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And speaking of Arizona and health care...

It's 3 am, I'm writing in the lobby of the Sheraton (grant applications FTW!), and I've struck up a conversation with the guy mopping the floors, who was born in Chihuhua, Mexico, and has two kids. He himself is not a citizen and has no insurance, but on hearing I'm a doctor he says his back hurts. So here I am Googling "free clinic phoenix" and feeling frustrated. Where's Phoenix's Bellevue? I gave him the phone number of Arizona's Medicaid, which I doubt he'd be eligible for - but maybe they can direct him somewhere.

Advocating for advocacy

I'm coming down off the high afforded by the Society for General Internal Medicine's 2011 annual meeting - collaborative and inspiring. I was surprised by my own reactions to two plenary addresses.

One was by Holly Atkinson, former head of Physicians for Human Rights, on the topic of advocacy and professionalism: "Should Medical Professionalism Include Advocacy?"

Not surprisingly, given Dr. Atkinson's history, her answer was Yes. The most interesting moment of her talk came with a question from the audience. The gist of the question was that requiring advocacy for professionalism implies that those of us who don't participate in advocacy aren't good doctors. In response, Atkinson proferred a definition of advocacy that was disappointingly weak. Everything is advocacy - an individual doctor who goes to bat for their patient is an advocate too! But if that's advocacy, the word loses useful meaning. I wanted Atkinson to bite the bullet and say - that's true! Doctors that don't advocate are lesser professionals. I wouldn't have agreed with her (I think every doctor has their own interests and talents, and politics - which is what Atkinson really meant - needn't always be among them), but I would have had more respect for her advocacy of "advocacy."

The second plenary was by Michael Marmot - Sir Michael Marmot to you. He was deliberately provocative, acid-tongued, and wholly self-possessed: an example of what an entertaining medical speaker should be. Again, though, I was not wholly satisfied. Marmot's research is unimpeachable - he is the giant whose Whitehall studies established the importance of the social gradient to health. His findings lead to some striking observations: the life expectancy in some neighborhoods of Glasgow is lower than in some poor countries, even though Scotland provides basic services that are often lacking in, say, Africa (drinking water, basic food and shelter, etc.). That's because the poor of Glasgow are sicker and dying sooner than the rich.

Marmot too is an advocate. But, like Atkinson's, his passionate call didn't echo with me - not because I'm cynical, but because (looking at the two speakers' biographies) they themselves, at the beginning of their careers (where I am now, more or less - not that I'm going to be an Atkinson or a Marmot) did not work as advocates. Marmot did research. Atkinson trained in global health and health juournalism, founding and editing what eventually became Journal Watch.

I agree wih their call to justice in health, but I think advocacy comes with knowledge. Rather than marching out to demosntrate, I need to gather facts first - in my own way. Then with time, perhaps, I will be able to advocate from my own heart what I have established in my own little corner of research.

Pass the book!

I'm very excited at the goodreads reception my new book is getting! And at how many people are lining up for a free copy.

I'd like to get more people the chance to see the book, of course. So I will release 5 more copies from their gilded cage to anyone who's willing to pass the book (http://pass-the-book.blogspot.com/).

If you've clicked on the link, understand the system, and would like to participate, send me an email (zackarysholemberger at gmail) or contact me through my web page.

Also, I am available to speak about matters Jewish, medical, Yiddishy, or poetical. Contact me if you're interested.


The Book is Out!: Not in the Same Breath: A Yiddish & English Book of Poetry

Become a Snake or a Lover
"[This] beautiful, sophisticated, deep and playful book just might turn you into a snake or a lover: The power is there. The sorrow and wry humor of Yiddish, leavened with Torah learning, resonate limitlessly, explosively. You're sure to fall for Not in the Same Breath." 

That's what Elinor Nauen had to say about Zackary Sholem Berger's new book of English and Yiddish poetry from Yiddish House LLC. Whether you like English, Yiddish, or fascinating illustrations, you won't want to miss this book. See below or click here for more details. 

"I read this book with great eagerness, much enjoyment and a real sense of satisfaction. ... May your readers multiply!" -- Dov-Ber Kerler, poet and chair in Yiddish Studies at Indiana University

Stay tuned for information about our launch party, tentatively scheduled for Sunday, July 17th, in Baltimore - featuring live music, poetry readings, special guests, books for sale, and video streaming to an on-line audience of millions!

Support independent publishing: Buy this book on Lulu.

