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When Valerie Kobylnik became pregnant for the first time nine years ago, she was convinced vaccines were toxic. She’d seen and read plenty of material to persuade her — anti-vaccine blogs, YouTube videos featuring the parents of “vaccine-injured” children, and books like Vaccine Epidemic.

So the interior design consultant decided with her Ukrainian-American husband not to vaccinate their son or his brother, now ages 8 and 6.

Word of their decision spread through their tight-knit community of immigrants from Russia and the former Soviet Union in Clark County, Washington. In total, there are 88,000 Eastern Europeans in the state. Many speak Russian and go to the same schools, churches, and festivals.

“I’d get a phone call from someone who said they got my number from an aunt,” Kobylnik, who moved to Washington state in 1991 from Kyrgyzstan, a former Soviet republic, explained. “Why didn’t you vaccinate? Tell me why I shouldn’t,” the moms would ask her. “I always tell people to do their own research,” she said.

To that, a common answer she’d get was, “You’ve done all the research, so tell me.” She’d try to cut these conversations short because she didn’t want to be responsible for other parents’ decisions. But she saw her vaccine doubt spread anyway.

Over the years, Kobylnik estimates she’s received at least a dozen unsolicited calls from worried moms in her community. She’s been approached at baby showers, bridal showers, and weddings. Simply being a member of the Slavic community made her a trustworthy source, effective at spreading vaccine fear, like a real-life social media meme.

Today, the very same Slavic community in Clark County is at the center of a measles outbreak that has infected 72 people, most of them children.

Much of the media and policy conversation about the outbreak has focused on fake news and social media. If only Facebook could banish false vaccine posts, the problem of vaccine hesitancy would go away.

But that narrative ignores a crucial part of the anti-vaccine problem in America today. Measles in Washington — like many recent measles outbreaks in the US — has been spreading in a particular type of community: tight-knit and traditional.

In Washington, the virus has predominantly hit Russian-speaking groups hailing mainly from Ukraine and Russia, according to a source close to the matter. These groups have the lowest rate of vaccination of any population in Washington, the state’s most recent data shows.

And they’re not unique. An ongoing measles outbreak in New York involves mostly people from an undervaccinated Orthodox Jewish community. Since October, 304 people have been sickened by the virus — the highest number in the state in decades. Before that, it was vaccine-refusing Amish in Ohio and Somali Americans in Minnesota.

These communities have become an urgent focus of health departments across the country, said Nancy Messonnier, the director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. When measles strikes, outbreaks in tight-knit groups tend to be “explosive” and more difficult to control.

According to CDC data, 12 of the 26 measles outbreaks in the past five years (involving more than five cases) centered on tight-knit communities, which Messonier defines as people of a similar background who share values and beliefs and interact often. And because these outbreaks have been bigger, they account for 75 percent of recent measles cases.

While the reasons for vaccine skepticism may be different in each of these communities, the groups themselves have a lot in common. They’re cohesive and conservative. They appear to trust each other more than outsiders. They also speak the same languages and read or watch the same news. “We think these communities are more alike,” Messonnier added, and their insularity helps “outbreaks escalate.”

More than Facebook, the real-life social networks in these groups seem to turbocharge the spread of anti-vaccine views, and along with them viruses like measles. Just look at what happened in Washington, where Kobylnik became an influencer — and later changed her mind about vaccines.

How anti-vaccine views spread in Washington

Like every recent US measles outbreak, the one in Washington was sparked by a traveler. The person brought the virus back from Eastern Europe, where there’s a measles epidemic. (In Ukraine, vaccine hesitancy helped the measles vaccine rate fall to 31 percent in 2016. In 2018, there were 54,000 measles cases. This year, there are already 28,600.)

When someone with the measles brings the virus into an undervaccinated community here, it can spread like wildfire because measles is so incredibly contagious. Nearly everybody in a population needs to be immunized in order to stop the virus from spreading. Even a 5 percent opt-out rate can threaten what’s known as “herd immunity.”

When an outbreak happens, people who can’t be vaccinated — such as newborn babies and some people with cancer or allergies — are put at risk. Up to 40 percent of patients have complications from the virus. These usually occur in the very young (children under 5), in adults over 20, and in anybody else who is undernourished or otherwise immunocompromised. Children under 5 have the highest probability of death.

In Washington, Russian-speaking populations have the lowest rate of vaccination, “a consistent pattern since 2008,” according to a 2012 health department report (the most recent data available).

