Image source: Babble.com

By Liz Paratz

The very first commandment of the Bible is to ‘be fruitful and multiply.’ But unfortunately, subsequent attempts to be ‘fruitful’ resulted in mix-ups with apples and ultimately got Adam and Eve expelled from the Garden of Eden. Not to mention, they were also cursed. Adam was condemned to toil for his food by the sweat of his brow, and Eve with the curse of labouring in pain.

Fast-forward a few thousand years and if we are condemned to ‘bring forth children in sorrow’, why do even the most religious of Jewish women use pain-relief in childbirth? Is it wrong? What do other religions following the Bible say about it?

Why is it so?

As one doctor pointed out to our class during our obstetrics and gynaecology rotation, childbirth (and the desire to have a ‘natural delivery’) is a unique phenomenon.

If someone fractures their leg and is rushed to the Emergency Department, the nurses and doctors don’t (usually) crowd around and encourage the screaming patient, telling them they’re doing great, that they just need to work through their pain, they need to breathe right, but they’re doing just great, and do they want a heat pack or some classical music? Rather, fast and effective pain relief is a key part of the management plan.

On the other hand, the attitude to pain in childbirth is much more complex. The American College of Obstetricians & Gynaecologists recognized this in 2004 with their position statement that, ‘Labour causes severe pain for many women. There is no other circumstance where it is considered acceptable to an individual to experience untreated severe pain, amenable to safe intervention, while under a physician’s care…’

What lies behind this hesitant attitude towards pain relief in childbirth?

Pain Relief in Western Culture

Historically, the question of whether to relieve pain in labouring women or uphold the Curse of Eve was basically an academic one. Even if doctors and midwives had wanted to relieve their patients’ pain, there weren’t really any pain-relieving drugs available.

However, by the Middle Ages, some (allegedly) pain-relieving herbs had been identified and the debate around the Curse of Eve began. The extremely powerful Church vilified midwives who offered any pain-relieving herbs as witches. They claimed these modern pain-relieving midwives were defying the Bible’s orders – by definition they were therefore servants of Satan. In 1591, King James VI (of King James Bible fame) ordered the Scottish midwife Agnes Sampson to be burnt alive for the sin of offering Euphemia MacLean (also burnt) pain relief during her labour.

About 250 years later, the mid-1850s marked the birth of obstetric anaesthesia. Appropriately, it was a painful and obstructed birth.

The editor of the Edinburgh Medical and Surgical Journal declared that pain was medically necessary during childbirth, and preventing it would pose risks to the mother. In case you were wondering about that claim, the editor graciously explained that, ‘pain is the mother’s safety, and its absence her destruction….it has been ordered that ‘in sorrow shall she bring forth’’. Any doctors who offered anaesthesia to their patients were thus painted as blasphemers ‘playing God’ and defying the natural order.

Another Irish professor of midwifery agreed with the editor’s position, because ‘after all, it was the Almighty who had seen fit to allot pain to natural labour, and most wisely we cannot doubt’.

Despite its ‘sinfulness’, obstetric anaesthesia took off. When Dr James Young Simpson used chloroform in a labour in 1847, the mother was so grateful that she named her baby ‘Anaesthesia’. In the next few years, the successful reputation of anaesthesia grew exponentially. Tragically, its popularity as a baby-name did not follow a similar trend.

In 1853, anaesthesia cracked the A-list when Queen Victoria gave birth to her 8^th child with the assistance of chloroform. Given that she was head of the Church of England, this effectively ended the religious opposition to obstetric anaesthesia.

Pain Relief and Judaism

But if using pain relief in labour were a real sin, then surely Queen Victoria’s use of chloroform shouldn’t have altered the Jewish perspective. If we were meant to be upholding the Curse of Eve, then we should still be shunning pain relief today.

In fact, it appears the Jewish take on ‘the Curse of Eve’ has always been a bit different  – for several reasons.

Reason 1 – Linguistic

In 1849, the editors of Canada’s British American Journal of Medical Science invited the Chief Rabbi of Canada, Rabbi Abraham de Sola, to write an article on the Jewish interpretation of Genesis 3:16.

According to R. de Sola, it was simple. The common English translation ‘in sorrow shall she bring forth’ was incorrect. Drawing upon the linguistic analyses of the deliciously-named medieval Rabbi Kimchi, he pronounced that a better translation would be ‘in toil or labour will she bring forth’.

He based this upon the Bible’s use of the word etzev, rather than a more explicit word for pain such as ke’ev, tzarah, yagon or anachah. By translating the phrase as ‘in toil shall she bring forth’, he then construed the ‘toil’ as referring only to the uterine contractions required to deliver the baby rather than the sensation of acute pain. Basically, uterine contractions required, pain optional.

Where this leaves elective C-sections is debatable, but hopefully Braxton-Hicks can qualify for contractions.

Reason 2 – Interpretative (aka what about Adam’s Curse?)

Some rabbinic authorities also point out that the Curse of Eve does not mean that women must suffer in childbirth, only that in the natural course of events they will suffer if no pain-relieving measures are taken. By contrast, a ‘natural birth’ in the Garden of Eden would apparently have been an entirely painless event.

The story of Adam neatly illustrates this distinction. After all, Adam was equally cursed – cursed with the need to toil for his food by the sweat of his brow. Surely then, the Industrial Revolution should have sparked mass paranoia that the new machines defied the Curse of Adam. This would be a logical parallel to the obstetric anaesthesia debate of the 1850’s.

And today, the descendants of Adam have gone to the non-toiling extreme. Plenty of men work in an office all day and then come home. Perhaps they drop by Safeway to pick up their daily bread. Regardless, at no point in this scenario does even a single drop of sweat form on anyone’s brow.

Most people see nothing particularly wrong with this picture. The accepted interpretation is that, had we stayed in the Garden of Eden, no toil would have been required to gain food at all. Since we have left, the natural course of events is that farming is a labour-intensive activity.

However, we are certainly not forbidden from inventing machines to simplify the labour required, or even synthesizing ridiculously artificial compounds with code-names to replace real food in our diet.

Likewise, women are not forbidden from making things easier with modern drugs – we just recognize that we wouldn’t have required them in the first place if we’d been able to ‘just say no’ to that apple-dealing snake.