About the Book
and how to buy it
Not in the Same Breath is the first original book by the poet and translator Zackary Sholem Berger. The Yiddish and English chapbook, with surprising illustrations and graphic design by Jeremy Kargon, isn't a customary bilingual edition of facing-page translations, but a collection of independent poems in the two languages. Whether you know English, Yiddish, or a little bit of both, there is much here to reward your perusal. Springing nimbly over centuries, the work connects English and Yiddish in unexpected and world-broadening ways.

The book features "rabbinic approval" (in almost-but-not-quite a parody of the style) by the well-known dissident Chassidic blogger Katle Kanye.

After you buy the book (click the buttons above), discuss it on Goodreads and join the discussion on Facebook.

Retailers! Contact the publisher or order the book through Baker & Taylor (ISBN 0972693947).

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Thoughts and experiences from Passover peregrinations:

1. There needs to be a slow klezmer version of the Doctor Who theme song.

2. Whenever I tell people I am researching doctor-patient communication, the listener always says, "Oh, yeah, that's a big problem" - which is intenresting in itself, that answer. What are people's experiences, and how does this affect their impression of doctors in general? I'm sure that's been looked into, but there's certainly some rich opinion-making going on there.

3. I still can't get Goethe.

4. Today is the anniversary of Hart Crane's death. His last words were not "Goodbye, everyone." He did not speak before jumping.

5. I need the haggadah done by this Israeli comics artist.


I Am Forbidden

In this morning's Publishers Lunch, the following "new deal" is included as a tidbit:
[...] Anouk Markovits's I AM FORBIDDEN, an English-language debut which takes the reader inside the world of the Satmar, the most insular and fundamentalist of Hasidic sects.
Assiduous (just now!) Googling reveals that Markovits is a novelist. No other information is available as we go to press quickly hit the Publish button.


A poem published in the first issue of Happiness Pony

Tell you what
I’ll divulge:
off the edge of this paper
there’s a huge
orchard. Apples.
If you don’t eat
them, they’ll
still grow.
If you do,
your belly’s full.
All the same

Yiddish companion poem here.


Shaken up

I was at my local mincha minyan (afternoon prayer group) today. Someone said, "Did you hear there was another earthquake in Japan today?" Said one of the rabbis, "Well, until they let those boys out..."

"Those boys," of course, being some mules in black coats who are currently in jail in Japan. (Other rabbis have spoken in public as obscenely as our local one did.)

Then another coreligionist of mine said, "Well, the Ran says that evil will be done in the place of those that did it."

"For that, thousands of  Japanese had to die?" I said.

I don't understand how people can say these things.


Eau du Dove

My work is going all to pieces: pieces of Sutzkever's "Ode to the Dove," that is. Part 1 appeared in InTranslation, and part 2 in Words Without Borders. Part 3 is now out in qarrtsiluni.


Dr. Social Media, MD: suggestions for practice integration

If social media were integrated into my practice: a wish list.

1. Patients could willingly sign away bits of their confidentiality so they could participate in a conversation with other folks suffering from the same problem. "What did Dr. Berger not tell you about diabetes," they could ask each other, and I - listening in - could improve. (Or get sued, too. Malpractice reform is another discussion.)

2. There are so many issues many of my patients face together, here in Baltimore: poverty, single parenthood, substance abuse, tobacco use, food deserts, obesity, etc. Couldn't we share information and experiences, without the sterility of anonymity?

3. The Perils of Procedures: talk about your history, what tests you underwent that Dr. Berger recommended (or advised against!), and share what happened.

4. Patients could recommend specialists they have seen, medications they have taken...

5. In short, it's like wrongdiagnosis.com or the innumerable disease-discussion boards, but connected to a particular doctor and his/her environment.


A quiet masterpiece set in 1920s Baltimore

It's a book about a steel worker in 1920s Baltimore. In less sure hands it might not have worked out so well. What about this self-published paperback made me, an inconstant and flightly reader, read all the way to the end? I'll let Celeste take it from here.


A poem with the word "fibrillate"

I always thought my medical vocabulary would come in handy somehow...

A poem of mine won a contest in the Forward to commemorate the 100th anniversary of the Triangle Shirtwaist fire. You can read it here.


Is Medicine Permitted?

In the 14 Adar issue of Simcha Lerner's Machshovos Zoros ("Outside-the-Box Thinking") there is a very interesting essay which I have excerpted below.

