Maybe cell phones do maraud a little bit, but so what?

Now, instead of thinking that the concern for cancer risk from cell phones is BS, I think the concerns are exaggerated and misplaced. Let me explain.

When I wrote my previous post, I was not aware of the meta-analysis from 2009 by Myung et al. in the Journal of Clinical Oncology. (A meta-analysis uses statistical techniques to classify and then pool results from a number of studies.) The work by Myung et al. needs some detailed discussion, but it presents some findings which bear consideration: first, that in the subgroup of studies they considered which were of higher quality, there is a positive association between any cell-phone use (compared to rare or never use) and brain tumors both benign and malignant. Second, there is a significant association, in all studies which consider cell-phone use of 10 years or longer, between that length of use and brain tumors.

There are some caveats here. First, the "high-quality studies" are all chips off one larger study, i.e. done by the same group of researchers - and the lower-quality studies are all from another larger study. This means that there haven't been too many separate groups studying this topic recently in a scientifically legitimate way. Second, all the studies considered in this meta-analysis (23 of them) are case-control studies, which for various reasons are often considered more susceptible to bias than cohort studies, in which groups of subjects are followed for the development of brain tumors. Thus the biases I talked about in my previous post still apply.

Since the associations are small, susceptible to bias, and only in a subgroup of available studies, I would say the jury is still out.

Even when the jury comes back from sequestration (cell phones turned off, I guess), my general impression from my previous post holds true. I would not make any individual change in lifestyle, much less any public policy decisions, based on these weak-if-true associations, just because there are so many things in this world (even confining ourselves to our individual and public health) which are more important to worry about.

Happy Rambam's yortsayt!

In honor thereof, Rambam's authorized manuscript copy of of the Mishneh Torah...online. Hat tip to Language Hat.

Goldberg the Tank Engine

Goldberg had been out all of Thursday and Friday; he was hot and tired. Towards Friday afternoon, he saw that the Driver and the Fireman were coming out. He decided to speak to them.

"Are we going out this evening?" he asked.

"Yes," said the Fireman, lighting the fire and making a lot of steam.

Goldberg looked cross. "It is my Sabbath," he said, "my day of rest. I do not want to go out on the Sabbath."

Goldberg's friend Patel the Locomotive chimed in. "Please do not make Goldberg go out on Saturday," he said.

The Driver pulled the lever, and Goldberg began to pull away. "Oh no!" he cried. "We are going out. I will have to travel beyond the inhabited boundaries of Sodor."

Patel shouted, "Help! Somebody help Goldberg!"

Another friend of Goldberg's, Peng the "Old Warrior," shunted a car onto the track that Goldberg was traveling on. There was a tremendous noise.

The Fireman shook his finger at Goldberg. "I am very cross that you are not going out today," he said. The Driver agreed.

"I am sorry," said Goldberg.

Epic recommendations

I asked my Facebook friends to recommend book-length poems to me. I am stashing the list here for my reference and anyone else's curiosity.

Garbage, A.R. Ammons
Letter from Iceland, W.H.Auden & Christopher Isherwood
A Poetics, Charles Bernstein

Beowulf
Der Geyer, M. Boraisho
The Ring and the Book, Robert Browning
Don Juan, Lord Byron
Watercolor Women/Opaque Men, Ana Castillo
Points for a Compass Rose, Evan S. Connell
The Bridge, Hart Crane
South America Mi Hija, Sharon Doubiago
The Song of Hiawatha

Sir Gawain and the Green Knight
The Odyssey, Homer
Anathemata, David Jones
Dizner Tshayld Harold, Moyshe Kulbak
Fungi from Yuggoth, H.P.Lovecraft
Idylls, Jonas Mekas
Pale Fire, Vladimir Nabokov
Collected Works of Billy the Kid, Michael Ondaatje
Metamorphoses, Ovid.
The Same Sea, Amos Oz
Eugene Onegin, Alexander Pushkin
Testimony, and Holocaust, Charles Reznikoff
Golden Gate, Vikram Seth
‎Paterson, William Carlos Williams
Deepstep Come Shining, C.D. Wright
A, Louis Zukofsky

Unanswered Questions for Philip Larkin in Poetry Magazine's new Q&A Issue

What are your thoughts about confessional poetry?


Many readers will be put off by the lines about mum and dad "fuck[ing] you up." Should they be, or not? What are the lines there for?


Whence the coastal shelf?


The last lines are more revealing than others in the poem. Tell us why you would rather not procreate.

Let us discuss the murderous cell phones stalking our fair land

Cancer and cell phones - I meant to blog about this for some time, since it has long trended among the most read articles at the Times website.

To be charitable, the article did make me go and look up the literature, so that's not a bad thing. In short, however, the Times treatment is irresponsible and fear-mongering.

First, let me remark that the Times article mentions by name a refereed study of cellphones in humans only in the 14th paragraph. And it neglects to mention the multiple studies which have shown no connection.

Now, let's consider the INTERPHONE study referred to in the Times piece (it's one of these with the fake acronyms). It showed no connection between cell phone use and cancers, when all brain cancers are taken together. Now, it's reasonable for them to analyze different cancers separately, since they are of different severity and prevalence. It's not questionable in itself that they looked at an effect on gliomas. However, this effect was not significant. Only when they looked at cell phone use for 10 years or longer did they find an association with gliomas.

Several caveats - screaming sumo-size caveats - were not mentioned in the Times piece. (A science reporter presumably would have read the article.)

1. As far as I can figure out from reading the article, it's a secondary analysis. There was no a priori hypothesis that cell phone use for 10 years would be associated with glioma. Post hoc analyses are suspect - as you know - since data mining is biased. How many associations were fished through and discarded before this positive one was found? There is always a probability of a false positive, so if there were twenty post-hoc associations (properly consigned to an on-line appendix, pace the Times's conspiratorial mutterings), the chance of one positive finding is 5% - just by probability.

2. The association itself is not statistically significant! This is mentioned nowhere in the Times article, but the authors of the study themselves make haste to note this up front, in the abstract - which makes them responsible. I would not call this a hook to hang anyone's hat on.

3. The INTERPHONE study is a case-control study. A big question in any study of this kind is how we are to judge the accuracy of the cases' self reporting. People with cancer are understandably eager to find a cause, and might recall cell phone use out of proportion to the controls. Such recall bias is hard to control for.

