On Oct. 12, Pennsylvania confirmed its sixth measles-associated death this year. The state’s outbreak has spread to dozens of counties, sickened over 1,200 people, and put 176 in the hospital. More than 4,400 confirmed cases of measles have emerged across America this year, the most in more than three decades.
It’s all the more upsetting because in 2000, the United States accomplished something extraordinary: We eliminated measles. This November, we could officially lose that status.
It’s tempting to fully blame the return of measles on vaccine misinformation and political polarization. While those forces matter, I believe we’re overlooking a deeper problem: America has gotten worse at persuading people to protect one another.
America’s public health communication, which tends to tell and not teach, has failed. We issue guidance and expect compliance. When people hesitate, we throw labels at them. You get one group that’s framed as “anti-vax,” another group that’s framed as “pro-vax,” and people from these two tribes stop listening to each other.
Stopping an outbreak requires understanding why people aren’t vaccinated, what might change their minds, and what barriers are getting in the way.
When America eliminated measles from our shores in 2000 it came as the result of a decades-long project of building collective immunity, due in no small part to mandates. School vaccine requirements gained speed in the 1970s and became widely enforced by the 1980s.
But when mandates or control measures are used as the main tool in a crisis response, a short-term impact can be difficult to sustain.
Consider the numbers: 37 years to build the immunity needed to eliminate the virus. Twenty-six years of resistance, suspicion, and misinformation to reintroduce it. Psychologists call the instinct to push back against restrictions on freedom “psychological reactance.” Left unaddressed, it has hardened into an us-versus-them mentality, and what now feels like vaccine tribalism.
I’ve spent much of my career fighting outbreaks around the world, where outreach health workers have built trust by knocking on doors, listening to people’s concerns, and enlisting religious leaders, neighbors, and other trusted voices. They approached skepticism with questions, not judgment.
What’s ironic is that in the parts of the world like I grew up in, in Liberia and throughout parts of Africa, many people still don’t have access to measles vaccines. You still see regular measles outbreaks. You see children die from measles. In those settings, you see people voluntarily take vaccines, regardless of the policy on mandates, because they see the consequences of not having that. As measles outbreaks spread in Pennsylvania and other states, it may be time to learn how other countries get their outbreaks under control.
The countries that do this well engage community leaders, religious leaders, and other respected figures to be part of the vaccination team. They treat people’s experience as expertise itself. And they act on a lesson I’ve learned over and over as a doctor: You don’t necessarily have to change someone’s beliefs to change their behaviors.
When such community-led methods have been applied here against other vaccine-preventable diseases, they work. In the summer of 2022, New York confronted a case of paralytic polio, a disease whose wild form had been eliminated here in 1979. State and local officials paired vaccination mandates with intensive, on-the-ground outreach in Hasidic Jewish and other communities where immunization rates were lowest. Public health workers and trusted community nurses held in-person discussions in synagogues, clinics, and living rooms to explain how polio spreads silently, why the outbreak appeared, and how a temporary vaccination requirement protected the most vulnerable. There were no new cases after 12 months.
While I served at the White House during the Covid pandemic, we worked with a program called Shots at the Shop, which capitalized on preexisting community and trust to disseminate truthful information about Covid-19 vaccines, supporting shop owner participants with $1,000 grants. These barbers and stylists reminded us that trust is not built from Washington, but by local trusted leaders.
What would it take to win back what we achieved in 2000?
First, fund trusted messengers for years, not weeks. Even as outbreaks end, the suspicion of vaccines used to control them can persist. Governors and health departments should give multiyear grants, during and in between outbreaks, to community organizations for door-to-door canvassing, education, and mobile outreach. And we should ensure these community leaders partner with messengers who residents already trust: Most Americans, around 80% – 90% in some surveys, still trust our own doctor or health care provider.
Second, give the people most at risk a seat at the table. Work with — not just for — those most at risk. Every state-level outbreak task force should ask: “Who lives with the consequences of this decision, and are they helping shape it?”
Third, approach the unvaccinated in a nonjudgmental way. Rather than “why are they acting this way?” or “why won’t they just follow the guidelines?,” public health officials should ask: “What barriers make it hard to follow the advice that makes sense?”
We may find, as I have, parents may be misinformed, unable to afford a bus ticket, or worried about taking time off work. If identified, some of these barriers can be resolved. Barrier-oriented questions reveal solutions. Blame-oriented ones don’t.
For decades, measles was invisible to most Americans, and the MMR vaccine, like many preventive tools, became a victim of its own success.
Seeing is believing. Now we are seeing again: unvaccinated patients in hospital beds, families grieving in Pennsylvania, and many parents worried about sending children back to school in under-vaccinated communities. We can retreat further into our “anti-vax” and “pro-vax” tribes. Or we can remember how we got to 2000: by finding common ground. Eliminating a disease happens door by door, conversation by conversation.
Raj Panjabi is a Harvard Medical School and Mass General Brigham physician, adviser to the Governors Public Health Alliance, and former White House senior director for global health security and biodefense at the National Security Council. He is author of “Safer: A Playbook — Turning Fear into Action and Crisis into Community.” (HarperOne).