Reason 3 – Medical

Under Jewish law, a woman is considered to be in a state of danger while she is in labour, and for 3 days post-partum (hence the recitation of the Birkat ha-Gomel prayer after illness, childbirth or danger, recognizing the peril through which the mother has passed).

Thus the principle of Pikuah Nefesh applies and, if medically necessary, any required drugs must be given. There are delivery scenarios that may meet these criteria, and Judaism is unequivocal that in such circumstances there is no question that pain relief must be administered.

Enough Reasons Already?

In the wider world, the threatening words of Genesis triggered moments of panic that modern medicine was defying God. However, the Jewish interpretation of the ‘Curse of Eve’ and its significance for modern medicine has traditionally been quite divergent from the Western mainstream.

From the beginning of anaesthesia, Judaism appears to have been open to new technology, and reassuringly inclusive of pain relief as part of delivery. Ultimately, if analgesia in childbirth facilitates having babies, then surely that is the most desired endpoint. After all, multiplication was and is the original name of the game – even if each generation doesn’t do it quite the same.

Holocaust survivors raise unique issues in the world of geriatrics

By Liz Paratz

The image of the Holocaust survivor who started afresh in the aftermath of the camps is familiar and powerful. We see it in films, in literature, and in our own families. The degree of transformation in these survivors – from dehumanization to success in a foreign country – is so compelling that it’s understandable why the media tend to focus in on such stories.

But that image of ‘the Holocaust survivor’ is beginning to change. As Holocaust survivors age, a number of unprecedented care issues arise. And, as Australia experiences the first waves of ‘the grey tsunami’, providing good care for Holocaust survivors raises unique issues within the world of geriatrics. Given that Australia is home to the second-largest per capita Holocaust survivor population in the world, we have an inescapable duty to recognize and work with these issues.

The worst-case scenario is often acknowledged to be the Holocaust survivor who develops dementia. For these people, dementia is a shocking blow. With 60 years between themselves and the Holocaust, a degree of distance and protection has been piled up, padded with human and material achievements.

But then memories of each achievement are steadily stripped away as the decades roll back. Inexorably, the survivor sees themself slipping back towards that horror-decade, the 1940s.

As they take the tumbling unstoppable journey they frequently revert to their mother-tongue, be it Yiddish, Polish or Russian. This rips apart their social support structure as children and grandchildren may now be unable to comfort them, and they cannot easily communicate their needs to medical staff.

But even for survivors who don’t develop dementia, there are still plenty of problems.

Doctors have identified an increase in post-traumatic stress disorder symptoms in Holocaust survivors as they age. This rise has been partially attributed to retirement and increased isolation, providing more time for reflection. Additionally, loss of independence may play a role. Much of the survivor population’s fear and anxiety about ageing is considered to be largely linked to Holocaust experiences.

For example, given that in the camps any sign of weakness could mean death, it is understandable that survivors experience out-of-proportion anxiety around issues like deafness and walking problems.

For these survivors, normal ageing processes like illness, frailty, dependency, and isolation provide cues to past trauma. Events such as the deaths of close friends, and awareness that one’s own death is approaching may further sharpen the grief, fear and mourning.

Some researchers declare that, ‘in the eyes of some survivors, Auschwitz was like a medical operation and the killing program was led by doctors, from beginning to end.’  But this version of ‘medicine’ as seen in the camps, and remembered by the survivors, was distorted and nightmarish.

Hence today ‘hospitalization…frequently brings about delusions of being in camp again. Survivors are once again confined and must submit to the humiliation of being helpless and being told what to do “for their own good”’. Other identified stressors associated with hospitalization or moving to a nursing home are ‘absence of family members; absence of personal belongings; lack of privacy; and invasion of one’s body by medical examinations and procedures’.

Unfortunately, as the survivors age, the number of diseases from which they suffer increases – and therefore so does their need for hospitalization.

Sometimes their co-morbidities are medical complications of the Holocaust. For example, young girls who survived the Holocaust now, as elderly women, have much higher rates of osteoporosis due to severe starvation at a critical time for bone development. Long-term alterations in the levels of stress hormones have also been tied to an increased risk of cardiac disease in survivors.

In other cases the Holocaust history may not be responsible for the disease process, yet can still affect prognosis. Survivor patients with cancer cope worse with their disease, and survivors with chronic pain suffer higher pain intensity and rates of depression.

Exposure to the medical environment may re-awaken terrible memories. The traumatic cues linked to the pseudo-scientific institutionalized nature of the camps may cause survivors to present as ‘difficult patients’ when in a hospital or nursing-home.

For example, receiving injections may trigger fears of being lethally injected with phenol.  Being taken by a nurse to shower may provoke extreme anxiety about lack of control, and flash-backs to what ‘being taken to shower’ meant in the camps. Losing weight as part of a generalized disease process or due to swallowing problems may also create great fear, as survivors fear they are starving to death like friends and family did in the war.

This fear of the medical system may have unfortunate consequences. A study in the Medical Journal of Australia* found that the Metropolitan Ambulance Service consistently recorded an inappropriately low number of call-outs by Holocaust survivors with chest pain during the 1990s. This was theorized to be due to survivors’ fear of calling a uniformed external agency who would take the patient away. For too many, this cut too close to suffocated memories of deportations.

In that specific case, the solution was the creation of Hatzolah, a Jewish first-responder service. This is practically a perfect example of creatively and sensitively meeting the unique needs of Holocaust survivors.

Other ways to soften survivors’ experience of ageing and medical interventions include providing Yiddish/ Russian/ Polish interpreters, maintaining a familiar environment and staff insofar as possible, providing medications in oral rather than intravenous or parenteral form and, if possible, even trying to avoid placing cannulae (drips).

Providing baths rather than showers, and organizing regular nutritional counselling around supporting the patient’s weight are further measures reported to significantly boost patients’ sense of autonomy and wellbeing.

Most of these successful medical interventions are simple and relatively inexpensive. From the community side, what can we do non-medically to deal with this phenomenon of ‘late effects of the Holocaust’ ?

