An unmistakable Divine message

Town and Village Synagogue: 334 East 14th Street.

Curly's Vegetarian Diner: Now at 328 East 14th Street.

The message:

Pray. Eat veggie nachos.

Why do African- and Hawaiian-Americans have a higher risk of lung cancer?
This article is illuminated by an accompanying background article in the Journal. See here, if you have NEJM access.

Ethnic and Racial Differences in the Smoking-Related Risk of Lung Cancer

Christopher A. Haiman, Sc.D., Daniel O. Stram, Ph.D., Lynne R. Wilkens, Dr.P.H., Malcolm C. Pike, Ph.D., Laurence N. Kolonel, M.D., Ph.D., Brian E. Henderson, M.D., and Loïc Le Marchand, M.D., Ph.D.

ABSTRACT

Background There is remarkable variation in the incidence of lung cancer among ethnic and racial groups in the United States.

Methods We investigated differences in the risk of lung cancer associated with cigarette smoking among 183,813 African-American, Japanese-American, Latino, Native Hawaiian, and white men and women in the Multiethnic Cohort Study. Our analysis included 1979 cases of incident lung cancer identified prospectively over an eight-year period, between baseline (1993 through 1996) and 2001.

Results The risk of lung cancer among ethnic and racial groups was modified by the number of cigarettes smoked per day. Among participants who smoked no more than 30 cigarettes per day, African Americans and Native Hawaiians had significantly greater risks of lung cancer than did the other groups. Among those who smoked no more than 10 and those who smoked 11 to 20 cigarettes per day, relative risks ranged from 0.21 to 0.39 (P<0.001) among Japanese Americans and Latinos and from 0.45 to 0.57 (P<0.001) among whites, as compared with African Americans. However, at levels exceeding 30 cigarettes per day, these differences were not significant. Differences in risk associated with smoking were observed among both men and women and for all histologic types of lung cancer.

Conclusions Among cigarette smokers, African Americans and Native Hawaiians are more susceptible to lung cancer than whites, Japanese Americans, and Latinos.

The Cherry Tree

1.

How many weeks of rest
with the sour cherries
before the summer sparks
what it can't have – sudden red
rising from the steaming ground

You can’t shut your eyes. They’re fixed
(though foreboding) on the ground forever
subsuming, reforming, engrossed in its layers
like a queen at her trousseau
again and again smoothing and folding knowing

thousand-root years bring growth and decay
to no conclusion but repetition.
Yet you stay to admire how this particular
season justifies itself before the magistrate
of the eye: distinct branches, self-defining trees

2.

Back now on peopled street: the mass is
miniature – diorama nestled in vastness.
This city is all facets’ fastness.

Back to kitchens and quick-wristed cooks which
train palates, tongues on new-thought dishes.

Back to those on battle pay, and
those who sent them, temples graying.

These wholes will lose their parts, but live as
cherry tree will have much to give us.

3.

The whole world an abstraction. This piece world
horizon not embracing but demanding
a sand-grained wind to tear the flag unfurled,
not suffering domestic understanding.
Domestic merely: home is not a womb
nor spouse a bosom friend. The unmet names
that know the truth of home are just in bloom
among those fields where runaway you came
to taste the flowers of what cannot be grown
except against the wall. Right there you found
what gardeners of every age have known:
since world is round its every part is round.
Each piece of fruit that stains the fingers orange
is only trap for seeds of future orange.

How to talk to people

Sick people, I mean.

MEDICINE MENSCH: So...? How Are Things?
By Zackary Sholem Berger
February 3, 2006

Do you like to talk to other people? Sometimes I do; it depends how many there are. If I'm at a party, I slink toward the chips and-salsa or talk only to my wife. (Wallflowers don't blossom; they just climb farther up the wall.) If I'm talking to a friend of mine, it can take me some time to shut up. But if I'm face to face with a person who's providing a paid service — a checkup, a haircut, a repair — I have to remind myself to use the pleasantries that keep ordinary conversation going. I clam up.

Now that I'm almost a doctor, and, more to the point, now that I'm starting a rotation called Ambulatory Care (outpatient medicine, where patients are seen in clinic), I'll get to see the entire range of patient-conversationalists. But I have to figure out how to talk just enough.

This is both easier and harder than it sounds. Easier because the person you're talking to gives signals; following those signals is a well-marked route to conversing in a non-annoying fashion. (If the patient is checking her watch, rolling her eyes, or — as in the movie "Airplane" — tying a noose round her own neck, it's a good sign that her patience is wearing thin.) Talking less is generally good advice in any situation. No one likes a bore, least of all a bore whose favorite topic is your illnesses. Even though patients would like to be fully informed, most of them would like their information in a few concise paragraphs, not in a long-winded discourse.

On the other hand, a doctor needs to talk to get his work done. A silent doctor, like a silent lawyer, invites suspicion. But so does talking: Like lawyer and client, doctor and patient never can have a normal conversation; each of them is waiting for the other word to drop. The patient dreads the openings "There's something you need to know" or "We need to take a look at that" in the same way that the doctor never can escape the "doorknob questions" that the patient remembers just when she's about to leave: "Oh, I've been meaning to ask you something"; "Just one more thing."

If the conversation starts off on the right foot, it won't be so fraught for the parties involved. The accepted pedagogy in medical school is that one must begin in an "open-ended" way, and only later "cone in" to more specific, useful questions. Translated from jargon, this means that ideally the physician would welcome the patient into the office, invite him to sit and then wait silently, like an oracle. If necessary, at the very most one can utter a single word: "Well?" or "So?" Thus encouraged, a patient will spill the whole story without undue interference from the doctor.

If this oracular opening actually were to be adopted in most doctors' offices, patients would get confused and think they wandered into the psychotherapy suite by mistake. I've tried it myself a couple of times, and it spooks the patient. Of course, there's a compromise available: You can start off without a torrent of detailed questions, but your intro can be friendly and personable.

I've tried to see which opener works best for me. There's "What brings you here today?" An old favorite, but I can never say it without thinking of the old, jokey answer: "A taxi, doctor." I could ask, "What seems to be the problem?" Fine, I suppose, but it's nothing I actually would say in the course of a normal conversation. "How are things?" I used that once, and the patient said "Fine, thanks" — and stopped talking right there. I had to restart the conversation from a standstill.

There's a difference between what's supposed to happen (according to the theory of the clinic visit) and what actually happens. According to theory, I open up in a general vein and then become more specific as the patient reveals her problems. But the truth is that our conversation only traces the surface of the problems affecting the patient. What people say to their doctors often doesn't point to the true nature of their ailment. An office visit that the doctor considers notably successful (a problem correctly diagnosed, inroads made into diabetes control or reduction of cardiovascular risk) can appear completely useless to the patient: Her annoying cough hasn't gone away, and her back still hurts.

This is the conundrum of outpatient medicine. Since the patients seen in hospitals (where young doctors get their start) are sicker on average than they were decades ago, the bulk of today's training is focused on keeping them alive, or, in rare instances, on curing them. But day-to-day clinic medicine (and the role of doctors throughout much of history) has been not to save lives but to improve them, to make the acute problem less acute and the chronic one easier to bear.

When residents talk, they often say that clinic patients are hard to deal with. Do they mean that hospitalized patients, with their long lists of potentially fatal medical problems, are easy to treat? Maybe it's that patients in clinic, with their multiple medium-sized problems, come with the same considerable challenges and small-scale opportunities that are present in any interaction. The aim is to make incremental improvements while keeping an eye out for those brief openings that allow a significant change for the good. For the average clinic visit of 10 minutes or so, that's plenty to talk about.

That's all we have time for today, I'm afraid. Same time next month?

Zackary Sholem Berger has another patient waiting, but he cares about you personally. Write to him at doctor@forward.com.

Take your bundle of [spice]...

I forgot, or more likely never knew, the meaning of אזוב (Exodus 12:22, שמות פרשת בא, ולקחתם אגדת אזוב). Onkelos translates it unhelpfully as איזובא. Saadiah Gaon says it means זעתר (za'athar), which Ibn Ezra translates as אוריגנו (origano/oreygano). (Ibn Ezra says of Saadiah's gloss that it "isn't likely" [זה לא יתכן] for Biblical and botanical reasons, but admits that he doesn't know what plant the word refers to.) Yidish-taytsh, I think, calls it אזובֿ, as does Yehoash.

The Septuagint renders the word as hyssopos 'hyssop.' Here's where I quote William H.C. Propp in Anchor Bible Exodus 1-18, where he chooses to call it "marjoram":

The LXX rendering . . . is based on the phonetic similarity to Hebrew 'ezob, a common translation technique for LXX (Tov 1979). But even when Hebrew and Greek words are truly related via borrowing, their meanings may differ slightly. 'Ezob is "Syrian hyssop" (Origanum syriacum l.) or marjoram, still used by Samaritans for Pesakh (Saadiah; Crowfoot and Baldensperger 1931). Greek hyssopos is a different plant altogether (Zohary 1982:96). A literalist might object that we should seek a native Egyptian plant, rather than a Palestinian, but no doubt later Israelite practice has been transplanted into an Egyptian setting.