Toward a Halakhic Theory of Medicine

The study of medicine is an important and often enjoyable way to learn about humanity and illnesses but it is also morally dubious. Most people enjoy discovering important details about the workings of the human body, complex diseases from different times and places that inform their health and life expectancies. But because learning about the body involves discovering and repeating uncomfortable facts about bodily functions and human desires, we must ask whether Judaism permits it. Are we allowed to publicly discuss unclean biological and physiological acts merely because someone is sick? For example, Rabbi Shtraussfogel, in his work "Fees for Divine Service," points out that if we discuss sexually transmitted infections, we might come to permit mixed dancing. Also, medicine might teach us that homosexuality is not an illness to be cured and genital herpes is a communicable disease. According to Rabbi Shtraussfogel, medicine serves to inspire. "We do not need tales of death, we need stories of miraculous cures." Rabbi Shtraussfogel's son-in-law, Rabbi Zamdkopf, used to say, "If God wanted there to be Jewish doctors,  He wouldn't have made people sick on Shabbos." Indeed, Rabbi Shtraussfogel used to make sure that he would fall ill only in a town that was at least 51% non-Jewish or non-observant.


Robust God-Talk and Wimpy Moral Scruples

In his essay on Jewish identity in Jewish Ideas Daily, Yehuda Mirsky makes the following comment:
the language of "Jewish identity" is at best a pale substitute for the robust God-talk whose place it tries to fill
To be fair, he does conclude that the yearning for Jewish identity is better than nothing. (He doesn't go out of his way to ground his assertions in anything more than anecdote, but I won't go into that here.) What does "robust God-talk" mean, though? This is reminiscent of similar terms, like "maximalist," "heteronomous," and "rigorous," which are thrown around by some to show how Strong and Committed they are. Religious Jews are Robust, while Jews that care about Jewish identity (as if that issue has not preoccupied Jews for thousands of years!) are decaffeinated.

Unfortunately, a lot of Robust God-Talk is indefensible. "The sole purpose of non-Jews is to serve Jews," said Rabbi Ovadiah Yosef. This talk is certainly  robust, and delivered by someone held by many to be one of God's foremost authorities. Other God-talk, similarly robust, called for Jews not to rent their apartments to Arabs.

I am sure Mirsky finds such robust God-talk repugnant. The question is, then, what robustness means, and why it is better than serious grappling with the difficult matter of Jewish identity. Mirsky contrasts the wimpy omphalocentrism of Jewish identity with "real, durable responsibilities." Which responsibilities, exactly, and what makes them more "real" then our commitments to our own ideals and the communities we inhabit by our choice?

Undefined, rhetoric like this serves only to validate a particular type of Jewish identity to the exclusion of others. Certainly we can do better.


Call me on your cell, sugar

You've probably heard about glucose metabolism and cell phones. This sentence in the abstract got my attention:
[M]etabolism in the region closest to the antenna (orbitofrontal cortex and temporal pole) was significantly higher for on than off conditions (35.7 vs 33.3 μmol/100 g per minute; mean difference, 2.4 [95% confidence interval, 0.67-4.2]; P = .004).
If anyone can tell me what 2.4 μmol glucose/100 g means - is this a lot or a little? - I would feel more informed. For now, though, I will continue to shrug at the marauding cell phones.

Update: In this study, the regional cerebral glucose consumption rate was about 37 μmol/100 g per minute. So 2.4 μmol/100 g per minute is less than a tenth of the normal value (if I understand correctly). Whether a change of less than 10% is significant - again, I'm trying to find the relevant literature.

Historical Update: A friend comments:
The first author [of the glucose and cell-phones paper] is Trotsky's great granddaughter. Maybe she should have tested whether ice picks near the head change glucose metabolism.


The jerky hominem

In his perfectly reasonable essay about the Internet (a topic crying out for an extended treatment in the New Yorker), Adam Gopnik says

But if reading a lot of novels gave you exceptional empathy university English departments should be filled with the most compassionate and generous-minded of souls, and, so far, they are not.
Ideals, philosophies, abstractions always fail - then what? Gopnik's point is clever but not, on further thought, true at all. We don't say that the jerkiness of some English professors proves that the novel doesn't build empathy. We say, "The jerky ones aren't doing it right." Similarly, the abuses of corrupt rabbis, priests, and imams - or the jerkiness of many religious people - serve to convince no one (except perhaps Christopher Hitchens) that religion is untrue by virtue of that fact. The abusers and the religious asshats aren't doing religion right, is what we say.

I often think of the ad hominem argument as one against a particular hominem, but sometimes, it turns out, you can make it against a group. Since all groups have human frailties, you can always point at a group and say, "Look! It contains twits!" Unfortunately for human beings, that proves nothing at all.


What's the word for mustard?

Check out my poem Zeneft - and my reading of it - at the literary journal qarrtsiluni, currently featuring its Translation issue.