Perhaps one of the best approaches we can take is recognizing, discussing and identifying all the complications, individual fears and stressors. With a better database of knowledge on this phenomenon, we can then more confidently explain to medical professionals the desirability of taking a full ‘Holocaust history’ in survivors, and the real need to develop sensitive and appropriate care plans.

* Chan T, Braitberg G et al, Hatzolah Emergency Medical Responder Service : To Save A Life, MJA 2007 ; 186 (12) ; 639-42

* Image from www.wacoisd.org

As Tevye said, there's an iBlessing for everything...

Even from the days of the Garden of Eden it has been documented that humanity has a terrible weakness for Apples. Liz Paratz takes a look at the appeal of the iPhone for the Jewish user.

iPhones Part 1

So far, the 21^st century appears to be the era when existential philosophy updated its status to ‘iPhone, therefore I am.’ The Ultimate Gadget stands miles ahead of all previous mobile phones – to be scrupulously exact, it makes them look like just a bunch of shoe phones.

Of course, the iPhone’s dominance is now threatened by multiple other tech companies and soon enough the iPhone will probably be just another phone amongst a range of similarly incredible super-phones. But for now it stands alone and unchallenged. It’s an iCon. It’s addictive. It’s cutting-edge (although sadly not cut-price).

Key to the extreme desirability of the iPhone is the concept of the ‘app’, where third parties can develop software applications to be bought and installed on the phone. Software developers around the world have created a flood of ‘apps’, and now the App Store now lists almost 134, 000 of them. The future has come to us, and it turns out it really IS a Planet of the Apps.

Of course, it was only a short time before Jewish apps started popping up. Now, Israeli software developers, tech-savvy rabbis and the lovely people at Birthright have all developed apps to ensure that, wherever you are, all the Jewish resources you could ever need are just a finger-slide away.

This list is an update on ten of the most used and useful Jewish apps. The reality is, though, that this list is just the tip of the Eisberg. There are many many more ‘best-of’ lists circulating out on the internet, and now even a website called JewishiPhoneCommunity.org (surely the most recent breakaway sub-group within the Jewish community).

So, here is just one of many lists of  ‘Good Jewish Apps’ -

1. iBlessing : This is pretty self-explanatory. A plate of all different kinds of food appears on the screen and upon touching the kind you’re about to consume, the correct blessing appears. You get to choose to say the blessing in either Hebrew or English, and the iPhone can say it along with you. Netilat Yadayim and bentsching are also included in the app.

2. Kosher : For kosher travellers, this app could be invaluable. Users can discover all the kosher restaurants in a city, with information even including the restaurant’s hasgacha and relevant blessings in Ashkenaz, Sefard, Edot Mizrach and Chabad.

3. Synagogue : Again, fabulous for religious travellers. This uses GPS technology to find all the synagogues in the city for you. Full demographic data is given, including affiliation (ie, Reform v Orthodox) and even the number of households in the congregation.

4. Parve-O-Meter : This timer counts down the time between eating milk and meat. The timer can be adjusted for your level of religiousness, going all the way up the scale to ‘Chassidic’. At the end of the period, a congratulatory bell rings.

5. Mizrach Compass : Basically, just a compass with a few bells and whistles to make it a ‘Jewish app’. This app calculates the direction of Jerusalem from any position. It plots the Kodesh Hakodashim (31° 46′ 40.8″ N, 35° 14′ 7.44″ E) as its reference point.

6. iGrogger : Pertinent to Purim….if your arthritis is getting in the way of shaking your grogger as loudly as possible, this app reproduces that horribly loud rattle at full volume to ensure that Haman’s name will never be heard. You get to build the grogger from multiple backgrounds, materials and textures and there are several options on sounds.

7. iBubbe : (Why would you?) This is described on appshopper.com as ‘the premiere virtual Jewish grandmother for the iPhone’ She comes with over 50 quotes and offers ‘advice, nagging and traditional Jewish songs’.

8. Pocket Luach : This is essentially a calendar, with the capacity to convert dates on the Jewish calendar to and from the regular calendar. It also lists the Parsha for each week and all Yomim Tovim.

9. Shabbat Clock : Very clever technology. This app allows religious Jews to use an alarm on Shabbat. The alarm is set in advance, and plays for only 1 minute. Prescheduled calls can even be made using the app. Obviously though, you can’t hit the snooze button.

10. Guess Who’s Jewish : On the lighter side, this app flips up images of 2 celebrities and asks you to pick which one is Jewish. It’s a time-filling on-hold-with-a-call-centre kind of game. And probably quite addictive.

iPhones Part 2 [now with free food]

But of course the power of the app is shaking up many fields beyond the Jewish community. In the medical world for example, many medical apps – ECG interpreters, anatomy atlases, and drug dosage calculators – offer a huge helping hand to forgetful time-pressured health-care workers. But with that much information at their fingertips, will patients even need doctors as much in the first place? Could it be that, in 2010, using an Apple product a day can keep the doctors away?

If you’re interested in this topic, want to catch up with fellow health-care professionals or are just feeling hungry on Sunday March 21^st, you should absolutely come along to Young AJMF’s free medical comedy ‘Great Debate’ evening.

This year’s topic – ‘That iPhones will destroy medicine as we know it,’ – will be debated by a team of ‘Doctors’ versus a team of ‘Medical Students’.

The function, organized by Young AJMF [the Australasian Jewish Medical Federation], is the society’s first social event of 2010 and is open to all health professionals and students. Partners are of course also welcome.

A gourmet kosher supper will be provided and the event is free of charge. To RSVP and find out location details etc, please join the Facebook group ‘Young AJMF’ and join the event page, or email youngajmf@gmail.com . We look forward to seeing you there.

*Acknowledgements to Apptism.com and Dorit Murray

In the story of Purim, Haman is a clear descendant of Amalek and the ‘bad guy’. The mission conducted by Esther and Mordechai to expose Haman and save the Jews is completely successful and ultimately Haman and his ten sons are hung from the gallows that was intended for the Jews.

As one rabbi has put it, ‘the Book of Esther immortalizes the dream of the Exiled Jew, as it says in verse 9:1 ‘and it shall be turned to the contrary, so that the Jews shall conquer their enemies’.