The marjoram tuft, readily available (cf. 1 Kgs 5:13), is essentially a brush (Cassuto 1967:143 [this is also implied in the commentaries of Ibn Ezra and Saadiah -- ZB]). Segal (1963:159) and Jacob (1992:328) plausibly infer that it insulates lay officiants from the dangers of the holy; true priests, in contrast, manipulate blood with their fingers. Marjoram is also used to apply blood in ritual purifications (Ps 51:9), particularly from skin disease (Leviticus 14 passim) and death (Num 19:18, cf v 6). According to Heb 9:19, it was also used for the Covenant ceremony of Exod 24:8.

What relationship Saadiah's term za'athar has to modern-day zaatar, and why marjoram is called Origanum (so what's oregano, then?), are puzzles for wiser minds to solve.

Oh, here's a useful note:

In the countries of the Eastern Mediterranean, there is often no clear distinction made between a couple of aromatic herbs of the mint family: Names like Turkish kekik or Arabic zatar/satar [زعتر, صعتر] and related forms in Hebrew and Persian, often in conjunction with qualifying or descriptive adjectives, may be applied to a varity of native herbs including, but not restricted to, oregano, marjoram, thyme and savory. Usage may vary even within a given language, depending on the region and particularly on the local flora. In Jordan, zahtar usually means a spice mixture containing such herbs (see sumac for more).

The argument from flawed design
[Corrected from an earlier version based on comments. Thanks to my bar-plugta.]

The argument from design begins with the observation that the universe is so intricately complex that only a builder could have created it. The only such builder is the Builder.

An offshoot of this argument is the Intelligent Design theory, which Hirhurim pointed out should better be called a religious philosophy. According to this so-called alternative to evolution, the details of biological systems require a Designer to assemble them all just so.

The problem with both the Intelligent Design philosophy and the argument from design is that complexity need not be explained by a Designer. But the problem of imperfections in the world's design is also relevant. Part of the idea of "complexity" inherent in the Design Argument (and the famous watch metaphor) is that the world's intricacy is necessary to its functioning, in the same way that a complicated mechanism underlies the way a watch works.

An "intelligent design" biologist (to the extent that one exists) would not credit evolution for regulatory proteins and their interlocking complexity. Rather, he would say that this is an instance of special creation, since nothing so complicated as protein-kinase molecular biology could have arisen by chance, even over millions of years.

But the complexity of biological systems is riddled with irregularities and imperfections that weaken the watchmaker metaphor and make us ask the question: what sort of designer would include them? Regulatory proteins can be hijacked by viruses or can malfunction through environmental insult. Even to some nephrologists I know, the kidneys seem like jerry-rigged, hopelessly complicated organs. And if the fine-tuned electrical conduction of the heart goes haywire, you can forget about the ventricles acting as pacemakers on their own. They're likely to conk out altogether, which is deadly to the organism.

Why would God build such imperfections into the system? The test for justifications of God's moral actions, as I think Paul van Inwagen touches upon in one of his lectures, is their narrative plausibility. (The well-known and ancient argument "I believe because it is impossible" can't help us in distinguishing between competing plausible accounts of God's actions.) If we compare the theory of evolution to the theory of special creation of biological systems, the second option presents us with questions that are very difficult to answer: if God specially created molecular biology, why couldn't He (or She) have done a better job? Why doesn't our heart work better? Why are we bipedal when it causes such pain over increased lifespans?

On the other hand, believing in both God and evolution provides a satisfying narrative. God created a system which is higher-order than even humans themselves, a mechanism which governs life in its complexity. This does not gainsay our moral responsibility or particularist relationships with God. Evolution and the Torah are not mutually exclusive. Rather, evolution (so to speak) is a construction more appropriate for the perfect Builder than imperfect special creation.

In other words, the argument from design assumes that complexity requires a Designer. Since not every kind of complexity needs a designer, though, we need to limit the argument to those sorts of complexity which fit the bill. I think that the irregularities and inconsistencies of biological systems -- those which intelligent design advocates hold to be prime examples of special creation -- argue against such "Designing" with a capital D.

A question was raised in the comments: how can we assume that God would design a complexity comprehensible by humans? But that's the very nature of designed complexity! If we point to an irregularity-riddled complexity and say, "This requires a Designer," we are left with very puzzling, perhaps indefensible notions of how the Designer must act.

Turn it and turn it, for stuffing is in it
...דמליתא בה (?)

The plush Torah is pretty cute, but its smile is incongruous. Torah makes you happy, it could be argued, but I wouldn't call it sunny or friendly. If I were an Amalekite I would see the plush Torah in my nightmares. (Then again, if I were an Amalekite, I'd have plenty of other things to worry about.)

*If anyone can think of a good Aramaic translation for "stuffing," half of my kingdom is theirs.

What hath frogs wrought

The word צפרדע (frog, or, collectively, "frogs") is found in two places in Psalms. The order of the plagues dealt the Egyptians differs in Psalms from the recounting in Exodus. One traditional explanation for this (as suggested by the Radak, R. David Kimchi) is that the true order is represented in Exodus, so there's nothing lost by a change in the order in Psalms (which according to this understanding presumably differs for rhetorical reasons). The historical-critical explanation, not surprisingly, is that different traditions, or source texts, underlie the various recountings of the Exodus tale.

This all means that variances in Psalms (when compared to Exodus) should be looked at closely. In this week's parasha, here's how Egypt is affected by the frogs:

כז וְאִם-מָאֵן אַתָּה, לְשַׁלֵּחַ: הִנֵּה אָנֹכִי, נֹגֵף אֶת-כָּל-גְּבוּלְךָ--בַּצְפַרְדְּעִים.
Exodus 7:27 And if thou refuse to let them go, behold, I will smite all thy borders with frogs.
כח וְשָׁרַץ הַיְאֹר, צְפַרְדְּעִים, וְעָלוּ וּבָאוּ בְּבֵיתֶךָ, וּבַחֲדַר מִשְׁכָּבְךָ וְעַל-מִטָּתֶךָ; וּבְבֵית עֲבָדֶיךָ וּבְעַמֶּךָ, וּבְתַנּוּרֶיךָ וּבְמִשְׁאֲרוֹתֶיךָ.
28 And the river shall swarm with frogs, which shall go up and come into thy house, and into thy bed-chamber, and upon thy bed, and into the house of thy servants, and upon thy people, and into thine ovens, and into thy kneading-troughs.
כט וּבְכָה וּבְעַמְּךָ, וּבְכָל-עֲבָדֶיךָ--יַעֲלוּ, הַצְפַרְדְּעִים.
29 And the frogs shall come up both upon thee, and upon thy people, and upon all thy servants.'

ב וַיֵּט אַהֲרֹן אֶת-יָדוֹ, עַל מֵימֵי מִצְרָיִם; וַתַּעַל, הַצְּפַרְדֵּעַ, וַתְּכַס, אֶת-אֶרֶץ מִצְרָיִם.
Exodus 8:2 And Aaron stretched out his hand over the waters of Egypt; and the frogs came up, and covered the land of Egypt.
ג וַיַּעֲשׂוּ-כֵן הַחַרְטֻמִּים, בְּלָטֵיהֶם; וַיַּעֲלוּ אֶת-הַצְפַרְדְּעִים, עַל-אֶרֶץ מִצְרָיִם.
3 And the magicians did in like manner with their secret arts, and brought up frogs upon the land of Egypt.
ד וַיִּקְרָא פַרְעֹה לְמֹשֶׁה וּלְאַהֲרֹן, וַיֹּאמֶר הַעְתִּירוּ אֶל-יְהוָה, וְיָסֵר הַצְפַרְדְּעִים, מִמֶּנִּי וּמֵעַמִּי; וַאֲשַׁלְּחָה, אֶת-הָעָם, וְיִזְבְּחוּ, לַיהוָה.
4 Then Pharaoh called for Moses and Aaron, and said: 'Entreat the LORD, that He take away the frogs from me, and from my people; and I will let the people go, that they may sacrifice unto the LORD.'

Let's compare Psalm 78:

מה יְשַׁלַּח בָּהֶם עָרֹב, וַיֹּאכְלֵם; וּצְפַרְדֵּעַ, וַתַּשְׁחִיתֵם.
45 He sent among them swarms of flies, which devoured them; and frogs, which destroyed them.

"Them" refers here to the Egyptians, I think.

The question is: which destruction is meant? The emphasis in Exodus is on the frogs' unstoppable fecundity, not on their destructive power. Rashi, commenting on the word "destroyed them" (ותשחיתם) in the verse in Psalms, says שומטין את ביציהם, "they [the frogs] took away their [the Egyptians'?] eggs." The reference is unclear to me, and I bet he's referring to a midrash I can't find right now. Perhaps Rashi is making an association with the root ש.ח.ת "destruction," which is known to Jews in the phrase השחתת זרע "[wanton] destruction of seed."

Perhaps it is the case (using a historical-critical approach) that the Psalmist knew of a different tradition, in which the frogs were not fecund but destructive. Rashi is combining their two effects, if I understand him correctly: since they were so multiplicative, they stole or took away the eggs of other creatures. Unfortunately, I'm still not clear on what Rashi means and whose eggs he's referring to. Any help here?

Prosperity = death?
This week's epidemiology abstract.

While mortality has decreased over the past century, superimposed on that decline have been occasional spikes. This study endeavored to confirm this observation by correlating economic with mortality indices in a statistical way. I haven't read the article yet, but the abstract piques my interest.

