Embracing a community’s practice to promote the measles vaccine

Mimicking a news-sharing custom common among ultraorthodox Jewish communities, two Penn Nursing students created and placed large posters around a Jerusalem neighborhood, deriving content from a mystical technique that assigns a numerical value to each Hebrew letter.

A girl in a blue fleece standing in front of a wall of black and white posters in Hebrew. Boxes of children's toys are in front of the wall.
Naomi Shapiro, a senior in Penn Nursing, in front of a wall of pashkevilim. These posters often contain language that can seem harsh or extreme to someone not accustomed to their tone. But within the community, they are well-received and taken seriously.

Despite a 50-year-old measles vaccine program in the United States and a declaration 20 years ago that the disease had been eradicated here, measles is making news again, with the Centers for Disease Control and Prevention (CDC) reporting 127 cases in 10 states through mid-February. 

In 2018, the CDC reported almost 400 cases, including 64 from an ultraorthodox Jewish community in Brooklyn, near where Penn Nursing senior Naomi Shapiro grew up. In all likelihood, that rash of cases began when an unvaccinated child traveled to Israel, where an ongoing measles outbreak persists, then returned home with the disease, spreading it to others in the close-knit community who also hadn’t been vaccinated.  

Two girls in blue Penn Nursing fleeces standing in front of a poster in Hebrew.
Penn Nursing seniors Liat Greenwood (left) and Naomi Shapiro created the black-and-white poster behind them to encourage vaccination against the measles in Jerusalem, where they studied abroad in fall 2018. 

Shapiro and classmate Liat Greenwood, also a senior in Penn Nursing, were both raised orthodox and continue the practice today. They know what it means to be part of such a group, how news gets disseminated, and who people trust. As future nurses, they also understand the importance of preventive medicine and inoculations.  

So, during their fall semester abroad in Jerusalem, they used their background and what they’ve learned in nursing school to create an outreach program promoting the measles vaccine geared at an ultra-religious Jewish group called Haredi. Because many in that community get their news from black-and-white posters called pashkevilim hung around the neighborhood, the Penn students decided to make one. 

“In Jerusalem, there is a huge measles outbreak. There were 2,690 cases of the measles in 2018 alone, which is a huge increase from the fewer than 40 cases in 2017,” Shapiro says. “We had visited some of the well mother–baby clinics and we saw how they worked, but we couldn’t do all that much during our clinicals. We decided to address this outbreak” in a different way.

Doing that meant meeting the community where they were, both literally and figuratively.  

Pashkevilim, also called broadsides, use strong language to prescribe “appropriate” behavior. To someone not accustomed to their tone, they can seem harsh or extreme. But within the community, they are well-received and taken seriously. That’s why Greenwood and Shapiro took great pains to study as many of the health-related broadsides they could find, and sought instruction and guidance from a nurse who had worked closely with the Haredi. 

Liat Greenwood, a senior in Penn Nursing, stands in front of a wall of pashkevilim, also called broadsides. They represent one of the main sources of news for ultraorthodox communities in Israel and elsewhere. 

One of their professors from Hebrew University recommended that their poster’s content follow a practice called gematria, which assigns a numerical value to each Hebrew letter of a word. “This is a mystical technique that holds a lot of weight in the community,” says Greenwood, who grew up in West Orange, New Jersey. “From our fieldwork, we learned that, especially in insular communities, it’s important to understand what they value. This is something they place high value on.” 

Using gematria, they calculated a numerical value of 500 for the Hebrew word for “measles,” then looked for other words and phrases with the same value. They came up with the Biblical phrase for “spiller of blood.”   

“We were trying to say that all those who refuse measles vaccinations, it’s as if you are a spiller of blood,” Shapiro says. “We took this phrase from a different one that’s well-known in the community: ‘All those who embarrass others, it’s as if he spills bloods.’ It’s the same idea.” 

Greenwood explains further. “The numerical value for the word ‘cancer’ is the same as the numerical value for ‘internet.’ A poster that went up 15 years ago said something like, ‘They are the same value, therefore if you use the internet, you will get cancer.’ It’s a similar kind of syntax that’s not shocking to the community and that we knew they would respond to.” 

They hung 40 copies in a part of Jerusalem called Me’a She’arim, and then spent the next day walking around the neighborhood trying to gauge community members’ reactions. Ten had been either taken down or covered over, but the Penn students did not experience a negative response to the message.

Shapiro and Greenwood left Israel shortly after completing the project, and while they don’t have long-term data on the effects of their broadside, they do plan to incorporate their experience in future work in Philadelphia, particularly with insular communities that can be otherwise hard to reach. 

“Even though both of us are practicing orthodox Jews, I didn’t really know what it meant [to be ultraorthodox] until I immersed myself where they live,” Greenwood says. “It’s made me more thoughtful of cultural competence. But to really be able to do preventive care in these communities, you need to not just be culturally competent, you need to embrace that community’s values, too.”