So the story of Purim in this sense might be understood as a model for Jewish communities to aspire to in the Diaspora when confronted with anti-Semitism and genocidal tyrants. It’s an inspiring story where a brave Jewish girl confronts evil and saves the entire Jewish people without a single life being lost. And then the bad guy gets hung with his sons. As a Jewish revenge fantasy, it pre-dated Quentin Tarantino’s Inglourious Basterds by a long way.

Many people today draw parallels between the Shoah and the story of Purim. Within this context, Haman and Hitler share not only a philosophy but even somewhat similar names. Furthermore, in the Nuremberg Trials 10 men were hanged, reminiscent of the hanging of Haman’s ten sons.

Even the fact they were all hanged on a simple wooden gallows is surprising, given that most executions in the 20^th century tended to be a somewhat more modern matter of death by firing squad. However, even this detail echoed the executions of Purim.

Not only that, but the parallels become even more apparent when it is considered that in both cases there was an 11^th person scheduled to be hanged (Haman’s daughter and Hermann Goering) who committed suicide right beforehand.

And then, to take things well over into the zone of eerie, it was documented in newspapers around the world that the last words of Julius Streicher, editor of the violently anti-Semitic newspaper Der Sturmer, were ‘Purim Fest 1946’.

But unfortunately, as we all know, there is a major difference between Purim and the Shoah. While Esther’s acts saved all the Jews of Shushan, 6 million Jews perished in the Shoah.

Which is what brings us to the success of movies like Inglourious Basterds.

Does this movie cynically exploit our ‘Dream of the Exiled Jew, where the Jews conquer their enemies’? If we look closely, it seems that the movie deliberately reframes the tragedy of the Shoah as a Purim story.

Shoshana is clearly Esther. Like Queen Esther she masks her Jewish identity, posing as Emmanuelle Mimieux. She is chosen on account of her beauty to be the mistress (or ‘queen’) of Frederick Zoller, a young German military hero who is rather apolitical and neutral – in other words, an Ahashverosh figure.

However, he hangs out with some serious Amalekites – his boss Colonel Landa is known as ‘the Jew Hunter’, counts himself as a key architect of wiping out the Jews, and is bringing Hitler and other top Nazi officials to France for a night to celebrate their victories in WWII and their genocidal plans.

But brave Shoshana devises a plot, disguising herself as a French collaborator and turning the tables on the Nazis. At the last moment, the plot is reversed, and Hitler is trapped in a burning theatre where Shoshana reveals on a giant screen that she is in fact a Jew.

The plot of Inglourious Basterds seems to be so blatantly like the story of Purim that it almost conjures up an image of Tarantino reading the megillah, then growling, ‘Purim, I’ll raise you. How about Purim plus Brad Pitt and some scalpings?’

Maybe it’s that type of insight that makes an acclaimed director… knowing when a story that has been told for generations and generations just isn’t quite enough. Tarantino would seem to think that it’s good, but it needs some updating and some Basterds….

Chag sameach.

Will Dr Moses' tablets improve your health?

By Liz Paratz

This is the final instalment in the ‘Judaism Under the Microscope’ series, applying evidence-based medicine to 6000 years of Jewish practice. Here, Liz takes a look at whether religious people are healthier overall.

The question of whether being religious equates with being healthier is a hot one. Now, evidence-based medicine has come to the party to weigh in on whether a religious lifestyle results in medical benefits ; and if so, whether ‘religion’ should be an approved therapy in the medical landscape. After all, if religious attendance shows medical benefits, shouldn’t High Holiday seats be reimbursable on Medicare just like any doctor’s appointment?

Well firstly, there are many studies on the issue of increased life-expectancy in religious people.

A US national study of 21 000 adults documented a strong association between religious attendance and mortality. People who had never attended services had a 19 times higher risk of death over an 8-year period than those who attended more than once a week. Striking differences in life expectancy were also evident, with life expectancy at age 20 for religious people who attended services being, on average, seven and a half years longer than for the non-religious.

Another study specifically examining Israeli Jews used 16 years of mortality data comparing secular kibbutzim to religious kibbutzim. Overall, they found that mortality was significantly higher in the secular kibbutzim, associated with higher intake of meat, dairy products and coffee, less fish and much more smoking and reported stress.

Another article was provocatively titled ‘Religious Attendance :  More Cost-Effective Than Lipitor?’ (Lipitor is a widely-used cholesterol-lowering agent). It compared the increase in life expectancy noted in people who regularly attended religious services to the increase gained from statins, and then predicted cost-effectiveness. Cost was based on price of statins and the assumption that people would contribute 10% of their income to their religious community. The authors’ conclusion was that ‘the real-world, practical significance of regular religious attendance is comparable to commonly recommended therapies, and rough estimates even suggest that religious attendance may be more cost-effective than statins.’ So perhaps in this post-Marx age religion has become the poor person’s statin, rather than the opiate of the masses.

Other studies have focused on more short-term parameters. For example, being religious might improve life expectancy, but does it affect the course of your diabetes? Or your recovery from surgery or your risk of a heart attack? At this point, it would seem that the answer may be yes.

C-reactive protein (usually abbreviated to CRP) is a marker of inflammation in the body, and a raised CRP is usually not a good thing. In the context of diabetes, a raised CRP has been shown to be associated with increased risk of vascular complications like heart attack and peripheral arterial disease. The researchers in ‘C-Reactive Protein, Diabetes + Attendance At Religious Services’ examined a group of diabetics who were regular religious service attenders versus diabetics who did not attend religious services.

Impressively, even after adjusting for demographic variables, health status, smoking, social support, mobility, and body mass index, the diabetics who did not attend any religious services were still more than two times more likely to have a raised CRP compared to the religious diabetics. The researchers’ conclusion was thus that, ‘attendance at religious services has been linked epidemiologically to improved morbidity and mortality from cardiovascular causes’.

Religiousness has also been documented to be associated with shorter hospital stays in patients undergoing coronary artery bypass grafting, and longer walking distances at discharge in patients undergoing hip surgery.

However, the exact mechanism by which a religious lifestyle brings about an increase in life-expectancy and general health is still debated. In 2007, the Medical Journal of Australia dedicated a supplementary issue to the inter-relationship of religion and medicine, trying to elucidate how religiousness might bring health benefits and whether religion could even be recommended as another therapy.