Increasing mortality during the expansions of the US economy, 1900–1996
Author: Granados, José A Tapia
Source: International Journal of Epidemiology, Volume 34, Number 6, December 2005, pp. 1194-1202(9)

Background In Western countries mortality dropped throughout the 20th century, but over and above the long-term falling trend, the death rate has oscillated over time. It has been postulated that these short-term oscillations may be related to changes in the economy.

Methods To ascertain if these short-term oscillations are related to fluctuations in the economy, age-adjusted total mortality and mortality for specific population groups, ages and causes of death were transformed into rate of change or percentage deviation from trend, and were correlated and regressed on indicators of the US economy during the 20th century, transformed in the same way.

Results Statistically and demographically significant results show that the decline of total mortality and mortality for different groups, ages and causes accelerated during recessions and was reduced or even reversed during periods of economic expansion—with the exception of suicides which increase during recessions. In recent decades these effects are stronger for women and non-whites.

Conclusions Economic expansions are associated with increasing mortality. Suggested pathways to explain this deceleration or even reversal of the secular decline in mortality during economic expansions include both material and psychosocial effects of the economic upturns: expansion of traffic and industrial activity directly raising injury-related mortality, decreased immunity levels (owing to rising stress and reduction of sleep time, social interaction and social support), and increased consumption of tobacco, alcohol and saturated fats.

Keywords: Economic conditions; macroeconomic factors; economic recession; unemployment; mortality determinants; age-specific death rates; causes of death; demography

A Herculean feat
To (unngggh) somehow use the power of the Bible (unnggh) without (arrgh) being religious! Whew!

Amy Davidson of The New Yorker and Ari Shavit of Ha'aretz hit upon a thing called The Bible as Literature. Strange but true!

Sharon talked about his own attachment to the land in your interviews with him. You said earlier that the settlers saw him as too secular. It’s a strange thing—he speaks about the land in Biblical terms, evoking Biblical figures, without ever being religious.

Sharon was a godless person, in a very profound way. He had no religion, no faith. When you look at the brutal chapters of his biography, you can say that there was something of the brutal secularist about him; this was the modus operandi of a person who’s really not God-fearing in any way. This is fact No. 1. Fact No. 2 is that he had a very strong sense of history, with a special attachment to the land, and a very strong Biblical memory—the Bible and the land came together in a potent fusion process within him. He was truly a nationalist romantic, in an almost scary way. The two sides seem to be contradictory, but, if you look at the history of Zionism, you see that there is not that much of a contradiction. For the early Zionists, the Labor-movement Zionists, history replaced God, and the Bible replaced both the Talmud and the Orthodox way of living as a Jew. History was the God of the Zionists. The idea was to bring the Jews—who, in the old Zionist terminology, had lived outside of history—back to the family of nations, the theatre of nations, where there is peace and war. This was the great thrill of the founding fathers of Zionism. And, in the same way, the Bible, being taken and read as the book about Jews living in this land, with a real, physical life as a nation, cultivating the land, defending the land—this was very powerful for the young Zionists and the young Sabras of Sharon’s generation. He took it perhaps to a bit of an extreme, because he was a person of extremes, but this intimate relationship with the land and with Biblical legacy and tradition actually goes well together with the godless dimension of his personality, and, in many ways, makes him the last of this early line of Zionists; we are not going to see any more of this type in the future.

Entsiklopedia haYehudit

This appears to be a free, readily searchable compendium of information about (traditional religious) Judaism taken from already published sources. In Hebrew.

O-bashing, continued
Third in an ever-more intermittent series.

I don't think boys younger than bar-mitzvah age should ever wear suits. It makes them look like Little Lord Fauntleroy or pint-size members of the Mob. Yet this appears to be de rigueur in many of my neighborhood Charedi shuls. Is the Shtetl, as imagined by Orthodox ideologues, populated by suit-wearing nine-year-olds?

(A Shtetl, thus capitalized, is a magical, mythically pious place, which even in the modern age harbored no doubt, heresy, or heterodoxy. Some very important Orthodox rabbis, whose naivete in this matter is charming, have quoted works of Yiddish literature [literature! that's imaginative writing, folks, whose relationship to reality is -- at its closest -- beside the point!] as a faithful historical record of what life in the Shtetl must have been like. Cf. R. Soloveitchik in Halachic Man, part 2, with a long footnote quoting I.L. Peretz, and, I believe, R. Aharon Lichtenstein referencing Sholem Aleichem, though I can't find the Lichtenstein text right now.)

But these are aesthetic criticisms, and can easily be refuted. ("Why, I find suit-wearing nine-year-olds deliciously heartwarming!")

This installment address a broader fault of Orthodoxy, viz.: the inability to admit (or, better, face the fact) that great rabbis of the past were often wrong in many ways. I'll take two examples in summary form. (These are examples I've encountered recently in my own Torah study, which means they're more interesting for me to blog about than rehashed and well-known sources [e.g. misogynistic sayings from the Gemara]).

In the tractate Eruvin of the Babylonian Talmud, page 59a (ערובין נט. תוספות ד"ה ותחומין דרבנן, for those of you following along at home), the writers of the Tosefot talk about whether certain classes of people are believable as witnesses for certain classes of ritual law (eruvs, kosher slaughter, setting aside of the challah). Their argument concludes: "If searching for chametz were a Torah-level requirement, women would not be believable [as to their testimony that such a search had been properly completed], even if they're directly involved in the task, because searching for chametz requires punctiliousness and great care. Therefore [in this case] one should worry about women's laziness more than in another case. That too is the meaning of the Jerusalem Talmud, [where it is said that] women are not believable with regard to searching for chametz, because they are lazy and search only the most minimal amount."

Now, I can't say that I'm surprised at such a statement. Misogynistic statements in the Gemara are a dime-a-dozen (as are legal innovations for the benefit of women, albeit with lesser frequency). Nor is this Tosfos a vital pillar of Jewish thought or law (though women's "unfitness" as witnesses has been a long and, actually, quite sordid chapter of halachah). (It's a very interesting Tosfos, of course, as most of them are, but not for its misogyny. I think this Tosfos might hint that "bedikas khomets" is more akin to "Pesach cleaning" than a modern-day halachist would admit.) The reason I bring it up here is that I can guess exactly how an average Orthodox rabbi would respond to it: with apologetics. Perhaps "Oh, we don't pasken like Tosfos here" (I don't know if we do or not), or "This is a metaphysical truth about women's innate capacities" or even "Who are we to criticize Tosfos"?

Here's the most cogent and satisfying way to read the statement of Tosfos with regard to women's laziness: It's wrong. Case closed. This doesn't mean that I'm arrogant, or reject the authority of Torah, or think I know more than the Baalei Tosfos. It doesn't even mean that I eat pork chops with a side of cheescake on Yom Kippur. It just means that sometimes rabbis are wrong. We gay-loving, jeans-wearing, Debbie Friedman-singing Conservative Jews certainly have our faults (hint: only one of those three activities is a sin in my book, and it's not being gay), but we can respect rabbis while calling them on their mistakes and not get tied up in knots about it.

There's a second example I'll give. It's shorter. According to halachah (the Rambam, at any rate, and I believe the Shulchan Aruch and the Remo as well; consult your local rabbi if you're brave enough to talk to her about it!), you're not allowed to have sex during the daytime or by the light of a candle. Why's that? A longish discussion in tractate Niddah of the Babylonian Talmud, starting on 16b, comes down to this: there's an angel (or demon, pick your translation) who deals with conception, and she's only active at night. Now this Gemara is not wrong, exactly. It's a convincing and consistent implication of a magical state of affairs. Unfortunately, I don't believe in the Gemara's magic. What do I do about it? Again, I could wax apologetic (it's a metaphorical apperception of a metaphysical truth! it's a guard against overpromiscuousness in the married couple! it's a segule for exciting lovemaking!), or I could say: I understand (or at least I think I do), and I don't agree. Case closed.

Elie Wiesel's Night
was written in what language?

This article in the Times (which discusses discrepancies among various translations) doesn't name the language of the original until the seventeenth (!) paragraph. (No prizes for guessing which language.)

What did you eat that summer?

Diarrheal Illness Detected Through Syndromic Surveillance After a Massive Power Outage: New York City, August 2003.
Am J Public Health. 2005 Dec 27
Marx Ph D M P H MA, Rodriguez M P H CV, Greenko M P H J, Das M P H D, Heffernan M P H R, Karpati M D M P H AM, Mostashari M D M Sc F, Balter M D S, Layton M D M, Weiss M D M P H D

Objectives. We investigated increases in diarrheal illness detected through syndromic surveillance after a power outage in New York City on August 14, 2003.

Methods. The New York City Department of Health and Mental Hygiene uses emergency department, pharmacy, and absentee data to conduct syndromic surveillance for diarrhea. We conducted a case-control investigation among patients presenting during August 16 to 18, 2003, to emergency departments that participated in syndromic surveillance. We compared risk factors for diarrheal illness ascertained through structured telephone interviews for case patients presenting with diarrheal symptoms and control patients selected from a stratified random sample of nondiarrheal patients.

Results. Increases in diarrhea were detected in all data streams. Of 758 patients selected for the investigation, 301 (40%) received the full interview. Among patients 13 years and older, consumption of meat (odds ratio [OR]=2.7, 95% confidence interval [CI]=1.2, 6.1) and seafood (OR=4.8; 95% CI=1.6, 14) between the power outage and symptom onset was associated with diarrheal illness.