In Which Leon Wieseltier, Writer of Long Sentences, Lets Sense Plummet Into Disrepute

"I have watched ideals and traditions that I cherish -- a certain sort of liberalism; a certain sort of philosophy; the speaking of Hebrew; easel painting; the joyful making of books; long sentences; and even the sound of a voice, in personal communications--fall into disrepute. (We all have such a list.)"

Thus Leon Wieseltier in The New Republic (on what should be known, for as long as he occupies the real estate, as the Back Page Without Paragraphs). Do you know what is on my list, Leon? Making sense.

The "speaking of Hebrew" is in disrepute? 

There's a country where they speak Hebrew, Leon. All the time. 

And I'm not sure what you mean by "the sound of a voice, in personal communications," but I spoke to a fair number of people today.

Banal midrash

Are Velveteen Rabbi's "Torah poems" any good? My review gives the answer.


Herring and Coconuts

Two translations of mine are featured in the new issue of the journal Eleven Eleven from the California College of the Arts: one of Dvoyre Fogel's Herring Barrels, the other of Moyshe Nadir's My Pedigree. Let me know what you think!


What have I just started translating?

These sentences are the beginning of a famous Yiddish novel. If you guess what I'm translating, you will win a hearty congratulations and a drink the next time I see you in person.

The city of N is built in three rings. First ring: the very center, the trade market. Second: the great city itself, with the many houses, streets, byways, alleys around the market, where most of the dense habitation is located. Third: suburbs.


What should be translated?

The Yiddish Book Center (that Yiddish Book Center) has a blog post up by David Schlitt where he asks the question, "What Yiddish titles and/or authors would you most like to see translated?" An excellent question, that (and it's no surprise that I left a comment there). Follow the discussion, if you would.


I Have a Hat Today

Yesterday, I spent a fascinating 15 or 20 minutes looking at video of King's famous speech. ("Why is it in black and white?" asked my seven-year-old, and I resisted the temptation to give her the Calvin and Hobbes answer.) Two things I noticed:

1. The white folks were acting stereotypically white, sitting on their hands, pained smiles pasted on their faces, occcasionally nodding.

2. 1963 straddled an important boundary in history - in this case, between massive hat-wearing and widespread hatlessness. I didn't notice whether the white folks or black folks wore more hats, but it seemed to me like the split was about 50-50 total between hatteds and bareheads. 



I'm doing about as well as I'd expect.
I'd expect to turn half cartwheels.
I'd tear up the floorboards
to find more floorboards
printed by my pacing.
You expect a letter
but you'll get a palimpsest.


Setting Out

Setting Out
Bei Dao 

To TT, on his 24th birthday

In the watch store called The Stars
Twelve celestial hours chime
Along the clouds’ unending path
Twenty four mountains spin around

Migrating birds set out from you
The earth is covered with written signs
Waves turn the pages, wind reads aloud
Roots’ meaning is drawn out by trees

With song a music box protects
The juniormost of all the gods
Querulous teapot teaches how
To know the taste of wind and storm

Reality is another dream
The air is full of banknote kites
Fire’s ice and thunder’s shock
The chessboard kingdom sets its traps

The gravely ill disseminate
All the rumors of the age
But only those who guard the night
Will breach the lines of dawn’s defense

Shadows clear up, rainbows push
The swinging doors when seasons change
In the watch store called The Stars
Twelve celestial hours chime

Original here. Translation mine.

Not enough statistics?

Well, thanks for all the bioethics and Yiddish and poetry (the Yiddish bioethics poetry is yet to be written), say you, but what about statistics and mathematics blogs?

I didn't know Jordan Ellenberg (the novelist and mathematician of the Do the Math feature in Slate) has a blog. And he often links to the Three-toed Sloth. Andrew Gelman writes well about all sorts of statisticky stuff, though he's a touch more technical.

There you are. More such links please from you, if you know about them. (Or, heck, if you're an electrical engineer or astronomer or chemist and know about interesting blogs in those fields, the more the merrier.)


What does halachah say about how to improve American health care? Not much.

Someone skeptical about halachah might ask, "Does Jewish law have anything useful to say about a public policy debate as complicated and multifactorial as health care?" Unfortunately, after reading the chapter devoted to health care in Rabbi Jill Jacobs' There Shall Be No Needy, I have to say no.

I wanted Jacobs' book to provide halachic metaphors to help me understand better what it means to support health care reform - and, ideally, to help me judge the relative ethical benefits and risks of various alternatives, even in a general way. I don't need halachah to tell me about the necessity of health care, the critical role of the health care provider, or the community's role in providing such care: these are relatively uncontroversial, things that even opponents of health care reform support. Halachah should be a source of Jewish wisdom and  something more than the deployment of righteous cliches. It should provide a particular perspective, not a reinterpretation of universalist principles which can be found in any liberal ethos.