Many of the researchers contended that most studies still fail to adequately control for confounding factors that differentiate a ‘religious’ group from a ‘non-religious’ group. Such oversights can be as basic as failing to consider, when examining the link between church attendance and mortality, the fact that healthy people are more likely to be capable of attending church while very sick people will be confined to a hospital bed.

Finally, a study published in 2000 in the New England Journal of Medicine neatly encapsulates the issues that come with considering religion as just another therapy. The authors point out that religion is a personal choice. As such, it falls into the category of several other activities that may yield health benefits, but may not be appropriate to prescribe as therapy.

For example, several studies have linked being married to better health status. Yet doctors don’t promote JDate the same way they do Quitline. Likewise, having babies at a younger age is now thought to decrease the risk of breast cancer. But again, it would be extremely out-of-place for doctors to push young female patients into having babies before they’re personally ready. It’s just definitely in a different category to encouraging regular exercise.

But ultimately, perhaps the best reason for not prescribing religion as therapy may be that to do so demeans religion itself. While religious people appear to be obtaining benefit from their choice of lifestyle, there’s no evidence suggesting benefit to atheists who adopt the accoutrements of a frum life.

Radically changing your chosen lifestyle in the hope of maybe increasing your post-op walking distance is a big move to make. And, when there are so many other simpler ways of improving your health – more exercise, better diet, drinking less, quitting smoking – becoming religious only for the health benefits looks a bit like climbing Mt Everest for a breath of fresh air.

* Image from http://img.dailymail.co.uk/i/pix/2008/03_01/mosesHeston2703_468x611.jpg

 

Overdose on these and you will fulfil the mitzvah of being unable to tell Haman from Mordechai*

By Liz Paratz

Liz continues her series on whether Judaism and Jewish practice are in fact good for the Jews. Previous posts in the series can be found here, here, and here. This week she puts chagim under the microscope.

Pesach : The Israel Poison Information Centre analysed over 5000 paediatric cases of poison exposure in the 12 weeks around Pesach. A highly significant 38% increase in the average weekly poison exposure rate was observed at the time when houses were being cleaned to remove all traces of chametz, compared to the 10 weeks after Pesach. This increase in poison exposure was attributed to children taste-testing chemicals and medicines from suddenly-unlocked cupboards.

But Pesach gets even more problematic. For apparently the rush to make matzah in under 18 minutes causes a spike in hand trauma cases among bakers. According to the article ‘Passover hand injuries’, typical injuries are amputations at different levels, crush injuries and burns. Oy.

So, while a certain matzah brand promises us its product has ‘NO….fat, cholesterol, salt, water, calories, air etc’, who knows what undeclared blood, sweat, tears and tendons did go into it?

But the Seder gets it right in some ways. Unlike what ClipArt might have you believe, the bronchi of the lungs are not at a protractor-perfect 90 degrees to each other. Instead, the right main bronchus is shorter, wider and more vertically-oriented than the left, meaning that food going down the wrong way is much more likely to head to the right lung and cause an aspiration pneumonia. In fact, one study quantified the difference ; more than 75% of inhaled foreign bodies fall to the right lung rather than the left.

Obviously, if we were to lean to the right, the risk would be even greater. So when ingesting large quantities of food, and particularly if 4 cups of wine are involved, it makes perfect anatomic sense to lean to our left.

And here’s some more happy news too. An article published in The Lancet in 1988 suggests that people in a terminal phase of illness are less likely to die at Pesach, but rather somehow manage to hold off death for a week to enjoy one last Seder.

In a somewhat farcical ‘Methods’ section, the researchers describe how, due to Constitutional reasons, religion does not appear on American death certificates and consequently they weren’t sure which deceased people were Jewish.

They therefore consulted the Dictionary Of Jewish Names And Their History, cross-referencing with the Los Angeles telephone directory in order to work out which Ashkenazi names could be considered ‘common’. By this super-scientific modus operandi they compiled a definitive list of ‘Common Jewish Names’ ranging all the way from Adler to Zaks, and taking in Weinberg, Weiner, Weinstein and Weintraub along the way.

The results? Unequivocally pro-Pesach. Examining the deathdates of almost 2000 recently-deceased Jews demonstrated that the number of deaths was significantly lower than expected in the week before Pesach, and then higher in the week after. This dip-peak pattern was not mirrored in the control groups, cringeworthily described as ‘Blacks, Orientals and Jewish infants’ (the article was written 21 years ago, but still….)

Interestingly, in years when Pesach fell on a weekend, the death rate dropped even more. The researchers postulate that this is because when Pesach is on a weekend it is easier for the entire family to come visit from interstate and overseas, making the Seders even more of a family/social event, thus providing an even greater incentive to postpone dying. Obviously, this depends on the family.

Purim : Purim is the festival of firecrackers, alcohol and drug overdose. It makes Pesach look as bland as matzah. First off, the firecrackers. The emergency department of the Western Galilee Hospital has compiled all their data from 1999-2003 of the Jewish, Druze and Arab patients who presented to the hospital with injuries secondary to fire-crackers, crackers, skyrockets and homemade explosive devices. Not so surprisingly, the Jewish patients’ presentation spiked during Purim.

The risks of alcohol intoxication are well-documented, and the link between Purim and alcohol abuse is hardly new. What is more intriguing is the possibility that even the quietest little cookie-monster may end up admitted to hospital under the Drug + Alcohol team.

In a case report in JAMA, an 8-year-old previously healthy boy was hospitalized with vomiting, abdominal pain, and pallor followed by hallucinations, sweating, and pinpoint pupils. These are classic signs of an overdose on an opioid such as heroin or morphine.

But the 8-year-old was no heroin addict, just a kid with a serious hamantashen habit who had devoured about 1.4kg of poppyseed in the last day. Poppies are the natural source of opium, with the drug located in the seed’s capsule.

Standard supermarket poppy-seeds are processed to remove the capsule, but unfortunately these hamantashen were proper homemade ones. Luckily the boy made an uneventful recovery over a 12-hour period.

High Holidays : For the intrepid shofar-blowers of any congregation, Rosh Hashanah is much more than honey and apples – it’s truly risky business. Again, JAMA has the details.