Conclusions. Diarrhea may have resulted from consumption of meat or seafood that spoiled after the power outage. Syndromic surveillance enabled prompt detection and systematic investigation of citywide illness that would otherwise have gone undetected.

Circumcision made normal
As discussed by polemicists.

In the new issue (January 19th) of the New England Journal of Medicine, David L. Gollaher of the California Healthcare Institute reviews two histories of circumcision: Leonard B. Glick's Marked In Your Flesh: Circumcision From Ancient Judea to Modern America, and Robert Darby's A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain. (Glick's book was reviewed some time ago in the Forward by Jay Michaelson.)

The NEJM review isn't available on-line yet, but here are some quotes:

Although circumcision has a long and interesting past, its historiography has suffered from a lack of objectivity. Most books and articles on the subject have an agenda, either to advocate the practice as an effective, preventive health measure or, more commonly, to attack it as genital mutilation that violates the rights of children. The books by Leonard Glick and Robert Darby are firmly in the anticircumcision camp. These authors aim to use historical analysis to strip circumcision of its medical and cultural legitimacy by exposing the myths, erroneous beliefs, and bad science that have been used to promote it.

Glick, an anthropologist with a medical degree, describes himself as "a scholarly activist" who belongs to "several organizations dedicated to ending all forms of genital injury to male and female children throughout the world." His tone is that of one who has seen the light, as he puts it, "that male infant circumcision is medically unnecessary, harmful to normal sexuality, and ethically unjustifiable." Marked in Your Flesh is less a historical narrative than a polemic. . . .

[. . .] Although [Glick] states that modern scholarship has overturned received wisdom about the authorship and provenance of the Torah, he treats the account in Genesis of Abraham as a historical record. This treatment is not trivial. Many Jews, Christians, and Muslims believe that God appeared to Abraham and told him to cut his foreskin, and that the failure of Abraham's descendants to do so thousands of years hence violates a sacred covenant. Such a belief is a matter of religious faith, however, not of documented history.

[. . .] On this topic [how circumcision came to be a widely accepted procedure in American hospitals], Glick presents few new sources or fresh insights. [. . .]

Perhaps one third of Marked in Your Flesh is devoted to reviewing the medical debate about neonatal circumcision. Professional journals have published thousands of papers about whether circumcision leads to a lower incidence of urinary tract infection, cancer, and sexually transmitted diseases. A balanced reading of the record suggests that circumcision carries both benefit and harm. It prevents rare penile cancer, but occasionally it seriously injures a baby. The American Academy of Pediatrics Task Force on Circumcision reviewed the medical literature and reported in 1999 that "existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.

The task force saw the ambiguity in the data on the health benefits of circumcision. This ambiguity only increases when one learns, for example, that in July 2005 French and South African AIDS researchers halted a large, randomized, controlled trial of adult male circumcision to reduce the incidence of AIDS after early results showed that men who had undergone the procedure had a dramatically reduced risk of contracting HIV through intercourse with infected women. Much more research is necessary, which may not bear out this result. But while reading Glick's book, one senses that the idea of benefiting from circumcision is inconceivable to him. This unwillingness to suspend the belief that circumcision is an unalloyed evil weakens Marked in Your Flesh and limits its explanatory power.

Keeping it real
(not by Mark Strand)

In a field
I'm not one of
the cows.
This is
always the case.
For all x not equal to me
I am not x.

When I walk
I don't stay still
and always
the air moves in
since gas is infinitely
compressible.

We all have reasons
for moving.
I've been
kicked out by my girlfriend.

A crown of thorns at Thorn Farm

If you're curious as to the meaning of אטד in this week's parshe (its only appearance in the Chumash) you might do worse than look at this Wikipedia article (in Hebrew, I'm afraid). Remember though that the Ivrit meaning of the word is not the same as its Biblical meaning. Don't forget the midrash which explains the curious name of the place at which Jacob was mourned (Thorn Farm, or גורן אטד) by saying that the descendants of Esau, Ishmael, and Keturah festooned his casket with crowns as a farm is ringed with thorns.

Join the club

Will someone please help this man before his second thoughts about utensil-submersion become dangerous?

Permissible criticism, or O-bashing part II
Second in an intermittent series of friendly, well-meant criticism.

What do we talk about when we talk about what's wrong with Orthodoxy? A commenter on my previous post suggested that what I'm trying to do here is a "tit-for-tat" in response to Avi Shafran's Moment article "The Conservative Lie." I hope not. Shafran's argument can be summarized as follows: Conservative Judaism claims that it adheres to halachah. However, Conservative Jews and their leaders are predictably lenient, lax in observance; and cavalier about the importance of halachah to their movement. These facts show, says Shafran, that Conservative Judaism is a failure.

I doubt Shafran's interpretation of the evidence. But even taking these claims at face value, Shafran is only applying Orthodox criteria to the Conservative movement, finding the two don't match, and exclaiming, "See! Conservative Judaism is a failure!" It is a failure in Orthodox terms, but these terms are not the only valid ones. Conservative Judaism's approach to halachah is multi-faceted, and Conservative Torah scholars do not speak with one voice -- that very fact makes it very difficult to say how halachah plays a role in Conservative Judaism. (The same could be said about Orthodox or Reform Judaism, as far as that goes.) That Conservative Jews are lax in their observance, or even that they do not recognize the importance of halachah, is a problem to be solved, not an indictment of Conservative Judaism. Laxness of observance and halachic ignorance have afflicted Judaism forever. They might even be the status quo.

Shafran understands halachah according to its ultra-Orthodox interpretation: strict constructionism. But Conservative Judaism can be (and, I think, tries to be) both halachic and lenient. This dichotomy is unfathomable to Shafran, but does not make it any the less true.

The reason I'm rehashing Shafran's old essay is to try and make a stab at what I have to do to criticize Orthodoxy in useful ways. A commenter on my last post suggested that I should not judge Orthodoxy by Conservative standards. Certainly not. But, on the other hand, I can't judge Orthodoxy by Orthodox standards, for two obvious reasons: first, I'm not Orthodox; and second, because Orthodoxy might be too various to define usefully. A possible way out is sociological. Clearly, Orthodoxy plays a necessary role in Jewish society. (Not the only necessary role, or the most authentic role, but a necessary role. I make this claim because it's defensible.) If we can figure out what makes Orthodoxy necessary, and (further) point out where Orthodoxy is departing from this necessary role, this might be a useful beginning for outside criticism of Orthodoxy. In short: not to criticize Orthodoxy for what can't be by its very nature, but for what it should be and is departing from.

Maybe I've set myself too hard a task, because there's not just one necessary function which Orthodoxy performs. Let's try anyway. One definite function of Orthodoxy is to present itself as a uniquely authentic, traditional Jewish religious culture. I'm using the term "present itself" not to be snide, but to recognize that Orthodoxy is mythic (in the positive sense of myth popularized among Conservative Jews by Neil Gillman), fervently believing in its own authenticity. Whether or not that authenticity is unique is not germane to our present discussion. What matters is that Orthodoxy itself is unique by its belief in that authenticity. It's a self-creation through mythogenesis.

Call this the Myth of Religious-Cultural Authenticity. The hyphenate is important, because it's the subject of my first criticism -- which, like much else I'm saying here, is not original. Today's Orthodox Judaism is in danger of ignoring the "cultural" half of its motivating authenticity myth, and focusing exclusively on the "halachic." Not that Orthodoxy should (God forbid) change its fervent adherence to its own halachic standards (though what those standards are, how they're articulated, and how they're actually observed, is a fascinating, fraught, and ultimately very confusing terrain). But halachah to the exclusion of culture can drain Orthodoxy of what makes it convincing and meaningful not just to its followers but to its non-Orthodox observers: a central myth of traditional living as carried through the generations. (Alan Brill wrote about this in scholarly fashion in an article in Edah, which I discussed here. Also here, here, and here.)

I'd like to suggest that the sector of Orthodoxy which is managing to preserve both ends of the authenticity myth is the Charedi (and in particular the Chasidic) sector, and that modern Orthodoxy, though it is well-nigh tangent at times to my own Conservative Judaism, is most susceptible to this over-halachization I'm criticizing here.

Obviously, this is all a footnote to Rupture and Reconstruction.

Ebony and Ivory

Why can New York, the center of some universes, produce nothing better than the mealy, tasteless black-and-white cookie, a baked good I keep trying in vain hopes of being proven wrong, while it is Baltimore (a city I have nothing against, and in whose direction epidemiologists pray three times daily) which has given rise to the Queen of Cookies, the Chocolate-Topped? What say you, O Chocolate Lady?

Metzitzah b'peh and neonatal herpes II

Steven I. Weiss (aka Canonist) is on the case. Here's a comparison he makes:

On this issue, if we take the number of metzitzah b'feh procedures per year of 2,500, and assume one infection for those infants per year (which for whatever reason seems to be a number that everyone feels comfortable tossing around), we can compare that 1/2,500 ratio to that of the population generally. Of the roughly 120,000 New York City births per year, the Department of Health says there are roughly 30 infections, or 1/4000. So if all those numbers prove out — which for infections generally, infections in metzitzah b'feh cases, and number of procedures per year have a lot of valence — there's a difference in likelihood that could be somewhere between 33% and 50%.