4. Even if recall bias is controlled for, the correlation between recollected number of cell phone calls and the actual number of cell calls is not perfect. Heavier cell phone users tend to overestimate the number of calls they have made. In addition, the correlation between subject recall and their actual exposure to electromagnetic frequency is not airtight either.

5. Let's say the effect is real (which I very much doubt by reason of the sumo caveats just mentioned). (This would contradict another case-control study done on the very relationship between gliomas and cell phone use, in 2005, which was negative.) How high should this putative danger even rank on our public-health agenda?  Gliomas are rare.

To quote a 2004 study in the journal Cancer (first thing I could Google): "The incidence rate of central nervous system (CNS) tumors in 2000 was 6.7 per 100,000 persons as reported from the Surveillance, Epidemiology, and End Results (SEER) registry and gliomas account for approximately 51% of all CNS tumors.". Let's say then 3.5 per 100,000 people. or 10,000 cases a year, more or less. Horrible cases to be sure. If cell phone use increased this number to 20,000 cases a year that would be a tragedy, but a tragedy comparable to the million deaths caused yearly by malaria?

6. In toto: bullshit.

Update: but see some second thoughts here.

Contemporary Yiddish Literature: a personal view

The original of an article of mine published in Polish.

What people used to call "Yiddish literature" without qualification is fading away, and what we are not used to calling "Yiddish literature" is thick on the ground.

We'll start with the first. This includes everyone who writes in Yiddish who is not Chasidic. For lack of a better word, we'll call them secular Yiddish writers, though their ideological, religious, and cultural sympathies run the gamut from the settler poetry of Velvl Chernin to the loud radicalism of songwriter Daniel Kahn. They are the heirs to the literary tradition of Eastern Europe and America, what was Yiddish literature with a capital L: a social phenomenon complete with newspapers, journals, books, printers, publics, writers, controversies, scandals, sex, and violence.

For secular Yiddish writers, nearly all of that has fallen away. Traditional venues, things still published on paper, can be counted on the fingers of one hand. There's the newspaper: the Yiddish Forward. There are the two or three literary journals. There is about a book, maybe two or three books at most, published a year. There is the Internet, certainly providing community - or the illusion of community - and a way for writers and readers to interact. But this cannot substitute for a community of people who spend their lives and make their living writing and reading. At this point, the number of people who make their living writing Yiddish in the secular community is about a minyan: the number of people on staff at the Yiddish Forward.

This does not mean that individual writers are not still producing individual works worth reading, or that the few literary institutions that still exist in the Yiddish secular world are not valuable. The Yiddish Forward, polished to a high literary sheen by Boris Sandler, has few parallels among Jewish publications anywhere - except perhaps the cultural pages of Israel's Haaretz in Hebrew. I suspect that some readers find it difficult to understand its mix of politics, culture, and academic analysis, but won't admit it. Gilgulim, a literary journal in Paris, is lovely (and I hope will come out for many more issues). Afn Shvel, the journal of the League for Yiddish, has been transformed into a modern publication, beautifully laid out and with a variegated content. It looks like the 21st century's last gesture towards the relevance of print in Yiddish.

There are a number of writers still working in Yiddish, though it's hard to know exactly how many - probably a hundred or so. Which to mention is an interesting question. In a healthy, king-size literature, like English, critics try to predict things: which writers will turn the great ship of written language in some unlooked for direction? out of all the abundance, what is worth reading? The first question is irrelevant to contemporary secular Yiddish literature, since the greatest ship of all is the daily language use of the ultra-Orthodox. We are gnats on it. The second question is irrelevant for other reasons. If you wanted to, you could easily afford to buy every single new book published this year by secular Yiddish writers. But let me name-check some loves of mine: anything published in Gilgulim; the strict, erudite, and tightly edited reviews of Mikhail Krutikov in the Forverts; the prolific post-Holocaust yearning of Alexander Shpigelblat; the monumentum aere perennius of Avrom Sutzkever, may his poetry be for a blessing.

The editors asked me to address some particular questions of contemporary secular Yiddish literature. They want to know what the challenges are. The challenges of writing in Yiddish! I don't know if writing in a language without readers is harder than writing in a language almost without fellow writers. But then they gave me an excuse to answer another question: is there communication between Chasidim and secular writers?

Chasidim: our brothers and sisters who create a literature merely by virtue of speaking a language daily and expressing themselves in writing. An enviable writing, as natural as breathing. But most would never call what they write literature, since they don't believe in aesthetics and know that secular literature is viewed by most in their community with suspicion.

So much of what is worth reading in Chasidic literature is written by anonymous hundreds who post at great length on a number of message boards. They write in a variety of genres and though I don't think much of what's written there is worth reading, it has the virtue of life, slippery and unmediated. There are a very few writers who write literature with a capital L - the blogger Katle Kanye is the most widely known of them, though there are others (such as Pinchas Glauber) who are on a similar level.

Do the secular and the ultra-Orthodox have something to say to each other? I read them, but they (with some exceptions) don't read me, and have never heard of me. There is no incentive for a Chasidic writer to read a secular writer, unless they want to benefit from a secular esthetic and the variety of topics available to it. That would be strange indeed - but stranger things have happened to Jews and Yiddish. Why shouldn't some of the strange things be blessings?

If I could imagine a work of literature in Yiddish, what would it be? An epic poem about today's Chasidim, written in Chasidic Yiddish, perhaps. Or a sprawling novel of contemporary Jewish life (about either sector, ultra-Orthodox or secular) written by an observer "on the other side." More than likely, though, the coming Yiddish classic will be written in a genre not even on my radar, outside my dyadic model of contemporary Yiddish culture. I look forward to it.

Market day seen clear-eyed - or open-nosed

"In the middle of the traffic jam of people and horses, there's dirt. Filth. In winter - the snow's not snow. Manure, horse urine, hay, straw, hoops, barrels, boxes, puddles of colored oil, rarely cleaned up by day."

--from The Family Mashber by Der Nister (my translation - all three sentences of it)

A pointless exam can be just as bad as a stupid MRI

Dr. Abraham Verghese, says the Times, is reviving the lost art of the physical exam. He cuts quite a figure on the wards, with his white coat, his stories, and his diagnostic maneuvers, reminding us of "the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope."