A 17-year-old boy was admitted with ‘notable pain in the midline of the neck anteriorly and difficulty swallowing after his blowing of the Shofar’.  A work-up in the emergency department resulted in a diagnosis of interstitial emphysema. In other words, the lungs had been subjected to such extreme pressure that air was forced out from the lungs into the surrounding tissues.

So, that rounds up chagim for now – next up, the medical considerations of going to shul, and other manifestations of ‘a religious lifestyle’.

* Image source: MelindaLewin.com

Image source: www.customminifig.co.uk

This article is the third in a series on the medical benefits (or otherwise) of Jewish food, culture, and religion. In this series, Liz Paratz peruses the medical literature for evidence-based answers to the big question: Being Jewish – is it good for the Jews? This week Liz investigates Jewish clothing and ritual. (You can find the other articles in this series here and here)

Circumcision (brit milah):

The big news on circumcision is that it’s no longer just a mere tribal mark and a bris is no longer just a social occasion. Rather, ‘the snip’ is the new HIV preventer. Dr Stephen Moses won the 2008/09 Top Canadian Achievement in Health Research Prize for his work ‘Male circumcision: a new approach to reducing HIV transmission’.

This trial (which was in no way sponsored by any mohels), where men were randomized into circumcised and uncircumcised groups, was meant to finish in September 2007 – at which point any disparities in HIV incidence would be analysed to see if they were significant. However, the trial was stopped in December 2006 – because the Data Safety and Monitoring Board declared that the results were so compelling (circumcision provided a 53% protective effect against HIV) that it would be unethical for the trial to continue. It was thus immediately cut short (please excuse the pun), and all the men in the uncircumcised group offered a bris. Ultimately, all three of the randomized trials conducted (in South Africa, Uganda and Kenya) were stopped early for this reason.

Male circumcision has since been recognized as a preventative HIV measure by the World Health Organisation and the Joint United Nations Programme on HIV/AIDS, while the Government of Kenya has established a National Task Force on Male Circumcision. It sounds much more interesting to work at than most government departments.

It is now estimated that mass male circumcision in sub-Saharan Africa could prevent more than 7.7 million people from acquiring HIV, and 3 million from dying from AIDS over the next 20 years. The benefits of circumcision are not just limited to HIV, either – it apparently affords some protection against sexually transmitted, ulcerative, and urinary tract infections as well as penile cancer. Interestingly, though, it appears that the male has to be circumcised as a baby rather than receive an adult circumcision in order to receive the protection against penile cancer.

Of note, though, is the finding from a meta-analysis of 11, 050 men that men who engage in sex during the healing period of circumcision actually place themselves at an increased risk of exposure to infections.

Davening:

You might think that, when you pray, it’s an out-of-body experience, your soul is all that matters, and your body is unimportant and unaffected. Well, that might also be what the 13 patients in ‘Davener’s dermatosis: a variant of friction hypermelanosis’ thought when they first presented with their strange and seemingly inexplicable skin markings. These patients all presented complaining of what the dermatologists characterized as ‘an elongated, vertical, midline, hyperpigmented patch with indistinct borders, which was distributed along the skin overlying the bony protuberances of the inferior thoracic and lumbar vertebrae’. Investigation revealed all the students were yeshiva students (and all were very thin), while the lesion turned out to be caused by friction from davening against the yeshiva’s rigid backrests. The dermatologists named this disease (a previously unknown form of benign friction hypomelanosis) ‘davener’s dermatosis’ in the students’ honour.

Yarmulkes and their bobby-pins:

It’s exquisitely obscure, but beware the bobby-pins on your kippah. In ‘Pseudo Alopecia Areata Caused by Skull-caps with Metal Pin Fasteners used by Orthodox Jews in Israel’, 37 patients who had developed patches of baldness on their scalp were analysed. The patches were found to correspond to the placement of their yarmulke’s bobby-pins….very House. The solution was not so intricate ; the patients were advised to use big Sephardic kippot without any bobby-pins.

Tefillin:

It seems that if you are a frum male, the phone number of a good dermatologist is a must. First there was the bobby-pin-induced pseudo alopecia areata, now there’s tefillin contact dermatitis. A series of case studies has been reported in which the leather of the tefillin triggers a ‘unilateral allergic contact dermatitis of the left arm’. Researchers have hypothesised that ‘the physical trauma associated with the tight winding of the straps for up to 1 hr per day may have predisposed our patients to have become sensitized to the chrome in the leather straps.’

On the other hand, (this reference is thanks to Ariel) traditional Chinese medicine says that tefillin are truly beneficial. In ‘Tefillin : An Ancient Acupuncture Point Prescription For Mental Clarity’, the knots and wrappings are analysed and it is determined that, ‘regardless of the belief system behind the procedure, it seems clear that putting on tefillin is a unique way of stimulating a very precise set of acupuncture points that appears designed to clear the mind and harmonise the spirit.’

The authors analysed 4 different techniques of putting on tefillin (Ashkenazi, Sephardi, Chassidic and Sefard), and determined that tefillin stimulates 3 skull points (Shenting DU-24, Shangxing DU-23 and Fengfu DU-16) as well as many of the more than 50 acupuncture points of the arm. Unfortunately, the Ashkenazi technique is least stimulating – it stimulates 3 points fewer compared to the other techniques, which all contact the same number of points.

And, notably, the Sephardi technique wins out over all the others as the strongest stimulator of the Pericardium Channel, which calms the heart and steadies the mind.

Image source: pratie.blogspot.com

This article is the second in a series on the medical benefits (or otherwise) of Jewish food, culture, and religion. In this series, Liz Paratz peruses the medical literature for evidence-based answers to the big question: Being Jewish – is it good for the Jews? This is the second and final instalment on Jewish food.

Keeping Milk and Meat Separate (Milchig and Fleishig)

Personally, I didn’t expect to find that much hard data on the laws of milchig and fleishig when I started running search terms through PubMed, so this was probably the most surprising set of results of all.