This is a pretty good first try at a non-technical comparison of the incidence of neonatal herpes in the MBP population and New York as a whole (disregaring Canonist's terminology, which isn't what I'd use). But for an accurate, epidemiologically valid comparison, beyond nailing down the numbers as specifically as possible (Agudath Israel has an interest in exaggerating the frequency of metzitzah, for example), one would have to find a control group which is as comparable as possible to the MBP population. Ideally, that would be an ultra-Orthodox group which doesn't perform MBP. I haven't looked for differential neonatal herpes rates by religion or ethnicity, but I doubt those are followed up on by the Department of Health. A more likely tack is to find a zip code heavily populated by non-MBP Charedim and find the incidence of neonatal herpes within that area.

Taking Weiss's comparison as the best we've got, there's one thing that must be said upfront: Neonatal herpes is underreported. The question is whether the underreporting is differential, i.e., whether MBP parents (or their pediatricians) underreport neonatal herpes more than, less than, or with the same frequency as non-MBP parents (i.e. parents city-wide excluding those performing MBP). I have no idea what the answer is, but engaging in complete speculation, I would imagine that (a) the MBP population, like most Charedim, are "plugged in" to perinatal care to an extent greater than their socioeconomic status would predict, and thus (b) they would tend to report cases of neonatal herpes greater than other parents in the city, by and large, so that (c) underreporting would be greater among New York parents as a whole in comparison to MBP parents. This would overestimate any reported difference in incidence between MBP and non-MBP births.

I think there would be some interesting research here. More important than that, though, is what the DOH is doing to encourage reporting of neonatal herpes and the minimization of MBP.

Silence

Haven’t been through cataclysm, haven’t lived to see redemption,
Haven’t carved through simple moments to the bottom of their motion.
I don’t know how I’ve gotten through the day-to-day,
Not that this should hint at any courage or ennui.

No leaf bears a script. No earth-turn vibrates song.
No locust shaves a symphony from roadside corn.
Life is all that unifies, cell-in-body pulse.
There's no perfect zero. Should I add a shaky plus?

I ask the stones and pavement, stifling air, electron-work,
Tonguing waves and frozen moon, desert-wet and winter-choke:
I ask for one full full-stop, one moment ringing silence.
They call each to another and their speech is fluent muteness.

The resident at rest?
Saving lives: the Sabbath as a normal workday.

MEDICINE MENSCH: Good Shabbos, I'm Off to Work
By Zackary Sholem Berger

People outside the medical field don't understand the process by which beginning doctors are trained. Were I to start this column right off and say, "I'm interviewing for residencies now" (which happens to be true), many reading this would scratch their heads, wondering when, if ever, I'll finally finish my schooling. Let me explain.

Medical school is only the first step. A medical school graduate (which I will be this May, God and registrar willing) will get an M.D., but at that point the degree is only good for hanging on a wall, getting a nonclinical job or applying for further training. Any physician who wants to practice with a state license needs to undergo such training — in other words, a residency.

Residents are apprentices in the guild system that medicine still preserves: uniforms, vocabulary and work hours all set the doctor apart. To what extent these vestiges can be shed, without disrupting the core of the physician's identity, is a discussion that has lasted the past few decades. Uniforms (the white coats) haven't been abandoned, and medicalese is a thriving dialect. But my work hours as a resident will not be the same as the chain-gang days of old, when young doctors would stagger to and from the hospital — uphill both ways — at either end of a 36-hour shift. New York's "405 regulations," passed in the 1980s, placed restrictions on residents' total work hours and required minimum rest periods. These guidelines have now been adopted nationally, so that hospitals must now keep closer tabs on how long their residents work.

Work hours of a different sort will play a role in my decision of where to spend residency. (I'm in the middle of applying to residency programs in the subspecialty known as primary care, but I haven't yet come close to deciding where I want to be. What follows are just general principles, not pros or cons of any specific program.) The issue is this: Should I work on the Sabbath?

Most people's first response is: "But I thought doctors could work on the Sabbath." Without getting pedantic about the halachic or exegetical details of the principle, it's true that "saving a life sets aside the Sabbath," as does (broadly speaking) the treatment of a dangerously ill patient. But does doctors' work always entail saving lives? And are there Jewish reasons outside of Jewish law that might make it preferable for Jewish doctors to work on the Sabbath?

A resident doctor working in the hospital on the Sabbath does not spend all 25 hours, from Friday night to Saturday night, nimbly plucking the gravely ill from the mouth of death. Some of the time is spent dealing with busywork ("Sign this!" "Send that!" "Answer that intrusive page!"), while much of the rest is spent talking to patients, other caregivers and family members about matters that, while necessary, do not mean the difference between life and death. Not everything that a doctor does during a shift is lifesaving. This is a message reinforced by the changing work hours of medicine: If doctoring is a job like any other — with shifts, overtime and holiday bonuses — why shouldn't doctors get a regular weekend, or at least one day out of seven predictably free? In other words, the Jewish legal realities of the practice of medicine (the Sabbath "work" of the doctor is more often than not something less than lifesaving), coupled with the economic and family desiderata of the young doctor (it's nice to have some regular time off), has encouraged the development of the Sabbath-observant residency program in which residents work the same number of hours as their peers, but switch off their Friday-Saturday calls to others.

This development might be taken as a sign of the salutary tolerance that American institutions demonstrate for traditional Jewish observance, something that wasn't true in our grandparents' or even our parents' generation. I don't exactly disagree with this assessment; I find these programs to be quite attractive, and I'm applying to several of them.

But there's a downside here: Gaining your soul — not having to work on the Sabbath — might mean losing the world. Part of being a doctor is the relative cushiness of the profession itself, with its good salary and societal esteem. But part of being a Jewish doctor is something different: striking a balance between God's law and human law; between death, which might strike at any time, and the call to a life of rest and contemplation, which must be obeyed one day in every seven, lest it be snowed under by the detritus of the everyday. It's like being a religious Jew: Part of keeping the commandments is knowing when not to keep them, seeing where the boundaries are and when they might (or must not) be overstepped. How can you know what it means not to eat nonkosher food if you've never seen it on a menu? Spiritual concentration requires the rigorous exercise of contact with the nonspiritual; isolation can encourage a religiosity that does not allow itself contact with the outside world.

In short, being a Sabbath-observant resident might be the best of both worlds. But I'm not sure if a Jew is supposed to allow himself that.

Chicken soup and gefilte fish, preferably in vacuum-packed containers suitable for opening in trayf, unsanitary call rooms, may be sent, general delivery, to doctor@forward.com.

George in the News

The Jewish Telegraphic Agency published a breaking news item about George der Naygeriker.

Oy, baby.
Two sweet.

This post will be of interest to people who have a DVD player and use it to brainwash their child with multicolored Jewish images.

OyBaby was a fun, fluffy, undemanding DVD. It was catchy from start to finish. OyBaby 2 manages to be both frumer (more gratuitous/unconvincing/sentimental references to the tradition) and more goyish (less Hebrew, more bad English translations).

This does not mean, of course, that my daughter is not fixed to the spot whenever I put the disc in the player. I enable her addiction. And anything that pleases my daughter short of firecrackers, a chainsaw, or a pork chop is still a wonderful gift. Thanks to the aunt who gave it.

Interesting epi abstract of the week
Courtesy of your friends at the American Journal of Epidemiology.

[No comment from me, since I know nothing about this area of research. But I couldn't resist posting this.]

Association of Body Mass Index with Suicide Mortality: A Prospective Cohort Study of More than One Million Men

Patrik K. E. Magnusson 1, Finn Rasmussen 2,3, Debbie A. Lawlor 4, Per Tynelius 2,3 and David Gunnell 4

1 Department of Genetics and Pathology, Uppsala University, Uppsala, Sweden
2 Child and Adolescent Public Health Epidemiology Group, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
3 Division of Epidemiology, Stockholm Centre of Public Health, Stockholm, Sweden
4 Department of Social Medicine, University of Bristol, Bristol, United Kingdom

The authors investigated the association of body mass index (BMI) with suicide in a record linkage study based on the Swedish Military Service Conscription Register, the Population and Housing Censuses, and the Cause of Death Register. The cohort studied consisted of 1,299,177 Swedish men who were conscripted in 1968–1999, had their BMI measured at age 18–19 years, and were followed up for as long as 31 years. A strong inverse association was found between BMI and suicide. For each 5-kg/m2 increase in BMI, the risk of suicide decreased by 15% (95% confidence interval: 9, 21). The association was similar when subjects with mental disorder at baseline were excluded from the analysis. BMI-suicide associations were similar in relation to suicide deaths occurring in the first 5 years of follow-up (hazard ratio for each 5-kg/m2 increase in BMI = 0.84, 95% confidence interval: 0.73, 0.96) compared with associations 10 years after baseline (hazard ratio = 0.87, 95% confidence interval: 0.79, 0.96), indicating that weight loss as a consequence of mental illness does not explain the BMI-suicide association and that factors influencing BMI may be causally implicated in the etiology of mental disorders leading to suicide.

Some healthy O-bashing, part I
Or: Friends don't let friends wreck their train.

There's a certain sort of sermon that's regularly given these days in Conservative synagogues, judging from my experience and that of a highly non-random sample of friends and acquaintances. The rabbi explains that despite the grave errors and benighted ways of Orthodoxy, he would never think of engaging in "Orthodox bashing."