Here's where the definitions of art and science matter, though. The margin here is too narrow to contain a detailed discussion of where these two bugbears embrace and where they face off, fangs bared.

The applicable stab of a definition in this case, I think, is this: in a science, we try and apply a community's rigorous professional definition to our individual classifications. In art, we try and apply our own individual classifications a priori. Yes, rigorous professional definitions are important to art as well, but less so.

Verghese's approach to the physical exam falls short whether it's seen as an art or a science, and flirts with nostalgia as its sole justification. If it's art, then why should Verghese pick out the 25 maneuvers he and his Stanford colleagues choose to the exclusion of all others? And, if it's science, why does Verghese seem to ignore the incomplete but abdundant literature on the evidence-based physical examination?

The worst thing about the Times article is the way it conflates evidence-based medicine with ignorance of the physical exam. A pointless physical exam can be just as bad as a stupid MRI. I suspect that Verghese can make a stronger case for the physical exam than "this is the way the giants of old practiced medicine," but I have yet to see it.

Poetry on the loose

Catch me at Yugntruf's Yiddish Tog this Sunday in New York! I'll be reading poetry (I'm so predictable).

This Be The Translation

There's a not-bad Hebrew translation of the Larkin poem. And whoever wrote it (I don't see a name) links to some guy's Yiddish version.

The Wrong Kind of Poetry

The editors at ZEEK recently came out with a poetry manifesto. Since the journal devotes significant space to poetry, and there are precious few publications which consider Jewish poetry in a serious way, I looked forward to their treatment of the subject. I glanced at the last paragraph and saw that the authors wanted to “blast open the possibility of what Jewish poetry can be” — certainly an ambitious goal. I hoped that the manifesto would tell us how.

Read more: http://blogs.forward.com/the-arty-semite/132823/#ixzz14JZhcs6W

When utilitarianism falls down: DIY foreign aid and Singer

You probably have read by now about the do-it-yourselfers of foreign aid who are risk-taking, inspiring, and just this side of crazy.

I appreciate that Nicholas Kristof mentions the difficulties they have run into in practical aspects of their life (jobs are lost, lives are abandoned) because it makes Kristof seem less sanctimonious. At first blush this seems to bolster Kristof's unofficial anointing of Peter Singer as the official philosopher of the "culture of social engagement" (I suppose this is like being the anti-Nietzsche). Singer is, after all, a utilitarian. If, on the one hand, you don't have a date, a job, a bed, or a car, but on the other hand are building a shelter for orphans in Nepal - you can easily reckon up "greatest good for the greatest number" and come out in the win column.

But not so fast, Utility Man! It's all about how the utilities are calculated. What happens when the shelter gets bigger and better? Now it's a school, with

[...]classes from kindergarten through sixth grade, as well as a library, a cafeteria and an outdoor auditorium. The plan is to expand it one year at a time until it is a high school as well.

At what point should Maggie Doyne - according to Singer - say "That's enough now! Let's stop here and give the rest of the money to people who need it even more. There are poorer orphans down the road, or in Burma or Africa." Does the school really need a library, a cafeteria, and an outdoor auditorium?

Of course this is ridiculous. The orphans should have a great school. But at this point we aren't talking any more about the greatest good for the greatest number. We are talking about needy orphans who Maggie Doyne fell in love with and wants to help. Utilitarianism falls down but compassion keeps on.

My recent New York reading, recorded

Here's a recording of the Yiddish-English poetry reading under the auspices of the League for Yiddish, under the title "What Would Glatshteyn Do," which took place on August 1st in New York. You can hear me at about the 2:30 mark.

PDFs of the poems in Yiddish and English are here.

Współczesna literatura jidysz

That's Polish for "Contemporary Yiddish Literature." An article of mine in English by that title was translated into Polish for the inaugural issue of the journal Cwishn, "a Jewish literary quarterly." I haven't seen the translation yet, so if there are any Polish readers in the audience, let me know how it is.

I plan to post the English article at some point.

The thought I just can't catch

Naturally it reveals itself to me,
the thought I just can't catch,
as I highstep out of the bath.

More here.

The Popular Language that Few Bother to Learn

Will Yiddish scholarship, the eternal victim, fall prey to lackluster language learning?

Twenty years ago there were four American universities with Yiddish programs: the Jewish Theological Seminary, Harvard, Columbia, and UCLA. Now there are more than a dozen. From Michigan to Maryland, from Chicago to Santa Cruz, students are learning about Yiddish literature and culture. Interest in Yiddish is growing even as its speakers (outside Charedi enclaves) continue to decline in numbers. But interest in the topic of Yiddish does not translate into a stable foundation for teaching the language, which makes some scholars nervous about the future of Yiddish scholarship.

More here.

After the article's publication, a number of comments were published in another issue of Mendele.

An Altar Barbecue

To the barbecue of sacrifice
the hyssop branches add their spice...

...for more, become a backer here!

When our things get old

When our things weren't supposed to think so much, when they were old-school cars, squat rotary phones, and pea-colored refrigerators, they broke down because their bodies broke down. A wire shorted or a fan belt broke. Now when our things have brains bigger than ours, they do what brains do with age: break down slowly. Startup takes longer than it should, programs pop up that we want hidden away, data is corrupted, thoughts ooze slowly through the tangle of pipes.

Then the decision comes. When there is no bright flash before the burst bulb, when there is no flat tire to the thinking machine, when do we throw it away?

What should a bilingual book of poetry look like?

Should every poem be "available" in both languages -- via translation? "equivalent" poems? how? Or does there not need to be an exact symmetry? You can read what promises to be an enlightening discussion by pledging even just one thin dollar at Kickstarter and becoming a prenumerant (pre-subscriber) of my poetry manuscript.

Ode to the Dove at Words Without Borders

Trapped on the lips are sounds, like pearls of forts oceanate
are mute for thousands of years, and over the muteness—a blade.
"Dove darling, childhood's child, let the lips speak, give them speech
Become now the cry of the sounds, or else the dream is extinct . . ."

Read more.

Not in the Same Breath: A Yiddish and English Book of Poetry

Get in on the ground floor and support my nascent book of poetry over at Kickstarter!