Essentially, there’s good news and there’s bad news. I’ll start with the good news –

It’s definitely good to separate meat meals from milk meals : In articles such as ‘Inhibition of haem-iron absorption in man by calcium’ (1992), and replicated in other studies since, Swedish researchers found that calcium blocks the absorption of iron in your gut – so it kind of defeats the purpose of eating the meat in the first place. This is basic physiology, but the degree to which the blocking was found to occur is what really amazed me. The researchers fed subjects either plain hamburgers or hamburgers with calcium, and discovered that when calcium was present, iron absorption was decreased by 41%. In other words, you only get a little over half the nutritional value from your meat if there’s a slice of cheese lying on top of it.

And so, the authors’ conclusion essentially ends up being a recommendation that the whole world should adopt the Jewish dietary laws (though they don’t refer to them as such). As they say,

‘Both iron and calcium are nutritionally essential. Present interactions between calcium and iron must be considered in dietary recommendations, in the composition of single meals, and in the design of daily menus in order to satisfy the requirements for both nutrients in a feasible way…. Attempts should be made to keep the calcium content low in main meals providing iron. This can be done, for example, by reducing the intake of dairy products with these meals and by covering calcium requirements in breakfast meals and in the in-between meals.’

And there you have it, a bona fide medical order from Dr Leif to separate your milk and meat.

But there’s always a flipside : Unfortunately, it turns out that this aspect of kashrut comes with a gender divide; keeping milk and meat separate is good for females’ health but not for males’. The issue was raised in an article about the quality of ultra-Orthodox teenagers’ bones. The teenagers’ risk factors for poor bone quality were pinpointed as being ‘engagement in scholarly rather than physical activity’ (no weightbearing exercise), ‘modest dress and usually inner-city dwelling’ (reduced sunlight exposure, needed for making vitamin D) and, of course, keeping milk meals separate from meat meals (possibly reducing the calcium intake).

The results in this study were pretty shocking. While the girls’ bones were OK, the boys had a mean z score value of -1.71, which is osteopenia (often described as ‘early osteoporosis’, and meaning their bones are already pretty crumbly). That this could be the norm in a population of boys aged 15 to 19 years old from Brooklyn, New York, is really quite frightening – and, even worse, 27% of the boys already had established osteoporosis. These boys should be at their peak bone mass, but instead they already had the skeletons of 80-year-olds.

One possible explanation for the gender difference is that while the girls took a balanced approach to choosing milk versus meat, the boys chose to eat meat almost every meal. This meant they were getting next to no calcium, resulting in absolutely rubbish bone quality.

So the key to getting the balance right? Reviewing the above articles suggests; keep milk and meat separate, but try to alternate the meals. And preferably (but more controversially) don’t wait 6 hours to have your yoghurt.

Some miscellanies (gefilte fish and vodka)

Gefilte fish: Fish is considered a bit of a wonderfood these days, with the news that omega-3 fatty acids increase intelligence. Since gefilte fish is usually a blend of at least 3 kinds of fish, you’d think it should be gefilte the brim with those fatty acids, and thus high up on the list of winners.

But some bad news has been broadcast to the world from JAMA, the Journal of the American Medical Association (how on earth did multiple articles on such an obscure food make it into such a high-profile journal?)

Apparently the bad news is that gefilte fish may contain parasites, putting you at risk of contracting diphyllobothriasis. With a name like that, it’s already scary. The larval parasites (baby form) are tiny, and therefore no amount of chopping or blending is guaranteed to satisfactorily destroy them. The symptoms are abdominal discomfort, vomiting, diarrhoea and weight loss. The parasites – who, by the way, grow up to 10m long – stay in your gut for decades, and can even cause a total blockage of your whole gut. Not even a double-dose of chrain will save you.

A further risk arises when the gefilte fish is home-made. Several cases of botulism have been reported under these circumstances, sometimes with fatal outcomes. It has been observed that the simmering process fails to inactivate the Clostridium botulinum spores (the dangerous bit).

So, it seems that gefilte fish fails. I should probably reveal my bias here. I’m really not a fan of gefilte fish, and therefore glad to find some backing for my prejudice. And as far as I’m concerned, any fatty acid requirements can easily be filled by a liberal intake of smoked salmon bagels.

Vodka : There are obviously plenty of articles on alcohol in general, but unfortunately none that specifically examine kosher wines. Other than kiddush wine, I felt that vodka would surely come second-place as the drink of choice of many Jews.

The verdict seems to be that if used appropriately, vodka has clear benefits. One study, led by a Dr Cohen, discovered that vodka can help to prevent stomach ulcers. Truly. Maybe. One of the problems with taking aspirin is that it can trigger an ulcer in the stomach. So Dr Cohen gave half his patients vodka before their aspirin – and the other (unlucky) half just got an aspirin. The ones who had vodka beforehand got considerably less stomach damage from the aspirin, which I consider to be one of the more exciting medical discoveries made this century. Importantly though, the vodka has to be taken in a small dose; Cohen used 37.5mL, which I suppose is a shot.

But, you could ask, what did I mean by ‘appropriately used’? Well…..there is one case report on a 23-year-old woman who allowed her boyfriend to pour a bottle of vodka (a whole litre?? – it doesn’t say) into her rectum. Not so surprisingly, she developed rectal bleeding and diarrhoea, losing part of the inner lining of her colon. Notwithstanding this tragic tale, it seems that for those who can remember which end the Stolichnaya goes in, vodka can be good for you.

And on that happy note, the meta-analysis of Jewish food is done. Next up, will be religious practices.

Adapted from VisualParadox.com

By Liz Paratz

The medical world today is very proud of its shiny fabulous new tool, called ‘evidence-based medicine’. EBM, as it is known in short, is basically the simple-sounding idea that you don’t do anything without having data to show that it works.

For example, 500 years ago, it was pretty cutting-edge to hand your crippled arthritis patient a bottle of snake oil and tell them that this being the Year of the Snake, it would do the trick. But now, prior to prescribing you must know that the snake oil was tested on 5000 arthritic patients with incredible results.

The developer of EBM is usually said to be Professor Archie Cochrane, a Scottish epidemiologist of the 1970s. But I believe the Jewish community already had a strong tendency towards this sceptical, evidence-based approach long before Cochrane gathered his first set of data. One of the best examples of the Jewish scientific approach is the question asked when any issue, personality, or indeed arthritis therapy is mentioned, ‘Yes, paracetamol indeed, but is it good for the Jews?’ And surely Professor Cochrane would agree; after all, what use is in vitro effectiveness if you can’t prove clinical efficacy in a given population?

