalities and convenience and access aside, there are broader issues around vaccine confidence and messaging these communities, what we’ve seen, particularly in the US, being targeted with misinformation, and misconceptions. So, there’s a complex picture. I think it is important to convey from the beginning that might underlie declining levels of vaccine coverage and localized outbreaks in particular communities.

Maggie Fox  04:05

There was a case in New York of deliberate targeting. There was a group that was sending pamphlets to some of these communities warning them against vaccines. Is this happening in London as well?

 

Ben Kasstan-Dabush  04:17

I didn’t see it to the same extent. In 2022, there was a polio case in Brooklyn County, and I was involved in valuing the public health response to that. It was quite clear that there was a targeting of messaging from the 2018 to 19 measles outbreaks to COVID-19 and that was very clear. It was less explicit in London. But, you know, in these linked populations, there’s also a transnational circulation of messages, right? And what I’ve seen is messages from the US context, being imported into places like Jerusalem and London.

Maggie Fox  04:51

Is one issue the production of the vaccine itself? I know one version is made with pork gelatin, but there’s a version that’s not.

Ben Kasstan-Dabush  04:59

I mean that might be up to the individual family. What I do know is that in the UK, there is a medical authority, a particular rabbi who has made, a very clear statement that pork gelatin-derived vaccines are not a problem and can be accepted. Whether individuals may have their positions on that, I don’t know, but that’s a very clear position from a rabbinical authority. But what I can also say is, in many years of doing this work, that Charedi women or Charedi families may consult with rabbinical authorities on a number of issues, but vaccination doesn’t tend to be something they would consult a rabbi with. It’s very much in the spirit of authority of women, is discussed by women, and recommendations passed between women. “You know what? What are you doing? What have you thought about this?” And that might be from women who hold positions of influence in these communities, such as doulas or the wife of a rabbi.

So, I think it’s always important to remember, and not a centralized religion that —just because a rabbinical authority has said or taken a particular position that women and parents will follow that.

Maggie Fox  06:00

Oh, that’s interesting. So even though the religious leaders say, “This is cool, this is okay,” sometimes if the prominent women in the community say something else that can cause a problem!

 

Ben Kasstan-Dabush  06:10

There are always competing influences, and I think that raises a question for me that I’ve not yet found an answer to is — Why would Charedi women lead? You know, what defines Charedi is leading a life of more stringent interpretations of Jewish law. So then, why would you follow the guidance of somebody else other than a religious authority? And that, for me, is always an interesting question that I don’t have an answer to yet.

Maggie Fox  06:33

I think that’s probably the same in a lot of communities, though, right? Different people have different influences.

 

Ben Kasstan-Dabush  06:39

Absolutely! What we sometimes forget is we look at religious communities and emphasize the religious factor. But it’s also something to look at intersectionally, in terms of social and economic class, in terms of background, and education, all these kinds of issues can come together and play a role in your ability to discern competing sources of information.

Maggie Fox  07:01

So, you have some solutions. Can you tell us about some of the solutions you found?

Ben Kasstan-Dabush  07:06

I mean, it would be very unfair to say that these are my solutions. What I have been doing over the years is working with primary care teams, for example, community groups and part of coalitions, guiding, advising, and steering these. There are various ways to just make vaccines more accessible when parents want to have them, to ensure, for example, you have clinics on a Sunday. Children might not be in school. We know that in Charedi communities, where children tend to go to private religious schools, the days are much longer, so that means your clinic times also have to be slightly longer or more flexible or in the evening, right?

If we know that particular communities have a Deemer, are not unique in this, not engaging with mainstream media in the same way, or maybe have their community outlets, then it’s important to map those. Know what they are. How can messages be delivered via them? To also know when it’s a slightly different school system and messages around immunizations might not filter down in the same way, or if at all, to have alternative or complementary ways.

So, what I did was put together some coloring sheets with positive vaccine messages. You know, “Vaccinate! Don’t wait to vaccinate,” for example,  and using the names of Charedi Jewish children, such as Ellie Sheva or David, and making this relevant to you. Obviously, you know those are going to be for younger kids, but kind of word searches or activities with positive vaccine messaging, or even just awareness of different vaccines, for example.

I guess what my role has been, conducting research, understanding barriers, enabling the flow of information, and ideas of rhetoric. What do parents want to know? I share that with public health teams, and primary care services, so they can try and incorporate that into their strategies.

Maggie Fox  08:52

This is what we’ve heard from so many people doing this podcast, that you look to the community for the solutions! You can’t have people coming in from the outside saying, “This is what you should do!”

Ben Kasstan-Dabush  09:02

Well, I mean, that would be a top-down message, and you’re right, I think. Having these as co-delivered with community partners is extremely important. However, one of the questions around that is, you know, who gets to be involved in co-delivery projects, which community organizations are approached, and how is responsibility delegated? These are all kinds of key questions to consider and are important for transparency and accountability.

I think something that we don’t see enough of in co-delivery and co-design projects is, how people have been involved and invited to be involved. How have public health services done this kind of mapping and invitation process?

Maggie Fox  09:39

Now it sounds to me that you’re focusing on making the vaccines more available, rather than trying to persuade people that they want them in the first place.

Ben Kasstan-Dabush  09:49

I think, and I have long felt that the number of parents who would maybe refuse vaccination is smaller than those who delay vaccinations, particularly in this community context. Hence, if there’s a contingent acceptance, which, of course, is what delay is!  I’m going to vaccinate according to my schedule or my ideas, then try and engage with that in constructive ways, at the very least, to try and make sure that services are available again for when parents decide that they want them, but to ensure that parents have the information to know what are the risks of delaying vaccinations and how to avoid that?  That is a more timely vaccination to schedule.