Now, there's certainly a sort of Orthodox bashing which I don't want to engage in. I love Orthodoxy. Some of my best friends, etcetera. I think it's one of many authentic sorts of Judaism. (Not every sort of Judaism is authentic -- yes, I know the very word "authentic" is problematic, but I'm not going to go into that yet.) I don't want to be nasty about Orthodoxy and I certainly don't want to accuse its practitioners of anything but the healthiest and most Jewish of motives.

But I do think that bashing, done in a good-humored, respectful, and well-foundedly productive way, can be useful both to the bashee and the basher. For the sake of accuracy, perhaps, I should use another word rather than "bash," but then I wouldn't get as many people's attention. And people who have been reading this blog for a while know that bashing is not what gets done here. I could call it instead "criticism," but that's a boring word. What's a blog for if not for the judicious use of inflammatory prose?

So I think it's high time for some well-meant, well-reasoned, not unlearned Orthodox bashing. What I'm going to try to do here, over the next few days, should put you in mind of a response in Moment magazine a few years ago to the now-infamous Conservative Judaism is Wrong article by (I think it was) Avi Shafran. A Conservative rabbi wrote that Shafran's criticism was dead on, and should be accepted by the Conservative movement (at least partially) -- but, at the same time, Orthodox institutions should receive their share of healthy criticism.

I feel compelled to engage in this sort of criticism because I see Orthodoxy tearing itself apart. Its train is about to come off the tracks and explode in a fireball -- at least, ideologically speaking. And if this won't happen, something even worse could still come to pass: namely, that Orthodoxy could enjoy further sociological success (more yeshivot, more kollel students, more blat gemore learned every day, more Orthodox Jews) while continuing to be wrong in crucial, foundational ways.

Proof to come.

Update: I'm grateful to the link from On the Main Line. If I don't have a new bashpost up before Shabbos, please forgive me. I do mean to continue very soon. One response to the comments: if you refrain from criticizing group X on the basis of its defining characteristics, you make any interesting or far-reaching criticism pretty much impossible, no? That is, I don't think it makes much sense to say, "Fine, criticize Orthodoxy as much as you like. Just don't criticize those things about Orthodoxy which make it Orthodox." I take it that one of the points of criticism is to articulate a vision of group X which is at variance with group X's view of itself. No?

Hanukkah Dinner Theater

We just got back, quite late, from a trip to Arkansas (on which more later). I lit Hanukkah candles, which I set up in such a way so that they're facing our outside window and perpendicular to the air conditioner. (They're Sabbath-type mini-candles, with a metal disc at the bottom of the wax.) Though the AC isn't on, the slight breeze blowing through its apertures has been blowing the wax away, very slowly, from the burning wicks, so that the lights stand in the center of a waxen runway, like spotlights in the snow, or a marquee for the premiere of "This Is Hanukkah."

Those Long-Ago Desert Evenings

To keep clear the view of the mountain
the dancers were cut down.
Calf-powder scalded our insides
a castigation of embodiedness.
Song surged up to the summit
silence wafted down in rings.

What they say: He had gone up
and come down; he'd let them slip, no
hurled them like a sandal.
The mountain had split in two
like a roasted lamb and taken him in.

Children mock through the camp.
Wh-wh-who is for God come to meeee!
All around something is called out
a cross between You will and You never.

Poetry blogged
Yes or no? Yes and no.

I was talking with a friend the other day -- he's a great poet and a perfect mix of critique, appraisal, and support -- who asked me why didn't I, after all, post my poems on my blog. Part f it is my snobbery: there are venues for poetry, and I hope someday for my poems to be allowed into them. On the other hand, if my readers (the Daily Three-Dozen, as it is these days), would be interested in poems, then I would post them. In reality, I think most are here for the Jewish beat or the medicine beat. If you feel otherwise, lemme know.

On the other hand, I suppose I should give myself more credit: if I posted my poems, my readers might become interested in them by their very postedness. Who knows what could happen?

And, just to dig up on old post: I like Christmas trees.

I called the White House
What good it will do, I dunno.

Remind the President about Darfur.

Ikhl Shraibman
Khaval al d'avdin. What we have lost!

This Yiddish miniaturist, essayist, and writer of short stories based on Biblical characters was also an important figure among Jews in contemporary Kishinev, Moldova. He died on December 9th. [See the obituary in the Forward for more on his life and work.]

A Writer's Credo
[Shrayberisher ani-maymen; From the collection "Creation and Love", 2000. ]

My philosophy, from the first day I started to write until today: People should be good, and everything should be good for people.

Two little things. But a whole world could be founded on them, a new world where people would embrace each other and live in love and joy.

Would people be pleased with a world like that? Wouldn't they be bored? Wouldn't they even start dreaming about another world? I don't know. It's really hard to say and will never be possible to try out. Because -- a world like that will never be established.

But let's dream, at the very least, about a world like that.

Dreaming is also quite a fine thing of people's.

Never to this very day have people possessed such a fine thing as dreaming.

What else is a writer in this world, if not the most beautiful, the longest, the strongest dreamer?

1998

Left! Left!
Left, right, left.

Proletpen is a new anthology of American Communist Yiddish writers. (Three modifiers, no extra charge.) My review is mixed.

Metzitzah b'peh and neonatal herpes
Still real, still serious.

I received a message today from the New York City Department of Health and Mental Hygiene about metzitzah b'peh (MbP) and neonatal herpes, an issue that has been of concern for some months now. The complete message is below, but two points should be emphasized:

1. The New York City Department of Health recommends against the practice, but in any case suggests that parents be told before the bris if MbP is to be used, so that they can make an informed decision.

2. DOH has also prepared an "open letter to the Jewish community" on the issue.

The message also reviews the steadily accumulating evidence supporting the earlier fear that one mohel was behind the cases of neonatal herpes associated with MbP.

* * *

Dear Colleagues:

You may have heard about the Health Department’s recent investigation of several cases of herpes simplex type 1 infection in male infants following circumcision which included metzitzah b’peh.

Metzitzah b’peh is a practice performed by some mohelim (religious circumcisers) as part of the circumcision. After removing the foreskin, the mohel places his mouth on the baby’s freshly circumcised penis to draw away the blood. In 1998, the Health Department investigated two cases of neonatal herpes due to herpes simplex virus type 1 (HSV-1) – one of these infections occurred in 1988, the other in 1998. Both were associated with one mohel (Mohel A) who performed metzitzah b’peh during circumcision. Mohel A agreed to stop practicing metzitzah b’peh.

In November 2004, the Health Department was notified of 3 male infants with HSV-1. All were circumcised by one mohel (Mohel B), who performed metzitzah b’peh. The infants developed herpes infection in the genital area 8-10 days after circumcision and were hospitalized for several weeks. One baby died from the infection. Two cases were reported by physicians in 2005 and both are also consistent with infection from metzitzah b’peh. Every case occurred in the time frame consistent with transmission from metzitzah b’peh.

Our investigation found Mohel B to be the source of the 2004 cases, and metzitzah b’peh to be the means of infection for these and other cases, for the following reasons:

• The medical circumstances are inconsistent with infection acquired at delivery, in the newborn nursery, or from caretakers.

• Infection is consistent with acquisition of herpes at circumcision. For example, two infants who were circumcised several weeks after birth showed signs of infection in the time frame that would be expected were the infection acquired during circumcision.

• Several mothers tested negative for HSV-1, making it impossible for them to have been the source of infection.

• All infants tested culture-positive for HSV-1, which is found in the mouths of most adults.

• The location of herpes sores (on infant genitals and buttocks) is very unusual and strongly suggests that infection was introduced at the genitals.

With an estimated average of fewer than 30 cases of all forms of infant herpes infections occurring per year in New York City, the odds of one mohel being associated with 3 cases of neonatal herpes are infinitesimally small (about 6.9 million to 1). In the interest of allowing religious communities to address these health concerns first, the Health Department agreed to let rabbinical authorities ensure that the mohel stopped performing the practice at least until the authorities conclude an investigation. In addition, the connection between metzitzah b’peh and neonatal herpes has been documented in the medical literature. Three investigations published within the past 5 years (from New York City [1], Israel [2, 3] and Canada[3]) describe 11 cases of males with HSV-1 infections on their genitals following metzitzah b’peh. Among the 11 cases, there are 4 pairs of cases (including the 1988/1998 cases from New York City).

In the United States, approximately 70% of persons age 40 and older are infected with herpes simplex virus type 1. The mouth is the most common site of HSV-1 infection; HSV-1 spreads easily through infected saliva, especially when saliva comes in contact with a cut or break in the skin, such as occurs during metzitzah b’peh. Most adults with oral herpes do not know they are infected and do not have symptoms. Even without symptoms, however, people with oral herpes can spread the infection to others. If herpes lesions are present, they tend to occur (and recur) on the skin or mucous membranes at the site at which infection was introduced or in related dermatomes. HSV-1 infection is lifelong; antibody is evidence of infection.

Evaluation and management of an infant with suspected neonatal herpes infection

Infants in the first 6-8 weeks of life suspected of having herpes infections should always be hospitalized and treated with intravenous acyclovir [4, 5], a lumbar puncture should be performed at admission, and the infant should be managed in consultation with a pediatric infectious disease specialist. Herpes infection of the skin/eye/mucous membranes may progress to disseminated disease or central nervous system (CNS) infection. Infants with disseminated or CNS infection are at significant risk for death or serious sequelae even with treatment.