Losing Yiddish bookstores and cluck-cluck-clucking

The general point of Joseph Berger's article in the Times is that CYCO, the bookstore, is going out of business. This is sad, of course! Hayim is a great guy, has struggled manfully under trying circumstances, and I (with all my organizational and financial talents, which are +/- nil) will try and help find a substitute. I've bought hundreds of dollars of books from CYCO and we have sold hundreds of dollars of books through them.

This is not stupid.

But whenever Berger writes about Yiddish as a language - well, see my "friend's" twitter feed @yiddishseuss. Yiddish isn't spoken by anyone anymore, except for the Holocaust survivors. Oh, and the Chasidim, among whom it is "booming" and a "lingua franca," whatever those are supposed to mean. And Yiddish has a "lilt" and a "kvetch." If anyone wrote about another language the way J. Berger does (say, about African American English or Spanish) he/she would be rightfully run out of town on a herring-draped rail.

And the whole *tone* of the piece, such cluck-cluck-cluck and automatic nostalgizing, got on my nerves. Yes it is sad, but the bookstore is failing because organizational and economic support is lacking, not because J. Berger's parents failed to speak Yiddish with him. English bookstores are failing all over this great land of ours too.

Cluck-cluck-clucking won't help much. Finding a warehouse, setting up a real Web site, and donating some dough will. Can I do these things? Prolly not.

The "was" and the "still"

from Diary Poems
Avrom Sutzkever

Here and the there are together-together
and to swim reaching depths the ray bends itself downward.

Scythe is connected to stalk. This is how,
like violin player is one with the sound.

That's how the was is enbrothered with still,
that's how a woman and man are enlimbed.

--from Yiddish: Z.Sh.B.

Sutzkever on the Square

Some translations of mine of his Diary Poems (Lider fun togbukh) are included in the Summer/Fall 2010 issue of Washington Square. (If you would like to look at the process of translation in the raw & blogged, look over here.)

What Would Glatshteyn Do?

That's the English title of this bilingual poetry reading I'm participating in tonight at the Bowery Poetry Club. (What would Glatshteyn do, indeed? Probably look down his nose at us.) If you can't make it, you can catch it online. Hope to see you there.

Dear Friends,
If you can't make it to our program WWGD? [What Would Glatshteyn Do?] An Evening of Yiddish Poetry you can watch it online at the exact time of the event, Sunday, August 1 6:00 PM - 7:45 PM (EST). Go to bowerypoetrylive.com.

POETS AND SONGWRITERS:

Zackary Sholem Berger, Gitl Schaechter-Viswanath, Josh Waletzky
David Botwinik, Leyzer Burko, David Fallick, Samuel Marder, Charles Nydorf, Mindy Rinkewich, Elinor Robinson, Yefim Vinnitsky, Gershon Weiss, Jennifer Goodman Wolloch

TRANSLATIONS:
Albert Rosenblatt, Yaira Singer, Wojtek Tworek, Sheva Zucker

Don't miss the Yiddish poetry event of the millenium!

What is a "Best Hospital"?

U.S. News ranked the hospitals again, and my employer came in first, for the 20th year in a row. I can't be unhappy about that!

But how should you choose a hospital anyway? I wrote about that a little while ago - it's more complicated than U.S. News makes it out to be.

Unfortunately, as a recent research article points out, the U.S. News index is based nearly entirely on reputation. Which is not a terrible thing, as I pointed out, just incomplete.

Maybe we should rank hospitals (or, at any rate, medical schools) according to a different index, say social mission? Some folks tried that, and their results are presented in the Annals of Internal Medicine (subscription required).

In that list, Hopkins, as well as NYU - where I trained for residency - are ranked rock-bottom. But the criteria used to quantify social mission has some big problems, as an accompanying editorial points out (sub. req.).

Until we have comprehensive outcome measures, it looks like we're going to have to integrate all indices according to our own individual metrics. Isn't that called reputation?

Disorientation in shul

I went to a synagogue in San Francisco on Shabbos and Sunday, and I was asked to lead davening on Sunday. I did not refuse the customary three times, because I am greedy for the amud. (Good thing I found that imperfection to work on, as we start the long slow slide, or hard sweaty climb, into fast-n-forgiveness. Because I'm lacking any others. Yes that's right.)

Leading davening for the first time somewhere is disorienting. You know someone thinks you're going too fast. Someone else wonders why aren't you songful & joyous & Carlebachelicious; a third grumbles why you don't get the hell on with it already, some people work for a living.

And then, of course, it's disorienting for them. It's Bob's turn today! Fie on thee, you usurper, why are you displacing Bob?

I find this disorientation a useful microcosm of liberal Judaism. You're never quite sure. You don't have the fundamentalist's confidence that God has blessed your every move. You have the narrow ells of the religious life and the wide anomie-spaces of modernity. You're always going too fast and too slow, always displacing someone.

But then there's hot tea afterwards (hot tea is welcome in San Francisco, even in July) and someone brought biscotti. Good morning!

Anthologized

I can sing the praises of the Ecco Anthology of International Poetry.

I can also mention that my translation of Glatshteyn was included! I know this only because a friend was browsing at the Newark airport and picked up the book.

Buy the book!

Poverty and segregation: Baltimore versus Manhattan

I asked my cousin, who studies urban planning at Berkeley, the following (the question was provoked by my experiences with patients who come from desperate poverty here in Baltimore, something that I encountered only rarely among my Manhattan patients):

I keep comparing Balto. and NY. with regard to poverty and racial segregation. Can you point me to a good academic treatment of this topic? E.g.: Manhattan is segregated by income, obviously, but is it segregated by race when income is controlled for? And what is more influential in explaining Baltimore's neighborhood patterns, income or race?

I found her answer interesting.

It sounds like you're more interested in empirical evidence than theory (?), but I know more about the theory (and I think the theory is actually more interesting) so I'll start there. The classic debate about urban poverty, race, and segregation is represented by William Julius Wilson on one side, and Douglas Massey on the other. As I understand it, Wilson argues that segregation is at root a structural economic issue, not just a racial issue; Massey argues that segregation is caused primarily by racial discrimination. This debate is still simmering because - obviously - race and income segregation are so heavily intertwined that controlling for one of the other is exceedingly challenging, and even if you somehow distinguish between the two factors you still haven't really explained the black ghetto.