The problem also pops up in a 2016 Pediatrics study of vaccination uptake in the state’s immigrant groups, showing children of Ukrainian- and Russian-born parents were less likely to be vaccinated than their US-born counterparts. According to the 2016 study, 80 percent of the children of Ukrainian-born parents and 85 percent of the kids of Russian-born parents were vaccinated against measles — too low to sustain herd immunity. By comparison, 92 percent of their American counterparts were vaccinated at the time.

“Moms are more inclined to trust each rather than a random nurse they don’t know”

The Ukrainian and Russian coverage rates were even lower for the hepatitis A and pneumococcal vaccines. And these numbers might not reflect the current reality on the ground, said Dr. Tetyana Odarich, who works in urgent care in Clark County and also has a private practice in nearby Oregon.

Odarich’s practice caters to the Russian-language community, and over the years, she’s had to reassure dubious parents who’ve told her vaccines sicken all kids or that big pharma companies pay doctors like Odarich to peddle vaccines. (They don’t.)

But the myths persist. And Odarich estimates the immunization coverage rate for Russian-language families at her clinic hovers below 50 percent.

“These ideas spread like wildfire in this community,” says Odarich, who was born in Ukraine.

So where does the fear of vaccines come from? She believes it’s driven by a mistrust of government that built up after being exposed to years of propaganda and oppression in the Soviet Union.

“I went through the time of Chernobyl [the 1986 nuclear disaster],” she said. “There was a big explosion and the government didn’t tell people for over a week.” There, government was also synonymous with medicine since the state delivered health care. And she thinks her peers have had a tough time disentangling the two in America.

Another member of the Slavic community in Washington, Yuriy Stasyuk, echoed Odarich. He told me that a skepticism of liberal authority and elites, a legacy of living in the former USSR, contributes to vaccine refusal. Stasyuk, who emigrated to the US from the former USSR in 1991 at age 7 — part of a wave of refugees to the US.

But there’s another factor at play. “[It’s] an issue of tribalism. The community of Slavic people are close-knit — they know each other personally and there’s a strong sense of cultural identity,” he said. “The downside is that very often, people coming from outside of the culture or subculture, especially when they’re promoting values outside the traditional values and norms, can be viewed with suspicion.”

“Moms are more inclined to trust each rather than a random nurse they don’t know,” he added. So if other moms say vaccines are dangerous, whatever a public health official argues about the science might not hold much weight.

Kobylnik, who is now 32, learned that when she unintentionally became a source of vaccine doubt. Her skepticism was also rooted in a mistrust of the medical community. Growing up, she remembers being taken to a dentist who drilled into her teeth. Another doctor later confirmed that work was unnecessary, but it left her with “messed up” teeth.

Her parents told her, “[Doctors] aren’t here for [patients’] well-being — they’re just out to scam insurance companies.” She thinks views like these have been passed down from her parents’ generation to their kids. And many in her generation “choose to not to question it.”

Groupthink and vaccines

The vaccine that prevents measles (as well as mumps and rubella, hence the name MMR) has been proven to be effective and safe in dozens of studies, involving tens of thousands of people. Across the country, 91 percent of young children got the MMR vaccine in 2016, according to the CDC’s latest data.

There’s no question among researchers who’ve studied the shot that its benefits far outweigh its risks. That’s why it’s on the CDC’s vaccine schedule for children and a requirement for school entry across the US.

Still, MMR vaccine doubt was seeded in the 1990s, primarily by a study — and the media circus that ensued — from Andrew Wakefield, a discredited British doctor, who says there’s a link between vaccines and autism. The doubt has flourished and evolved since then, spurred on by anti-vaccine books, blogs, videos, and memes.

Since then, the overall number of parents who are opting out of vaccines for nonmedical reasons, while still a minority, has been creeping upward (from 1.1 percent in 2009-2010 to 2.2 percent by 2017-2018). In Clark County, it’s much higher: 7.9 percent of children had gotten exemptions from vaccines for entry to kindergarten in the 2017-2018 school year. Alan Melnick, the local health officer, told Vox that it’s not only Russian-language community members refusing vaccines or being affected by the outbreak.

But there’s a unique feature of tight-knit communities, like the one in Washington, that makes them even more prone to perpetuating false beliefs.

“Tight-knit groups are more susceptible to groupthink,” explained NYU psychologist Jay Van Bavel. “When you’re surrounded by people who hold a certain belief, it’s easy to sustain a belief that’s wrong.”

One major reason for this: Other group members — people whom you know well and trust — can affirm the wrong beliefs, and maybe even encourage them, as the Washington residents described.