For infants suspected of having herpes infection, cultures should always be done on skin vesicles if present. Other sites that may yield positive cultures and should be cultured include blood, nasopharynx, anorectum, conjunctivae, urine, and stool. Direct fluorescent antibody (DFA) staining, if available, may provide a rapid and specific diagnosis. The yield of culture and DFA from HSV skin vesicles is very good if specimens are properly collected. To collect a specimen from a vesicle, unroof or open the vesicle with a sterile needle or scalpel and vigorously rub or twist a sterile swab on the exposed base of the lesion. Use the swab to inoculate sterile viral transport medium and send immediately to the laboratory. Samples for DFA staining should be obtained in the same manner with the material from the lesion smeared onto a glass microscopic slide.

Cerebrospinal fluid (CSF) and blood specimens should be tested by polymerase chain reaction (PCR) for HSV-1 and herpes simplex virus type 2 (HSV-2). CSF cultures for HSV are usually negative in a patient with HSV encephalitis, so if a limited sample of CSF is available, PCR testing on the CSF should be done in preference to culture. Because of the passive transfer of maternal antibody, type-specific herpes serologic testing is not useful in making a herpes diagnosis in an infant unless maternal serologies are also done and are negative. Consult your institution’s clinical laboratory director to identify a laboratory licensed to perform viral culture and polymerase chain reaction for HSV-1 and HSV-2.

Reporting neonatal herpes cases to the Health Department

Up to 20% of neonatal herpes cases never develop skin lesions, so providers must maintain a high index of suspicion for herpes infection following circumcision which includes metzitzah b’peh. Providers should suspect herpes infection in male infants presenting with vesicular or pustular lesions on the genitals, perineum, buttocks, or related dermatomes in the weeks after circumcision, or, in any infant with fever or other signs of systemic illness in the weeks following circumcision.

New York City Health Code section 11.03(b) requires providers to report ‘unusual manifestations of disease. Providers should report all suspected cases of herpes occurring in the weeks following circumcision to the Health Department. Call 212-788-4423 and ask for the ‘neonatal herpes desk’. After hours call the Poison Control Center at 1-800-222-1222.

Health Department Recommendations with Regard to Metzitzah B’peh

The Health Department has issued an open letter to the Jewish community regarding the recent cases of neonatal herpes linked to metzitzah b’peh and the risk of HSV-1 transmission with metzitzah b’peh, and has developed a fact sheet to inform parents about this public health issue which will be available online and through 311 in English, Yiddish and Hebrew.

During metzitzah b’peh the mouth of the mohel comes into direct contact with the baby’s circumcision cut, risking transmission of herpes simplex virus to the infant. While severe illness associated with this practice may be rare, because there is no proven way to reduce the risk of herpes infection posed by metzitzah b’peh, the Health Department advises against this practice. Some parents whose infants had metzitzah b’peh say they did not know in advance that the mohel would perform it. The Health Department advises parents to ask the mohel several days in advance of the bris whether he performs metzitzah b’peh. This offers parents a chance to weigh the risks of metzitzah b’peh and choose another option if they wish. While some mohelim consider metzitzah b’peh the only acceptable way to draw blood away from the circumcision cut, others use different means. For example, a mohel may use a sterile glass tube or a glass tube attached to a rubber bulb to suction the blood away from the baby’s cut. Other mohelim use a sponge or sterile gauze pad to wipe the blood away. Unlike metzitzah b’peh, there is no evidence that any of these practices cause herpes infection.

Sincerely,
Susan Blank, MD, MPH Julia Schillinger, MD, MSc

Assistant Commissioner Director of Surveillance, Epidemiology, and Research

Bureau of Sexually Transmitted Disease Control
New York City Department of Health and Mental Hygiene
25 Worth Street
New York, NY 10013

1)Rubin LG, Lanzkowsky P. Cutaneous neonatal herpes simplex infection associated with ritual circumcision. Pediatric Infectious Diseases Journal. 2000. 19(3) 266-267.

2)Distel R, Hofer V, Bogger-Goren S, Shalit I, Garty BZ. Primary genital herpes simplex infection associated with Jewish ritual circumcision. Israel Medical Association Journal. 2003 Dec;5(12):893-4

3)Gesundheit B, Grisaru-Soen G, Greenberg D, Levtzion-Korach O, Malkin D, Petric M, Koren G, Tendler MD, Ben-Zeev B, Vardi A, Dagan R, Engelhard D. Neonatal genital herpes simplex virus type 1 infection after Jewish ritual circumcision: modern medicine and religious tradition. 2004. Pediatrics. 114(2):259-63

4)American Academy of Pediatrics. Herpes simplex. In: Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003: 344-353.

5)Kimberlin DW. Neonatal Herpes Simplex Infection. Clinical Microbiology Reviews. 2004. 17 (1): 1-13.

Lipa-logy: Or, in which a reader does my research
Just like the big-name blogs!

Cut-n-pasted from an e-mail. No editing, no effort . . .

Zackary,

A Google search on Lipa Schmeltzer unearthed a post of yours from this time last year.

Truth be told, I myself, was not too much into either FJM (Frum Jewish Music) in general or Lipa Schmeltzer in particular until last week when someone showed me a clip of Lipa's Hebrew Academy For Special Children (HASC) 2005 concert video performance. Lipa did a Yiddish sendup of "The Lion Sleeps Tonight".

The song, as you may know, started life in 1939 in South Africa as Solomon Linda's "Mbube", was recast as "Wimoweh" by the Weavers in 1950, as the immortal, international chart-topping "The Lion Sleeps Tonight" by the Tokens in 1961 and from there, after many re-recordings finally made it into the epic Lion King. However, arguably it did not reach its true destiny until it got its first Yiddish rendition.

While Lipa's version hues musically to the original, lyrically it does not. Interestingly though, the lyrics give two nods to the original. Suggestively, perhaps, the chorus "A-wee-ma-way" becomes the vaguely rhyming "Abi Me'Leibt" and more persuasively, the phrase "The Lion Sleeps Tonight" makes a cameo appearance in a scene at Penn Station.

In 2004 Lipa did a special rendition of "Gelt" for the HASC concert and both that performance and his "Abi Me'leibt" can be seen here. Additionally the "Abi Me'Leibt" video [can be seen here]. As something of an after-thought, if you wish, you may certainly use any of the above material for your blog, if you see fit, in which case I would prefer anonymity.

Birobidzhan dot gov

Random observations:

1. I don't see the name Birobizhan anywhere. The official abbreviation is now "JAR" (Jewish Autonomous Region). The title of the web site is written in Funky Jewish (or whatever that faux-Hebrew font is called). No Yiddish on the site.

. . . oh, wait. Mistake. Birobidzhan is the name of the main city, while the JAR is the name of the region. I think I knew that.

2. If anyone would like to further muse on the evil conspiracy between Yiddishists and gays-and-lesbians, feel free to note that the flag of the JAR features a rainbow stripe.

With regard to the region's heraldry [!], the following is noted: "The figure of the tiger is turned to the right toward a viewer that symbolizes an unusual history and original way of the Region’s development." "Unusual" and "original" is certainly one way to put it. ("Deportation" might be another, but let's not split hairs.)

3. In the matter of religious observance in the JAR, the site states:

On January 1, 2003 in the region 27 registered religious organizations have been acted. The leading position belongs to Russian Orthodox Church (ROC) of the Moscow Patriarchy. Ten parishes of ROC function on the territory of the region. Two Judaic communities actively work also. Besides, there are several Protestant religious organizations.

No longer confused, not yet overwhelmed
After a year of my medical-student ramblings, what have I learned?

MEDICINE MENSCH: Taking Stock
By Zackary Sholem Berger
December 2, 2005

There's a joke about travel writers turning experiences abroad into publishable material. Spend two months in China, say, and you can write a book; spend two years, and you can write an article. But spend 20 years, and you find you can't write anything at all. I feel the same way about the past year of being a medical student. Every day is packed with thousands of stories. Every patient is an epic unto herself. The first few months of being a medical student were an encounter with the world of the hospital. In such a first encounter (with a new book, a new person, a new language), you can ignore the occasional troubling aside and focus on the big picture. But as you get used to things, you can't avoid the episodes that are harder to talk about.

As a beginning medical student, I was mostly confused. As a fourth-year student who's just completed his sub-internship (a sort of pre-residency), I've become less confused and more intimately involved in the contradictions of the hospital. Once I become a resident, I might become too overwhelmed by life and death to write at all. Now, at the end of this column's first year, I thought I should take stock of my reactions to what I've seen. "Love" and "hate" are the first words that come to mind for many things I've encountered this past year. Sometimes I hate and love the same thing in succession.

I hate going into rooms of people who are very sick. They lie in their beds, staring at the wall. What's the right thing to say to them? Most of the time, as little as possible: I already know this from visiting the sick as a layperson. But as a doctor-in-the-making, I'm no longer someone who visits the sick. I now intrude on them for their own good, asking them questions they would rather not answer and viewing their bodies in ways that they never would countenance when healthy. While I try to build rapport, strengthening the doctor-patient relationship through our basic human connection, more often than not our conversation doesn't exceed the bare minimum. I need to get my work done; they need to get their rest. So I leave the room feeling guilty, while they lie there feeling no healthier than before.