Wilson's first foray on this subject: The Truly Disadvantaged (1987) - also has a recent book out called More Than Just Race

Massey's response (with Denton): American Apartheid (1993)

Good survey of the literature on the causes of inner-city poverty: Chapple and Teitz, "The Causes of Inner-City Poverty: Eight Hypotheses in Search of Reality"

Empirical evidence: I don't know of a good overview or study that anyone considers definitive. A lot of the literature is historic (particularly now right before the new Census data is released). Rather to my surprise I did not find any interesting looking case studies about either Baltimore or Manhattan but maybe I didn't look hard enough.

I was interested to note that when I searched WorldCat and my favorite urban planning database (Urban Studies and Planning: A SAGE Full-Text Collection), most of the empirical studies seemed to be by public health or education folks. See two citations below that look interesting, but are old. The problem with using 1990 or even 2000 data is that we think so much as changed - i.e. the suburbanization of poverty, gentrification of the inner-city, immigration. If I run into anything else I'll let you know.

Coulton, Claudia J., Chow, Julian, Wang, Edward C., Su, Marilyn, Geographic Concentration of Affluence and Poverty in 100 Metropolitan Areas, 1990, Urban Affairs Review 1996 32: 186-216 (link)

Osypuk, Theresa L., Galea, Sandro, McArdle, Nancy, Acevedo-Garcia, Dolores, Quantifying Separate and Unequal: Racial-Ethnic Distributions of Neighborhood Poverty in Metropolitan America, Urban Affairs Review 2009 45:25-65 (link)

Authentic values and real interests: Daniel Sulmasy's new model of end-of-life decision making

These are very brief notes from a talk I attended at the Osler Center Day this past Friday.

Sulmasy presented what he calls the traditional tripartite view of EOL decision making, each part of which suffers from significant defects. The top of the pyramid, the optimum, is customarily held to be the living will (LW). However, living wills are both too vague ("no heroic measures") and too specific ("CPR but no counterpulsation"), involve interpretation of texts, and aren't done by most people anyway (current living-will rates are about 15%, per Sulmasy).

The next best choice is held to be substituted judgment (SJ). Sulmasy pointed out that SJ (a) places significant psychological pressure on families, with attendant sequelae; (b) is difficult to instruct family members in, because its meaning is not really clear; and (c) isn't what most people, when asked hypothetically, want to happen when they're non compos mentis anyway.

Sulmasy pointed out - interestingly enough - that the legal pedigree of substituted judgment goes back to English law, when questions like "What happens when a crazy person inherits a bunch of money?" or "Can a lunatic be made to donate a kidney?" had the courts looking to SJ for answers. (The case law had names like A Lunatic, but I can't remember the references. The big Columbia Law reference which got the SJ ball rolling in the 70s is here.)

Then at the bottom of the heap is Best Interest of the Patient, which no one likes because it's (a) paternalistic and (b) difficult to discern (Sulmasy didn't give (b), but I think it's obvious).

Sulmasy made the point that while LWs are supposedly optimum, everyone acts like Substituted Judgment is better.

So what's the better model? Consider the patient as a person, says Sulmasy, and think of the authentic values of that person. Then take into account, further, the clinical facts of the case. Then, keeping in mind the real interests of that person in light of their values and the facts of the case, try to come to a decision which respects all of those.

This is where my paraphase probably falls flat. But the key here that Sulmasy emphasized is (a) the neo-Aristotelian nature of his enterprise, i.e. emphasizing full flourishing; and (b) the skepticism of Sulmasy towards "Western, liberal" thinking which values autonomy above all else.

Another word for mustard

That's not how the word is pronounced, I hissed.

But the damage was done:

You tore the tongue out from every martyr

because you could not say the word for mustard

I taught you a week ago.

Torturing them over again

when we tell jokes about old men and fish

or different words for penis.

Am I wholly serious here? I'm not

serious enough. Reread the page.

Learn my name in the language

I want to speak. Silence

is the deadest tongue.

Great Literature, defined

My son* has developed a theory of what makes a book good. It is very simple.

1. A book is good if it includes a fire truck.

I tried to review my knowledge of world literature with this aesthetic in mind, but I discovered how little I remember.

Is there a fire truck in Ulysses? Probably somewhere (yes it does yes, says Google). The Bible doesn't make the cut, unfortunately, and I don't remember any hoses and ladders in Proust - not that I've finished him off. I bet there are a lot of fires in Sholem Aleichem, but in his time it was probably all about horses and bucket brigades.

This is going to be a big paradigm shift, I can tell.

*Who is two.

Larkin in Yiddish

This Be The Verse.

Translating even one sentence is hard! A case study.

A story by Chaim Grade (yes, her husband) excerpted in this week's Yiddish Forward doesn't seem all that interesting from a narrative point of view, or innovative stylistically, but it's lovely writing all the same.

Here's the first sentence.

אונטער די קאַלטע שטיינערנע געוועלבן פֿון קלויז ישן זיצן זקנים בײַ דעמבענע שטענדערס.

Unter di kalte shteynerne gevelbn fun kloyz yoshn zitsn skeynim ba dembene shtenders.

Under the cold stone vaults of the * the old men sit at oaken *s.

Kloyz yoshn is a macaronic phrase, yoshn meaning - of course - old in loshn-koydesh, and kloyz being a smallish prayer- or study-house. "Old study house" doesn't get at it, because yoshn is part of the name here, not an adjective. Maybe Old Study House, but that seems like we're talking about a Society of Friends meeting place. Venerable? Ancient? Neither of those work.

Shtender - that's a common Jewish, or at least Yeshivish word. I think that when Grade is talking about the skeynim (old men, for lack of a better translation) sitting at the shtenders, he doesn't mean the podiums that people daven at, but rather the bookstands that rest on a table. "Bookstands" doesn't sound right, though.

Foreign minister, an office that doesn't really mean much

But Beinart never mentions that Lieberman’s party won only 12.5 percent of the vote.

Right-o! Only 12.5 percent. Because that's . . . wait a minute! That's a significant proportion of the population! Voting for a racist demagogue! (Sorry! A "populist.")

More (if you care) here. From the always entertaining Commentary.