There’s also social pressure to stay in the group. “When people highly identify with a group, they’re more motivated to hold beliefs that the other group members or group leaders hold,” said Van Bavel, who has studied this phenomenon in the political context. “All these are features of basic social psychology, and holding the right beliefs is part of how we sustain those relationships.” That is: Our personal identities get tied up with our group identities. To go against how the group thinks is to doubt ourselves. So we avoid it.

A challenge for public health

Similar dynamics have played out recently in the Orthodox Jewish community in New York. One vaccine-hesitant mom, who has no medical training, told me she created a library in her home, which is advertised in local anti-vaccine material, where parents come to borrow books about vaccines and discuss what they read. The library includes both pro- and anti-vaccine books, the mom said. “People can read and decide for themselves.”

Some Orthodox Jews also live outside the mainstream US culture, avoid technology, and hold rabbinic opinion in high esteem — which can help views that aren’t mainstream, like vaccine denialism, spread.

“Being a religious Jew, you also get used to having a minority viewpoint,” said Alexander Rapaport, the CEO of the Masbia Soup Kitchen Network in Brooklyn, and a public face of the Hasidic community, told me last fall. “So if something is not mainstream, it doesn’t take you away from believing it.”

He also explained that Orthodox Jews in New York go to school together, worship together, and live and travel together. This means a few unvaccinated people living in close proximity can be dangerous. But it also means that making inroads with public health messages requires extra effort.

The CDC’s immunization unit is well aware of the challenge and is now trying to shift its focus to reaching insular communities with vaccine doubts. “We’re realizing we need different approaches in each of [them], to understand local drivers,” Messonier explained. “We need to empower our local partners in order to be able to work with those communities.”

Part of that shift is not just about what type of messaging should be sent out, she added. “It’s about having the person saying it be somebody the community trusts.”

Why Kobylnik changed her mind and vaccinated her kids

In the latest Washington outbreak, Kobylnik’s experience is instructive. This year, she wound up giving her two children their first vaccine — to prevent measles — as measles cases mounted in Clark County. In part, her decision was inspired by a debate she had on social media with Yuriy Stasyuk, a Washington health data analyst and member of Kobylnik’s community, whom we met earlier in this story.

Stasyuk started posting criticism of the Russian-language community’s low vaccination rate on his personal Instagram page, along with vaccine facts.

Kobylnik pushed back, telling him about the videos she’d seen showing the parents of vaccine-injured kids.

Stasyuk reminded her: What about all the people who’ve had positive experiences?

A conversation ensued, and Stasyuk didn’t judge her for her views, like some of the doctors Kobylnik had met before. Instead, he helped her see she’d been a victim of confirmation bias — watching the scary videos and searching online using phrases like “vaccine-injured children” or “vaccines are dangerous” that confirmed her beliefs.

“When I was Googling, I [was] not looking for reasons to vaccinate. I [was] looking for reasons not to vaccinate,” Kobylnik told me.

She wants doctors and health officials to take a similarly gentle approach. “If doctors were more neutral about this, and didn’t take it so personally with parents, that’d go a really long way toward breaking the stigma with vaccines,” she said.

Van Bavel, the psychologist, endorsed that approach too, saying health officials “should reach out to the leaders or people in those social networks who are hubs for information, and try to educate them and help them disseminate the science.”

That’s something Odarich is already trying to do. She treads softly on the vaccine issue after realizing how fearful vaccine-hesitant patients are. When she senses a patient has entrenched views, instead of trying to debunk them right then and there, she offers Russian-language brochures containing science-based information about vaccines, urging the patient to take and read them.

“They’re people who have different views, but they’re still people,” Odarich said. “We have to create a safe environment to talk about vaccination.”

Editor’s note 3/20/19: A previous version of this story included a few paragraphs describing how one of Odarich’s patients objected to the measles, mumps, and rubella vaccine because she thought it contained cells originally extracted from women who are about to have an abortion. It also said that Odarich was left “speechless” by this claim because it was untrue.

In fact, the patient was partially right: the rubella component of the MMR vaccine contains traces of fetal cells because the vaccine continues to be grown in labs from embryonic cells originally obtained from an elective abortion in the 1960s. However, the quantity of residual DNA from these cells is less than 100 picograms (trillionths of a gram). According to the National Catholic Bioethics Center, using these vaccines is justified because the “risk to public health, if one chooses not to vaccinate, outweighs the legitimate concern about the origins of the vaccine.”

The paragraphs have been removed from the story for accuracy and clarity.