At the same time, there are patients I come to love even though I know them only slightly. An older, frum woman was admitted with pneumonia. The admitting team described her as demented. According to the technical meaning of the term, this was correct: She suffers from a constant, progressive decline in cognitive function. But too many assume that the demented patient is childlike, not deserving of the respect we would give anyone outside the hospital. I've seen more than one demented old woman called "sweetie," more than one writhing figure in the step-down unit called "nonverbal" while he's screaming in Yiddish for people to leave him alone. It takes extra effort to listen.

I walked into this woman's room last Tuesday and asked her how she was. She said something incomprehensible, and I bent closer to hear. "What's that?" I said, a trifle impatiently. "Ki tov," she said. "It's the day of ki tov." It was Tuesday, the third day, the day that God called good twice. I cried at that — not so anyone would see, of course. I loved that patient even though I didn't know her at all, because she had said something heartening.

I dislike walking the halls in a long white coat, hearing people call me "Doctor," running into relatives and families hungry for information that I don't have or can't give them. I am the "doctor figure" in whom they find comfort, even though there might be nothing I can do at the moment. At the same time, I try to tell them what I can — even if it's only the simplest details of the imaging study that's about to be performed or the tests that are about to be drawn.

There are other reactions that cannot be stopped and break into my best intentions like a freight train. At 5:30 in the evening on the last day of my sub-internship, half an hour before I was due to sign out to the night intern, I was called by a nurse who told me that over the past few hours a patient had become short of breath and incoherent. My first thought, you'll understand, was not, "Let's see what we can do to help this poor man." It was, "Why couldn't he have waited half an hour?"

But I drew the tests, asked the nurse for an EKG and took the man down for a CAT scan. We tried to figure out what the matter was, piece by piece. Maybe I've begun to acquire the everyday discipline that is more important than the drive to do good. Even if it's half an hour before you're due to go home, you go do what you're supposed to. (With your resident, or whoever your boss might be, providing a little push.)

I got into the elevator to go home, and a religious Jewish couple, seeing my yarmulke, gave me a smile. "What a Kiddush HaShem," they said, using the term for an act or person that shows Jews in a favorable light. I didn't feel like I had been sanctifying God's name — I was just learning how to do my job. Do the two overlap? We'll see.

Zackary Sholem Berger isn't a doctor yet. Complaints about how long it's taking should be sent to doctor@forward.com.

Dreidel maximization

I'm not a genius at math, but I was sitting with a couple of friends who are naturally gifted. They are not Jewish, and I was explaining to them how one plays dreidel. (Or "the dreidel game," as most Googlable references seem to call it.) They started talking about how one could do best at it.

That is, how should one set about to win the most money through dreidel? (That not being the point of the game, but never mind about that for now.) Game theory generally involves maximizing expected earnings through decision making; the problem with dreidel is that precious little decision is involved. Let's try and describe the game and then see what variables one might be able to play with to tweak the expectations.

The four possible dreidel outcomes, together with what happens to one's earnings, go more or less like this:

N (nun): {null}
G (gimel): +x
H (hey): +x/2
Sh (shin): -2R

You get x (the size of the pot) if the dreidel lands on gimel, and 1/2x (half the pot) if it lands on hey; if the dreidel lands on shin, you put in some ante (usually an even number, in my experience), hence 2R.

Some simple things even people like me can see straight off. The first is that your earnings from gimel and hey depend on how much there is in the pot. That is, x changes with the progression of the game, so I really should have written it as a function of time, f(t,x). But that would be getting ridiculous.

One way of thinking would be that to maximize your earnings you should sit as far away from the luckiest (or craftiest) dreidelist as possible, so that the pot has a chance to fill up again after he or she spins his out-of-proportion gimels.

Another simple observation is that the relative "influences" on the game of gimel, hey, and shin depend on how much the ante is. If there's only a finite supply of money (or peanuts, raisins, or whatever currency you've chosen) available to the player, and 2R (the size of the ante required when Shin is spun) is a considerable fraction of that supply, then one shin can lay you low no matter how many nuns or gimels you've gotten.

One way of modifying the game might be to make the shin-ante (R) vary with the number of players, the size of the pot as it stands, or the time elapsed.

Or not. 35 days till Chanukah.

PS: Of course, a real mathematician has made some progress on the problem. He has conjectured, based on some simple simulations, that the length of a two-person dreidel game is on the order of the square of the number of nuts (or whatever tokens are used), and the length of a k-person game -- on the order of that number of tokens to the kth power.

Para-rabbis and PAs
"Totem pole": descriptive, not prescriptive.

MEDICINE MENSCH: What Little I Know About Medicine
By Zackary Sholem Berger
November 11, 2005

I thought I would title this month's column "What I Don't Know About Medicine," but my editors want 800 words, not an encyclopedia. What I do know about medicine should fit nicely into the space allotted.

The rotation I'm starting this week is known in hospital jargon as the sub-internship; the registrar's office calls it "advanced medicine." In this rotation the medical student plays the role of an intern, a first-year resident. He can write orders on the computer, decide on a course of treatment and prescribe medications — all with the co-signature of a supervisor, of course. The main thing is that the student manages his own list of patients. In other words, I won't be following a resident around anymore; I will be a resident.

More precisely, I'll be pretending to be a resident. That's the catch of this rotation — it's the adolescence of medical education, in which one is something more than a senior student but something less than an intern. How much like an intern will I be? If one reasons by similarity of activity (lack of sleep; independent decision-making on behalf of actual patients), I could very well call myself the intern. Could I walk into my patient's room and say, "I'm Dr. Berger, and I'll be taking care of you during your stay in the hospital?" The second half of this statement is definitely true, but the first part (with "Dr.") isn't quite. I won't have my medical degree until my graduation in May 2006, and I won't have a license to practice medicine until I finish my boards, which stretch from now (while I'm still a medical student) until the end of my residency.

On this rotation, I don't plan to introduce myself as "Doctor" (that would be quite a stretch), but I understand why some of my colleagues would. While many patients don't understand the difference between senior medical students, interns, residents, fellows and attending physicians, they come to appreciate something of the hierarchy during their hospital stay. One thing soon becomes clear to them: Medical students are at the bottom of the totem pole of health care providers. (Or almost at the bottom —more on that subject, below.) If a sub-intern walks into a patient's room and starts out by saying, "My name's Joseph Brighteyes, I'm a medical student, and I'm here to take care of you," the patient is likely to respond, "That's great, Joe, but who's going to be my doctor?"

Is qualification defined more by knowledge or by capability? This larger question comes up when talking about the thousands of people whose elbow grease makes a big hospital run as smoothly as it can. Even lower on the pole than the medical student is the physician assistant. P.A.s train for fewer years than medical students, so they often get less respect from folks in medical academia. But in every rotation where, as a medical student, I've worked together with P.A.s or P.A. students, they have seemed more on the ball than the medical students — not as over-theoretically concerned with fascinating disease entities and more knowledgeable about what might immediately help the patient. Part of the reason is that the P.A. student spends more time in her early training (most P.A.s I've met are women) familiarizing herself with the way things actually are in the uncompromisingly practical universe of the hospital or clinic. Perhaps P.A.s can't name 12 different kinds of small-vessel disease. (I'm making up that number; I certainly can't name them, either — not off the top of my head.) But such encyclopedic knowledge is sometimes transcended, or rendered irrelevant, by practical considerations. On the other hand, you don't want to miss the rare diseases when they do pop up. So both kinds of training (practical and theoretical encyclopedic) are essential, even complementary. The trick is to appreciate both kinds of thinking at the same time, even though most people find one of them more congenial than the other.

A similar divide is evident in the Jewish tradition, especially with regard to Torah study. In previous generations — and even today in some circles — memorizing vast tracts of the Talmud is a prized skill. On the other hand, if you've dipped into any of the Talmud, you know that it takes considerable exegetical ingenuity to derive laws applicable to everyday life from the rich stew of magic, folklore, intellectual speculation, casual yeshiva talk and campfire tales about the destroyed Temple. (Even the strict constructionists, those who actually bury their fingernail clippings according to the magical practice of the rabbis, still have to exercise creativity in deriving everyday religious practice from Babylonian-Jewish digression.) The two skills — encyclopedic knowledge of the Talmud and the ability to apply the Talmud to everyday religious life — are complementary, but rarely are found in the same person. Many of the greatest talmudic scholars have famously refused to adjudicate Jewish law, protesting that they could see all sides of any issue.

Today's Jewish communities rely very much on what some people call "para-rabbis" — people who aren't religious scholars but are reliable, even expert, in the details of daily practice. You might have met some of them: the guy who knows everything about building a sukkah; the woman who is obsessed with reading Torah; the member of the local synagogue who knows exactly how to help a recently bereaved family.

In other words, Jews (at least religious Jews) depend on "rabbis' assistants." In the same way, a hospital must cobble together a vast number of people who have different abilities. Some sit in offices and absorb themselves in the study of disorders affecting 10 people in the entire world, while others, down amid the gore in the E.R., can contradict those same scholars with absolute certainty if they see in front of them a practical problem they know how to solve quickly and effectively.

Bit by bit, I hope to amass both kinds of knowledge till I can be considered a doctor (a learned person, according to the word's historical meaning) in at least one of these categories. But no matter what, there always will be plenty of material for my upcoming masterwork, "What Zack Berger Doesn't Know." I look forward to doing the research.

Zackary Sholem Berger is becoming a doctor, hour by sleepless hour. Feel free to write him about it at doctor@forward.com.