Adventures in Error Bars, Cell Phone Edition

So if you're worried about an exposure, and the exposure is difficult to measure (because, oh, you have no idea what the causal link would be between the exposure and the disease, so you don't know what you're measuring), and you keep doing studies about the exposure, you are eventually going to find a positive result (or weakly positive) because of the nature of chance.

That doesn't mean cell phones cause cancer. It means epidemiology is inexact.

Annals of Yiddish Lexicographical Video

From the talented Leizer Burko, a series of videos based on the life and work of Nahum Stutchkoff, thesaurus-maker and radio-playwright.

What's the benefit of diabetes screening?

Asymptomatic guy, obese, no high blood pressure. Do you screen him for diabetes? The USPSTF says the evidence is Incomplete. "Would a hemoglobin A1C [diabetes test] change your management?" I ask. Always my first question - I'm a skeptic to a fault. "Sure," comes back the answer. "If it was 8, you'd start metformin, right?"

Well, maybe. But that's the problem of the screen. If their number is 8, we put them in the Diabetes box. Then we "know" that we need to get their A1C at 7 . . .

But why do we know that? The evidence isn't so great that 8, say, is all that much worse than 7 with regard to clinical outcomes in an asymptomatic patient without evidence of micro- or macrovascular disease. Yes, if the number were 9, 10, 11, 12, then the answer becomes more and more definite, but you're going to start seeing symptoms somewhere in that range anyway.

[links to come, I hope]

I know I should be angry

We get comparatively low pay for more work than other specialties. The health care system is broken (even with the death panels!). But just today I saw two patients of mine in the hall, and I was happy to see them. I think they were happy to see me. And I get paid for this - a lot more money than other professionals get paid. Maybe I should get angry, but I'm not sure that would help.

Boing Splat Boing Splat

The fish is famous! (But buy it here, not on Amazon.)

X marks the spot

I take issue with Jay Michaelson's premise, well expressed though it is:

Fundamentally, religion works by saying that “if X, then things are okay."

Jay's a spiritualist, so wherever he drills in the rock of religion he finds spirituality. The gut shall rule forever and ever. But plenty of religious people actually believe X. They think X is the real thing. It's called eschatology.

You can psychologize their claims all you want, but there are people out there who believe what they say they do. It would be great if Locke's claim were in accord with the facts on the ground, and we could stick our heads in the sand until the nutsos go away. But - whoever the nutsos are - some of their claims are to be debated on face value. Gay marriage is great. The world was not created in six days. Our Israel policy is not determined by Revelations. And so on.

Tweet, whither wilt?

Half the time I can luxuriate in social media, buoyed by the multicolored sea of human interests & talents. The other half I scroll glumly through lmfaos and #wakeupyourfaceisonfire, thinking that all this is dust.

Hey! Over here! Poetry! Hey! Cold beer! Peanuts! Programs!

I feel like the Academy of American Poets' website focuses on poems and poetry, while the Poetry Foundation website is a bright poodle which has got hold of your pant leg. The Poetry Foundation twitter feed is a poodle which yip-yaps away distractingly at all hours about any text string which includes the word "poetry." A Google poodle.

Just because a thing can be well explicated

...whatever the thing is (poem, movie, course of treatment, political philosophy) doesn't mean it's any good.

Snake!

I turned the stick into a snake.
He said There must be some mistake.

I sang the suffering servant song.
He licked my heel with flicking tongue.

I rent my robe and loudly laughed.
He said I'd rather be a staff.

He crawled away and hissed So long.
I don't know what I'm doing wrong.

What happens if the Sabbath is boring?

Judith Shulevitz says in her new book - and everywhere else she makes her thoughts known - that the Sabbath is an island of tranquility, balm to the torn soul, etc., etc. Yes, but what happens when the Sabbath is boring?

I wonder if the Sabbathian (that's the person who can operate within Shulevitz's permissive, suggested boundaries) has a better answer to the question than the Sabbatarian (that's a more law-bound Sabbath observer, like me). The Sabbathian can say: if you're bored, that's the point! Boredom is something modern people try to escape from, while the Sabbath reminds us that boredom is the absence of things that should not be there anyway. We should not be buzzed and pinged, and their absence should leave space for a mysterium tremendum, not a grande ennui.

But - on the other hand - maybe the Sabbatarians have a better answer. If the Sabbath is boring - well, that's your fault! (Im davar reik hu - mikem: if it's an empty thing, whose fault is that?) The point of the Sabbath is finally eschatological, not sociological. There can be societies which are just, pure, and balanced, and wholly secular, without any need whatsoever of some artificial day of rest. (Indeed, secularists in America and Israel might legitimately scoff at Shulevitz's Rousseauvian naivete.) But no society - on the mystical Jewish view - can have the piece of eternity which the Sabbath affords. Only eternity itself, which is entirely Sabbath.

If you are mystical enough, that eternity could be vouchsafed even if you are on Blogger and Twitter and all the rest of them all the time. As long as you have a direct connection Upstairs.

Why matzah is tasteless

From the Sfas Emes (translated & paraphrased by your host):

How can the wise child ask for the reason behind a Biblically ordained law? It does say in the Bible, "He gives his sayings to Jacob, his laws and ordinances to Israel." There are cases in which one does not understand the reason behind a practice, but by the very practice itself one comes to know the reason nevertheless. Thus is matzah without a taste [טעם]* - so that it can fade into the background, leaving the eating of the matzah itself as the reason. Similarly, the last food eaten at the Seder should be matzah.

*This word can also mean "reason." - ZB

I'm sad...and I don't speak English!

Never fear! Though the New York City Department of Health and Mental Hygiene seems to have pulled the translated PHQ-9 (depression diagnosis) forms off their site, Albion saves the day.

A catalog of signs and arrows

I'm working on a catalog of signs, of arrows
with stubby beaks like sparrows,
resting places for gazes. Tomorrow

I'll make final edits and post, broadcast
to all my readers. Exact directions cast
a net of goals and safety. Last

night we mourned, drank, and fought.
Who died: it could be anyone. I ought
to tell you more and show you what I've brought.

Statins, heart disease, and risk - a conversation

What gives? How can someone with high blood cholesterol levels for 30+ years end up with clean arteries, if indeed there is any causation between blood cholesterol levels and plaque accumulation. ... Perhaps actual blood cholesterol levels have no cause of heart disease on their own a-priori. And, if any of these crazy hypotheses are true, then how can a health system prescribe drugs like statins so casually and routinely to anyone with cholesterol over 230? This is particularly true, when the long term side effects of such drugs must still be unknown.