Maggie Fox  10:25

You talk about protecting the community as well as your child. Is that a useful message?

Ben Kasstan-Dabush  10:30

It’s a really good question. Again, the experts would be your community partners. There are, of course, lots of teachings, a wealth of teachings in this community and others around collective responsibility, being responsible for one another, and those may be channel messages and also to make relevant and linked to that is I’ve often thought in this in Charedi communities, where there’s a big emphasis on learning. “You want your child to become that rabbi, that leading light, well, then surely children learn best from the yeshiva institution of instruction and not from the sick bed, and hence, vaccination would be the best way to achieve those dreams and visions that you’ve got for your child.” So, there are messages that can always be explored, but it’s harder for public health agencies or primary care teams to use religious messaging, and it’s best to put that in, the hands of community partners.

Maggie Fox  11:21

Can we talk about some of the community partners that you identified in your research that were particularly effective maybe?

 

Ben Kasstan-Dabush  11:28

Sure, I’ve seen many different kinds of community partnerships and approaches in the way that messaging, for example, is developed. And just what community partners can get away with, they can often speak so much more directly to their communities in a way that healthcare services might not be able to do.

But I think it’s always important to say that that responsibility shouldn’t be delegated entirely. There are certain aspects that healthcare services need to have responsibility over, for example, making sure that messages are accurate and clear, and not misleading. So, there’s always got to be a relationship. I think again, because of the larger family sizes, there’s a huge emphasis on the kind of children and mothers and babies’ spaces, and so those are key areas to try and engage in. Of course, it’s a world separated by gender. There are community spaces that men, the community spaces that women use. So, I guess, it’s thinking about the messages, how you want them to circulate in those worlds, and ultimately hope that they’ll come together in the family home where parents can talk about it. But very often, we’ve seen it as a responsibility of mums when it comes to immunization, and hence they’re the key partners as well. They’re also your community partners.

Maggie Fox  12:38

So, what would be an example of a place where moms and babies would go where you would reach out to people?

Ben Kasstan-Dabush  12:42

In London, there are children’s centers that receive funding from local governments. They might have activities, classes, and a kind of daycare for children. We’ve often seen also vaccines delivered in those spaces which are opportunistic, because you’ve got an audience coming there, and so there are people to engage with, and have those conversations, if not offer vaccines in arms.

Maggie Fox  13:09

So, would you then train the people who work there? Who exactly is being engaged with there? How is someone from the outside world, a public health expert, engaging with the community partners, as you call them?

Ben Kasstan-Dabush  13:23

Well in those spaces, for example, we’ve seen a National Health Service (NHS) nurse going into those spaces and vaccinating children, with the adverts, obviously being designed in advance and advertising clinic times and that being done by the community partners.

So that’s that approach to co-delivery, where you’ve got the expertise from the communities, advertising it in a way that works and sharing it in the right networks, but your NHS nurse, vaccinating, logging, and making sure that the records are being kept effectively. So that might be one example.

But we’ve also seen lots of different innovations, particularly since COVID-19, where that was a very different opportunity, right? There was funding for immunization programs we hadn’t seen before, of training volunteer vaccinators. For example, in the Charedi community, there’s an organization called “Hatzalah,” which is a rapid response service funded and manned by Charedi communities, and they were trained to vaccinate. And so, you’ve got people from your community who look like you who are vaccinating you, and that might just instill an extra layer of confidence, or at the very least, a novelty, an incentive to come forward.

So, these collaborations can take many forms, and it’s important to recognize that they’re not cost-neutral. They are expensive, right? Anything going beyond standard service is expensive, but it’s understanding this as an investment in community health that gets the door open, conversation started, confidence built, and that has value in its own right. In this context of declining immunization coverage, we tend to see, and I have, especially since COVID-19, very much consolidated by COVID-19 as the term vaccine hesitancy.

I think my hope for the take-home message to listeners would be that it very much emphasizes people’s problems, that they’re not making the right decisions, and takes away emphasis, again, from programming, how these are developed. Are they conducive? How can that relationship be improved? How can we learn from people’s needs? So, I hope that that is a take-home message.

Maggie Fox  15:21

Ben, thank you so much for joining us.

Ben Kasstan-Dabush  15:24

Thank you for your time

Maggie Fox  15:26

Listeners, if you enjoyed this podcast, please share it. You can learn more about this podcast and other important topics at onehealthtrust.org and let us know what else you would like to hear about at [email protected]. Thanks for joining us.

 

Guest

Dr. Ben Kasstan-Dabush speaking on a microphone

Dr. Ben Kasstan-Dabush (MSc, PhD) is lecturer of global public health at the University of Edinburgh and assistant professor of global health and development at the London School of Hygiene & Tropical Medicine. Ben trained as a medical anthropologist and his research interrogates ideas and narratives of health protection, what it means, and according to whom. He is an expert on vaccine equity and has supported UK Health Security Agency and the CDC with responses to the spread of infectious diseases such as measles and polio. Ben’s research has been funded by the Wellcome Trust, British Medical Association Foundation for Medical Research, and National Institute for Health Research. Recent media comments include GaviThe Guardian, and Forbes.

Credits

Hosted and written by Maggie Fox
Special guest: Ben Kasstan-Dabush
Produced and edited by Samantha Serrano
Music composed and sound edited by Raquel Krügel

Transcript edited by Namitha Prabhu