Since the first case of the latest outbreak was documented on April 11, 70 children in Minnesota have been diagnosed with measles. Of those 70 children, 68 had not received the measles, mumps and rubella (MMR) vaccine and, of those 68, 64 lived in the tight-knit Somali community centered in Hennepin County, which has been growing since the 1990s.
Measles is typically contracted through the lungs. Unlike other pathogens it leverages the body’s natural reaction against itself, using immune cells for growth and replication. The virus travels through the bloodstream and infects the capillaries, resulting in the telltale rash, while destroying epithelial tissue meant to protect a person from diseases. If the virus crosses a blood-brain barrier, it will enter a child’s brain, triggering neurological issues like encephalitis, or swelling of the brain, that can lead to deafness, intellectual disabilities, and death. In rare instances, children can develop subacute sclerosing panencephalitis—a chronic and fatal form of progressive brain inflammation that occurs 7 to 10 years later. However, most individuals who die from measles don’t die from the disease itself, but from common ailments like bacterial pneumonia that are easily cured in patients, particularly young patients, without compromised immune systems.
The Centers for Disease Control and Prevention estimates that for every 1,000 children who contract the measles, one or two will die from it. But it only took 460 cases to claim the lives of three Minnesotans during a massive outbreak 1990. The Minnesota Department of Health officials are aware of 8,250 people who have been exposed to the disease in 2017 so far and have asked 586 of these individuals to abstain from group settings like church or school.
During Ramadan, that’s a big ask for Hennepin’s overwhelming Muslim residents. Local parents will need to make difficult decisions to protect the health of their children–and not for the first time. The community has been roiled and split by the debate over the vaccination of children against measles since 2008, when researchers asserted that local autism rates were unusually high and anti-vaccine activists, who railed against MMR injections, descended on local mosques and libraries. The result? Sick children and more hard calls. Recent measles outbreaks have occurred in houses of worship, which amplifies the already significant public health concern about the rapid spread of a dangerous and preventable disease.
“Because of the low vaccination rates among the Somali community, this was something we were expecting,” says Asli Ashkir, a nurse and consultant for the Minnesota Department of Health.
Ashkir, who is of Somali descent herself, has been working in the Hennepin area, advocating for vaccination since 2013. She has been tasked with countering the anti-vaccine propaganda that has been in circulation for years. In 2008, when J. B. Handley penned “An Open Letter to the Somali Parents of Minnesota” encouraging Somalis to distrust the Minnesota Department of Health’s vaccine recommendations, the community started to turn against scientific consensus. In the years that followed anti-vaccine activists, including Andrew Wakefield, whose famously fraudulent 1998 research paper linking the MMR vaccine with autism sparked the “anti-vaxx” movement, and the late Dan Olmsted, showed up in Hennepin to evangelize.
Vaccination rates dropped precipitously. Prior to 2008 the Somali community’s MMR vaccination coverage rate was among the highest in the state. Over the following eight years it plummeted, falling to 42 percent. The average rate in Minnesota hovers between 89 and 90 percent.
Between 2010 and 2011, Wakefield visited the Somali community in Minneapolis several times. He spoke to groups of up to 100 at a time eager to understand who and why their kids have autism. They were desperate enough for answers to turn to a man who’d had his medical license revoked and was facing allegations from the British Medical Journal that his work was not just wrong, but intentionally dishonest. Dr. Abdirahman Mohamed, a Minneapolis Somali family practice physician, told MPR that Wakefield’s message had cost lives. “He’s using a vulnerable population here, mothers looking for answers,” Mohamed said. “He’s providing a fake hope.”
Jenny McCarthy Body Count—a pro-vaccine site that attempts to track the downstream effects of anti-vaccine activism by leveraging a combination of data from the CDC’s Morbidity and Mortality Weekly Reports and the National Vital Statistics Reports—projects that the anti-vax movement has caused 152,763 preventable diseases and 9,028 deaths so far.
Currently, the most high-profile anti-vaccine activist influencing the Somali community is Mark Blaxill, a Philadelphia-based Executive Director of XLP Capital, who eschews the “anti-vaxxer” label in favor of “pro-vaccine safety,” but draws connections between immunization and autism. Blaxill met with roughly 90 Somali parents on Sunday, April 30th, 2017 at the Safari restaurant in Minneapolis, presenting information on the dangers of measles, which he believes are overstated, and CDC immunization cover-up theory that has been debunked many times.