Lots of questions -- some scientific, some health-plan political... But mainly I am looking for just straight talk on this whole cholesterol/heart disease issue.

You ask a lot of good questions. Let me paraphrase them for ease of presentation.

1. How do statins help in heart disease - through lowering the cholesterol level or some other mechanism?

It's not clear - this is one of those topics where the pendulum of the literature swings back and forth, and I can't say that I've followed every swing. Some hold that statins lower cholesterol, cholesterol causes heart disease, and that's it (though all the details of what the worst cholesterol particles actually are, and how they work their deadly magic, are yet to be fully worked out). Others think that statins are "pleotropic" - i.e. they work in multiple ways, e.g. by reducing inflammation.

2. How could you have high cholesterol and still have clean coronaries?

It's quite possible. I would imagine pretty common. That's why one of the biggest statin-related controversies hasn't really hit the lay press yet. It's all about when to give the medicines. Should everyone be on a statin if their cholesterol is above a certain level ("treat to target," or what I think of as the "statin in the water" approach), or should a statin be used only if a patient's risk of coronary artery disease is above a certain level ("tailored treatment")? A recent study in the Annals of Internal Medicine supports the latter, but no one really does this yet since the guidelines of the major doctor groups favor the former.

3. How do I know if I need to take medicine for cholesterol?

One way to think of it is this: statins lead to a reduced risk of coronary artery disease. Great. But this only matters really if your ABSOLUTE RISK, before statins, is something that you, or your doctor, are concerned about. If your 10-year risk of heart disease is 1%, and the statin reduces it to 0.1%, that's a 90% risk reduction, but maybe you don't care about a 1% risk. (I might not.) One way to calculate your risk is the Framingham risk calculator.

4, Do clean coronary arteries on a coronary CT scan (i.e. a low calcium score) mean I can't have blockages in the heart arteries?

No.

(When) Is the physical exam useful?

The hope that the physical exam might bridge the gap between provider and patient is natural and even salutary, but we should clarify why we think the physical exam is useful.

More at KevinMD.

How can patients and doctors talk about risk?

Check out this presentation (based on other people's research) that I'm giving tomorrow at the meeting of the Mid-Atlantic branch of the Society of General Internal Medicine. The Power Point version, prettier in its Microsoft way, is here.

A case of ... what?

Recently I was staying with relatives, which gave me the chance to read the New York Times in print. It felt old-timey. I chanced upon an article in Lisa Sanders's Cases series, whose tropes can be summarized as follows:

1. Woman faints.

2. The doctors can't figure out what's wrong with her.

3. Bad Doctor says it's all in her head:

A neurologist in New York carefully examined her and her now thick chart and pronounced definitively that there was nothing wrong with her and that she should try to relax and maybe take up yoga.

4. Good Doctor notices a few key features and makes the diagnosis:

Ledereich watched as the patient calmly sat up. “I know what you’ve got!” he told her excitedly. Her sudden collapse looked as if a switch had been thrown and all her muscles just turned off. Ledereich realized that although it looked like syncope, it wasn’t; she hadn’t actually lost consciousness. What she probably had, Ledereich told her, was something called cataplexy, and that meant that she also had narcolepsy.

So far so good. But the treatment didn't cure the attacks:

But for reasons that neither the patient nor her doctors understand, after about six weeks, [the fainting spells] returned. At first, just occasionally. Then almost daily.

Thereafter she is left to do (more or less) what the Bad Doctor suggested: integrate her new diagnosis into her life.

The patient has learned to cope with her unusual condition; she no longer drives. And when she feels the warning signs, she tries to alert those around her to tell them not to worry. She’s part of a small community, andby now, most know her well enough not to call 911.

There are implications left unexplored here. First: that diagnoses can be partially but not entirely therapeutic. As Up To Date says about cataplexy, "these symptoms are often improved by medications." Often, but not always.

Second, that so much hinges on how the diagnosis is conveyed. Bad Doctor indicated that the woman affected with cataplexy "should just relax" - an abrupt and unhelpful direction, but not, for all that, unfounded. There is a connection between anxiety and cataplexy (and other sleep disorders) remarked upon in the literature.

Finally, a question is left unanswered (and unasked) at the end of the piece. What does the patient know that she has? Does she identify with her diagnosis of cataplexy in a way in which she wouldn't identify with a diagnosis of anxiety or other psychiatric disorder? Does the partial failure of GBH to treat her cataplexy at all detract from her trust/confidence in the diagnosis? In short, what does the patient think of all this?

The Ten Contradictions of American Health Care

Uwe Reinhardt at the Health Affairs Blog points out the contradictory wishes of most Americans with regard to health care.

[A]s the policy-making elite stews in its stalemate, the American plebs dreams of a political Messiah willing to build for them a health system that:

1. Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
2. Limits their families’ out-of-pocket payments for health care to make it “affordable.”
3. Keeps insurance premiums and taxes for health care low.
4. Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
5. Does not allow public or private insurers to let “costs” or “cost-effectiveness” ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
6. Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
7. On the other hand, grants every American the moral right – backed up by a government mandate called EMTALA– to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
8. Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
9. Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
10. Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging – e.g., charge $10 for an aspirin — and no one in health care earns excessive profits (or any at all).

That’s all.

This year's Purim doggerel

Gallows humor can be lame. And

Dangerous, too. (See under: Haman.)

But what did his ten sons* do wrong?

"Their names rhyme! Put 'em in the song."

פּורים: אַ באַגרעבעניש די שׂונאים!

מאָגן: אַ קיכעלע מיט מאָן אים!

הלכתא רבתא: עד דלא ידע!

די איבעריקע: יאַדאַ יאַדאַ יאַדאַ!

Happy Purim from Zack, Celeste, Blanca, and Micah!

אַ פֿרײלעכן פּורים פֿון שלום, סעלעסט, בײלקע, און מיכל!

*And 70,000 innocent others.

What's that you're reading?

