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Opening Vaccine Dialogue Across Cultures: Measles Outbreak in Minnesota

Nusheen Ameenuddin, MD, MPH, FAAP
July 26, 2017

“Most of you already know Dr. Nusheen, because she sees your kids” is how I was introduced on my home turf at the first of a series of talks with Minnesota’s Somali community.  It was during our state’s worst measles outbreak to date.

By the week before Memorial Day this year, Minnesota had already reached 69 measles cases, more than all U.S. cases in the previous year. Because the outbreak primarily affected unvaccinated Somali children, our state health department, American Academy of Pediatrics chapter and others partnered with leaders in the Somali community to train and dispatch teams of imams (religious leaders) and physicians to engage and inform the community about this threat.

I feel privileged to work with a vibrant patient population that includes many Somali-Americans. I met some families as new arrivals to this country, while others have become my second generation of patients. We are fortunate that Minnesota’s children’s health insurance coverage is at an all-time high of 97 percent, thanks to Medicaid and CHIP. But despite having some of the best health measures in the nation, we still struggle with the highest disparity in health outcomes between ethnic groups.

One particular area of concern centered around vaccination rates. In 2004, the MMR immunization rate for Somali children in Minnesota was 92 percent, higher than that of non-Somalis (88 percent). But due in large part to a targeted effort by anti-vaccination groups, MMR vaccination rates dropped dramatically, to 42 percent, over a decade.

Knowing that I would have to counter entrenched vaccine myths, I prepared for my first talk by reviewing pseudoscientific claims on anti-vaccine websites. But years of discussions with vaccine-hesitant parents of all backgrounds had taught me that facts alone would not convince skeptics, particularly when fear was involved.

In the mid-1980’s, the vaccine for HIB was released and thirty years later we no longer see this disease. Because of the effectiveness of this vaccine my younger partners only know of HIB meningitis through textbooks (and some of my anecdotes).

This is the recurring story of vaccine preventable diseases.

- See more at: https://www.aap.org/en-us/aap-voices/Pages/We-Can%27t-Let-Our-Guard-Down-Against-Vaccine-Preventable-Diseases.aspx#sthash.196pj2e8.dpuf
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Some injuries
It was my job to address parents' concerns and explain the science, extraordinarily rigorous safety testing and continuous monitoring behind vaccines that most people outside the field of pediatrics do not know."​​

Taking a page from the 2016 AAP Clinical Report Countering Vaccine Hesitancy, I knew that this dialogue was meant to be ongoing. It was my job to address parents' concerns and explain the science, extraordinarily rigorous safety testing and continuous monitoring behind vaccines that most people outside the field of pediatrics do not know. Sharing how parents of hospitalized measles patients heard their children gasping for air, feeling helpless to intervene, also reinforced how dangerous this disease was--even with modern medicine to assist.

I found an insightful article by public health nurse Sahra Noor, the CEO of a public health clinic in Minneapolis, who said that in health care, we are trained to talk to the head rather than the heart. She pointed out that it's not always the message that matters, but the messenger. Her piece changed my entire approach.

It struck me that my own background, as an American Muslim woman physician of Indian ancestry who wears a hijab (religious headscarf) might serve as an asset in establishing connections with the Somali community in other parts of our state where no one knew me. The irony that these same characteristics sometimes seemed to create an unintentional barrier for others was not lost on me. It also helped me appreciate what an honor it was to be invited to speak at mosques during Ramadan, the holiest month for Muslims.

Before each talk, I greeted the audience with the traditional "Peace be upon you," a gesture warmly returned. Then, I scrapped my didactic lecture and fell back on what I was taught in medical school: listen and learn.

I told audiences that they could ask me anything. Working in tandem with the imam and a Somali interpreter, whose efforts were crucial in establishing trust and relaying the message, I went through a brief debunking of measles, mumps and rubella (MMR) vaccine myths and explained how serious measles was, pointing out that nearly one-third of affected children required hospitalization.

​" I learned that before the civil war, Somalia had one of the highest vaccination rates in Africa. Elders shared stories of being wrapped in goat skin while ill with measles and seeing children die from this disease."​​

In the clinic, we don’t often have the luxury of time, but I was able to spend a few hours at each place I visited. Kneeling with people on the beautifully carpeted floors of different mosques during Ramadan, breaking fast with shared food, being embraced by women I just met who called me sister even with limited English, and standing shoulder to shoulder in prayer gave me the gift of getting to know people who opened up about their deeper concerns.

I was asked why children “stopped talking” (which is how many in the Somali community describe autism). After explaining what we did and did not know about the causes of autism, it was gratifying to hear a mother tell me that she would have her daughter vaccinated tomorrow.

However, it was some unexpected statements from community members that were far more enlightening and humbling. I learned that before the civil war, Somalia had one of the highest vaccination rates in Africa. Elders shared stories of being wrapped in goat skin while ill with measles and seeing children die from this disease. People spoke of the need for help to understand and manage other medical conditions like attention deficit hyperactivity disorder (ADHD). They asked us to come back.

At the end of each talk, I asked the community for help in leveraging their powerful oral tradition to combat anti-vaccine rumors. Within weeks of the outbreak, thanks to the dedicated work of public health officials and in particular, the active collaboration of the Somali community, we saw a significant uptick in MMR vaccinations and a subsequent slowing of new measles cases, with a total of 79 by mid-July.

The state’s ability to swiftly deliver mass vaccinations was due in large part to a robust Medicaid system that covered many of our most vulnerable children, including those in the Somali community. Caps to Medicaid would have impeded our ability to effectively contain the outbreak, provide necessary treatment and even routine preventive care.

One of my favorite experiences was meeting an entering medical student whose mother told me how excited he was that a doctor was coming to speak at the mosque. He explained to me why autism was so distressing to a community grounded in a strong oral tradition. He also said that he wished more of the young girls in the community had attended my talk so they might consider new possibilities for themselves. His words brought tears to my eyes, because I realized then that both the message and the messenger had an impact in ways that I had not anticipated.

The views expressed in this article are those of the authors, and not necessarily those of the American Academy of Pediatrics. ​​​​​


​​​Ab​out the ​​Author
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Nusheen Ameenuddin, MD, MPH, FAAP, vice-chairperson of the American Academy of Pediatrics Council on Communications and Media executive committee, practices community pediatrics and adolescent medicine at the Mayo Clinic in Rochester, Minnesota. She also serves on the Board of Directors for the Minnesota Chapter of the AAP.


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