Rabbi Jacobs' chapter is a skillful summary of the general principles of Jewish law regarding the provision of health care to the individual and community. She discusses the well-known arguments about the healer's permission to "interfere" in Divine creation when healing the sick, the need for the physician to be remunerated for their services; and the requirement inumbent on the community to provide for medical care. In an esthetic and moral sense, the passages she cites are useful - as Jacobs herself points out, they serve as a troubling reminder of the inefficiencies of the American health care system. (1)

After these summaries, however, Jacobs seems to get lost. She acknowledges that "today's system presents us with many more players than the doctor, the patient, and the immediate community" and goes out to find what halachah will tell us about these multiple factors. Unfortunately, there isn't much there (when has there been a health care system on earth as fragmented, oversized, and inefficient as ours?), so she has to limit herself to an unsatisfying historical aside on the history of Jewish hospitals and an unsurprising teshuvah by Rabbi Shlomo Goren holding that the Israeli government is required to provide health care. (2)

Jacobs acknowledges in passing that most Americans today receive health care through their employers (though she neglects to mention that veterans and Native Americans also are cared for by a national system), a state of affairs which has no halachic precedent. What then is there to say?

This is where the rubber meets the road. If there are no exact parallels in halachah to the matter at hand, perhaps there are at least useful metaphors, engaging stories, gripping ultimatums, solid philosophies. Jacobs: "From a Jewish perspective...a major problem with the American health care system is the lack of community oversight over the distribution of funds." This is disappointingly tepid and unfocused.

"Community oversight," like Mom and apple kugel, sounds good on its face. (I supported a public option and I think that a single-payer system is the way to go - I assume this is what Jacob is reaching towards with her "community oversight.") But what we need is help with a hard question: what kind of community oversight is needed, and at what level of government? Do we need more state control of apportionment of Medicare and Medicaid, or less (both could be called "community oversight")? Do we need Congressional interference in decisions about comparative effectiveness research? Should the Federal government have a role in deciding what health care should be available to which doctors? Democracy is all about the conflict of different communities, and "the Jewish perspective," at least as Jacobs is presenting it, has nothing whatever to say about these conflicting priorities.

In a concluding chapter which is useful in understanding her overall approach, Jacobs lays out her vision for how Jewish law and tradition should inform public policy (or the "public sphere," as she vaguely calls it). Unfortunately, this vision is not convincing.

Why unconvincing? Her "essential principles" ("the dignity of human life," "the inherent disparity of power" between different classes, and the reciprocal responsibilities of individual and community) are not unique to Judaism. This would not be a problem if halachah provided a unique perspective on issues of public policy - but I don't see any evidence of that here either. How, according to Jacobs, should Jewish law inform our discussions? "Jewish sources should help us to see various sides of an issue,challenge our assumptions, and enable us to formulate a response that takes multiple factors into account." Again, this is nothing we need halachah for - only a liberal cast of mind and general civic virtues of tolerance and open inquiry. (3)

It is not inspiring to say that halachah offers us no guide in some areas of life, but I think that's the case. I will not ask a posek the next time I prescribe an antibiotic and I don't think I need one either when considering various aspects of health care reform. (4) General moral guidelines about the importance of health care are available in halachah, should one choose to seek them there (though they can be found nearly everywhere else in a liberal society). For practical approaches to systematic reform, we should look elsewhere.

Update: See Rabbi Josh Yuter's shiur on the topic here, which I haven't listened to all of yet.

1. Jacobs says that our country's systematic inefficiencies and profit-driven nature "prevents many patients from being able to afford needed medical care." This is undoubtedly true, but another issue - which Jacobs does not explicitly address - is that Americans want too much medical care: too many labs, tests, and procedures, which drive up costs without improving care. This, among many other complications of the health care system, is something which our halachic predecessors simply could not envision, although I am sure one could, by stretching some precedent to the breaking point, find a proof text of use.

2.  Jacobs calls this teshuvah influential, but I suspect she is mixing up the chicken and the egg. Surely more determinative in today's halachic world is the fact that Israel is a democracy. Democracies legislate and administer national health care. Were Israel not a democracy, or not able to administer health care, the Goren teshuvah would be forgotten.

3. In fact, one could argue that Jewish law - in many places - does not place a premium on tolerance or open inquiry. There is the apikores and the min, after all.

4. In this regard, Rabbi Jacobs' philosophy bears a surprising (and disquieting) resemblance to Charedi daas Torah: that rabbis have a variety of expertise which equips them to offer advice even in practical situations far afield from their formal erudition.