Now there’s even a website – GoodfortheJews.com – that seems to have crunched almost every newsworthy issue. Recent headlines include Are Jewish Celebrities Good For The Jews?  Is Twitter Good For The Jews? Is Paul McCartney Good For The Jews? and Are Holocaust Movies Good For The Jews?’ with detailed analyses in the attached articles. This 6000-year-old tradition of scientific in-depth debate and paranoid over-analysis is surely the clear intellectual ancestor of today’s evidence-based wunderkind.

But, while obviously the world is a much better place thanks to our frantic examination of whether all those externalities are good for us, we should also remember to sweat the small stuff. Luckily, micro-analysing our Jewish lives has been preoccupying (mainly Jewish) doctors and scientists for decades now. And amazingly, such ethno-specific EBM research has made it into some of the most prestigious medical journals.

I’m talking about articles on the medical benefits and side effects of chicken soup, tefillin, gefilte fish, Shabbat, sheitels, milchig versus fleishig, using bobby pins to secure your yarmulke, brit milah and more. It’s all out there in the scientific literature; sometimes analysed in excruciating detail, and sometimes just a case study description. Every aspect of Jewish life has been teased apart and investigated to see just what we’re doing to ourselves every time we so much as daven next to a rigid-backed chair (very dangerous, it turns out…)

This week’s article kicks off a series which will broadly investigate 3 main areas of Jewish life – Jewish food, religion and chagim – and release the findings on what is good for the Jews, and what isn’t working so well. So, let’s stop debating the Jewish relevance of iSnack 2.0, Obama, and Ahmadinejad’s alleged Jewish heritage, and turn to the medical academia in order to start this literature review on the ultimate question of them all, ‘Being Jewish ; is it good for the Jews?’

Part 1. Jewish Food ; good for the Jews?

1A. Chicken Soup

Any discussion of Jewish food surely starts with ‘Jewish penicillin’ – chicken soup. Perhaps unsurprisingly, many researchers have dedicated themselves to investigating the hypothesis that chicken soup is, in fact, ‘good for the Jews’ (and everybody else).

Back in the 1970s, the first articles started appearing; one that deserves a particular mention is the ground-breaking Effects of drinking hot water, cold water and chicken soup on nasal mucus velocity and nasal airflow resistance. In other words, these valiant researchers gave their subjects either hot water, cold water or chicken soup; and then measured how fast they were able to blow out their shnot. Drinking chicken soup seemed to confer a clear performance advantage, allowing you to blow your nose at a sprinting 9.2mm per minute. Obviously, a discovery of such importance got everyone in the scientific world pretty excited, and the journal articles started flowing thick and fast (maybe even approaching 9.2mm/min).

The more serious Therapeutic Efficacy Of Chicken Soup came out in 1980, and reviewed the nasal mucus velocity findings along with Maimonides’ original advertising copy for chicken soup (‘an excellent food, as well as a medication for the beginning of leprosy, and fattens the body substance…’) It concluded approvingly, ‘The judicious use of chicken soup as an important element of the therapeutic approach to upper and lower respiratory tract infections seems to be fully justified’.

From this point, it seems that the floodgates had completely crashed open, chicken soup was the new aspirin, and whoever had invented it was surely entitled to a Nobel Prize – if only they could untangle the competing claims of all the bubbas. Researchers from the Chaim Sheba Medical Centre in Tel Aviv (including the Head of the Department of Neurorehabilitation, no less) rushed in to begin the real campaign ; it was time that chicken soup was recognised as not just a drug, but as an ESSENTIAL DRUG.

To clarify, the World Health Organisation has several ‘essential drugs’ – their benefits have to be evidence-based, efficient, flexible, forward-looking and ‘as relevant today as 20 years ago’. The chicken soup researchers – who seem to be entirely serious despite sounding more ridiculous than I do here – begin with the point that chicken soup is of course as relevant today as it was 2000 years ago.

They go on to contend that it does indeed meet all the other criteria. The lack of any randomized clinical trial is breezily explained away by the fact that you just couldn’t possibly have randomization, with a blind group who received no chicken soup, because to deny anyone chicken soup would be unethical. Furthermore, they ask, how could you even pick a target population (ie cancer patients, arthritis patients) in which to test it, when chicken soup is well-known to cure everything?

Although chicken soup hasn’t yet become a WHO-classified drug, it has accrued a few more articles in its support. It’s now also recognized as inhibiting neutrophil chemotaxis (movement of the inflammatory white blood cells), since a breakthrough study tested multiple components of the pot, with samples including the ultra-scientific, ‘near the chicken’, ‘top of pot near onions’, ‘top of pot near carrots’, ‘around the matzoh ball’, and of course the much-dreaded ‘upper lipid phase’ (in other words, the gross schmaltz on top).

And despite the obvious dangers of telling your mum she’s not making her chicken soup quite right, the authors of Chicken soup revisited: Calcium content of soup increases with duration of cooking are clearly fearless, suggesting you should update your fortieth-generation family recipe by chucking in a bone. Allowing the bone to cook in the mix for as long as possible allows the bone to break down a little, releasing calcium ions into the soup. This increases your calcium intake, theoretically helping to lower your risk of osteoporosis.

But of course, as with any person or soup that becomes too popular for its own good, there are always the haters. Some mean-spirited doctors out there have fuelled debate with their articles claiming that chicken soup can cause hypernatremia (too much salt in the blood), anaphylaxis, as well as the obvious risk of choking to death on that calcium-rich bone.

So, good for the Jews or not so much? At this point, it seems bubbacillin is a winner, especially for readers in the early stages of leprosy or with really slow nasal mucus. And even for the rest of us (hopefully the majority), there’s nothing like a warm bowl of the chickeny stuff to chase away the neutrophils. Just take the bone out first.

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Liz is a 5th-year med student, obsessed with coffee and finding juicy veins on everyone’s arms. Between coffees and cannulations, she mimics the famous room full of monkeys bashing away on typewriters, hopefully producing meaning at some point.