The below isn't mine. It's an excerpt from an article Why Live Without Writing by a famous German poet I've never heard of called Durs Grunbein, translated by Michael Hoffman and printed in the newest issue of Poetry. Except there is no such person, Durs Grunbein. There is a person "Durs Grunbein" whose "u" has an umlaut, but I don't feel like putting it in.

In his diaries, Hugo von Hofmannsthal brings up the story of a German officer in China who, following the Boxer Rebellion, participated in a penal expedition:

The officer sees a line of men sentenced to death, standing in a field. With his sword the executioner goes from man to man. There is no need for his assistants to tie or even to hold down any of them; as soon as it’s the next man’s turn, he stands there with feet apart, his hands gripping his knees, his neck stretched out, offering it to the blade. One of the last in line, still some way from coming due, is completely immersed in a book. The officer rides up to him and asks: “What’s that you’re reading?” The man looks up, asks back: “Why are you bothering me?” The officer asks: “How can you read now?” The man says: “I know that every line I read is something gained.” The officer rides to the general who has ordered the execution, and begs him for the man’s life for so long that he gets him off, rides back with the written acquittal, shows it to the officer in charge, and is allowed to go and take the man out of line. Tells him: “You’ve been acquitted, you’re free to go.” The man shuts his book, looks the officer in the eye, and says: “You have done a good thing. Your soul will have profited greatly from this hour”—and he nods to him, and sets off across the field.

If you read only one article on health care reform...

...then you've probably read it already, or you're never going to at all. But in case you haven't found that one article, hie yourself to The New Republic. There Harold Pollack has some clarity on the relationship between universal coverage and improved mortality

would universal coverage make people tangibly healthier? You betcha.

but says something else even more important:

there are other ways to save thousands of lives that are much more cost-effective than expanding health insurance coverage. We systematically neglect these other opportunities.

"With all that's forgotten I've long been obsessed": some of my obscure preoccupations online

A selection of my poetry in Yiddish and English is now available on-line through the good offices of Andrew Firestone of Melbourne and the site Yiddish Poetry. Recordings of someone else reading these poems will be uploaded soon. Please comment!

Inherit

I inherit
all knowledge left unwritten with martyrs
jokes that float to the edge of the glass
and pop, forgotten.

I speak ritual
storing emotion
for the controlled explosions
fusing life and death.

A thousand words from everyone,
each singing and dancing,
a little drop
in my labyrinthine neuroscape.

Books and Baltimore all Beautifully Brought to Blog

by the Baltimore Bibliophile.

The government of Israel mourns Sutzkever...not so much

Jeremy Dauber wrote a lovely piece for TNR (the print version only, it seems) about Sutzkever, though he skipped lightly over the problematic relationship between Israel and Yiddish:

To be the Yiddish poet of the State of Israel, winner of the Israel Prize and institutionally supported by no less than the Histadrut and Zalman Shazar, is no mean accomplishment, at a time when a commitment to “the negation of the Diaspora” and the negation of its mother tongue were standard procedure.

Nice use of the past tense, that ("were standard procedure," indeed). One would be more sanguine about the title "Yiddish poet of the State of Israel" if the State of Israel - or even the city of Tel Aviv - had bothered to send someone to the poet's funeral.

Only sing dinosaur songs with your children if they are learning about dinosaurs!!

From Music Together, which is sometimes too...earnest.

Music can be a powerful ally in learning nonmusical subjects because words gain meaning and energy when set to music. It is fun to sing songs about dinosaurs when children are learning about them. However, recent research in music-learning indicates that words can distract children from the music, particularly the tonal elements of a song. Therefore, songs without words are an important part of the Music Together curriculum. They allow children to have a more purely musical experience without being distracted by attempts to process language at the same time. This gives the tonal part of their music development a chance to catch up with language development, which is so much more emphasized in our culture.

The epic life of Avrom Sutzkever

Sutzkever’s work was outside the boundaries of school or ideology while benefiting from many of them. Like Marc Chagall, he was a virtuoso of the fiddle, the rose, the dove, and the rain, which in his hands became not cliches but inexhaustible possibilities. Even when the wellsprings of Yiddish culture dried up and it became ever narrower, Sutzkever found new depth in his craft, as if following his own map to buried meaning.

Read more in Tablet.

Mnemonics

The sleet on your cheek

is every forgotten face

The oilslick is a party

everyone remembered forever

overtaking the pure swan

of graceful forgetting

How should patients decide which hospitals are best for them?

Johns Hopkins Hospital is consistently named one of the best in the country. I can’t disagree with that; after all, I just started working there as an internist in September. Coincidentally, in the midst of the raging debate around health care reform, the past few months have seen increasing discussion of a small but crucial question: why do some of the best hospitals spend more money than others? If other hospitals named to the best-of lists consistently spend less money than my employer, shouldn’t we be emulating them instead? And how should an individual patient go about deciding which hospitals are the best for them?

Read more at KevinMD.

Doves, time, and pianos - together again

Three new translations of mine of three Yiddish poets - Avrom Sutskever, Yonia Fain, and Boris Karloff - are up now at InTranslation. Have a look! (And thanks to Alex Cigale for making me aware of the journal. While you're there, check out his translations from the Russian.)

Risky business

How can we use the best evidence to improve doctor-patient risk communication? That's the topic of my upcoming mini-workshop at the Mid-Atlantic SGIM meeting, my attendance at which is not just an excuse to go eat Indian food in Manhattan.

The latest news from Baltimore, in Yiddish

Public Yiddish television is made possible by the good offices of Youtube. And some kids who love the camera.

The cure for the common cold - what will it be like?

When it exists, it will be effective in 30% of people, and associated with intolerable side effects in another 10%. Thus doctors and patients, 60% of the time, will still have to hear the dreaded words: it's a viral infection, all we can do is try to improve your symptoms.

Progress doesn't march along, it sort of limps, gets lost, finds its way again, and lies down for a nap on occasion.

Future reasons for interrogation by the crack Western Wall egal-women arrest team

1. Tzitzit while ovarian.
2. Female etrogging.
3. Giving tzedakah while under the influence of X chromosomes.
4. Studying Torah . . . while female!
5. The tallit was too cute.
6. Singing. Singing is just bad. All singers should be arrested a priori.
7. Mitzvot are disruptive in general to the status quo. All the more so when done by women.
8. Arrest them all! Let Ovadiah Yosef sort them out.