“The hysteria that has been drummed up around some minor measles outbreaks has recently become unhinged,” Blaxill, the father of an autistic daughter, wrote in an email to Fatherly. Blaxill declined to be interviewed citing concerns with press fairness and accusing the Boston Herald of calling for his execution by hanging. (In an op-ed, Rachelle Cohen wrote that “lying to vulnerable people about the health and safety of their children ought to be a hanging offense.”)
Michael Mina, an MD/PhD who studies the long-term effects measles has on the immune system dismisses Blaxill’s dismissal. “There’s this myth that measles is a benign childhood disease and that myth exists because prior to the vaccine, every single kid got measles,” Mina explains. “Ultimately if you were to squeeze all the years of HIV together it would look like an acute measles infection.”
Mina published a study in 2015 that found that measles could make a person’s immune system more vulnerable to infectious diseases for two to three years, and as he hypothesizes, perhaps longer. What happens to the immune system in HIV over years happens in measles over the course of days and “HIV doesn’t do as much damage to all of the tissues.” He hopes to research this further with the current outbreak and is in talks with the Minnesota Department of Health about moving forward on that.
Mina is trying to figure out a way to work with the Minnesota Department of Health. The Somali population in Minnesota, by far the largest concentration Somalis in the U.S., is perfect for study for the same reasons it is intensely vulnerable.
Minnesota has a history of welcoming refugees and immigrants. There are approximately 85,700 Somalis in the U.S. and around 25,000 live in Minnesota–one out of three. They make up a significant part of the economy, paying an estimated $75 million in local and state taxes, owning $165 million in residential real estate, and operating roughly 600 businesses. Though they first began migrating to Minnesota in the 1980s and earlier, the population spiked after civil war broke out in Somalia in 1991. Many expatriates and community organizations helped immigrants move to Minnesota, leveraging a clan system that categorizes people into social groupings. In Somalia, that system tends to sort people by class, but in Minnesota it translates into the emergence of large extended families and a cohesive sense of community.
Minnesota’s Somali-Americans are generally observant of Somali and Islamic tradition, which is why Ramadan presents a potential public health hazard in the middle of an outbreak. The month-long holiday, which is meant to honor self-discipline, self-control, sacrifice, while encouraging a sense of generosity and charity. Individuals above the age of puberty abstain from food, liquids, smoking, and sex until sundown and then join each other (and their children) for post-fast meals. This creates numerous opportunities for viral spread leading up to the June 21 celebration of Laylat al-Qadr, the “night of power”, which honors the first Quran revelation was sent down to Muhammad and is regarded as the holiest day of the year, and Eid al-Fitr, the large feast marking the end of the celebration.
That final feast falls on June 25 this year and will span several days of gatherings in mosques and homes. The community will come together to share–for better and worse–everything. As of now, the Department of Health hasn’t issued any blanket bans or statements on gatherings. No one wants to cancel a holiday. But there are real and immediate concerns.
“We are encouraging people to avoid any groups of kids coming together,” Ashkir says of her work in the Somali community. In her opinion, which she was specific to separate from the Department of Health as a whole, is not worth the risk. “You never know when one of them is going to have the measles.”
“We’re concerned about Ramadan because it presents the opportunity for lots of large gatherings and mixing within the community,” Kristen Ehresmann, Director of Infectious Disease Epidemiology, Prevention and Control at the Minnesota Department of Health, to Fatherly. “In particular, we’re concerned about the end of Ramadan feast.”
According to the CDC, the measles virus is so contagious that it only takes one person to have it for 90 percent of the people close to that person to become infected if they are not immune.
In the end, the decision to stay home from Ramadan is up to the very parents whose genuine fears and questions regarding their children’s health have been triggered repeatedly by anti-vaccine activists. Parents may no longer be in a position to protect both their children and their cultural traditions. The closeness of their community, the very thing that brought many to America and allowed them to carve out lives for themselves and their families, has become a liability. Those are the big realities, the big thoughts. The smaller thought is the one that lingers: It is possible that everyone in Hennepin County has tried to do right. And it is possible–even likely–that all of those efforts will end in the death of a child.