Kindling… (#notaChanukahpost)

Kindling… (#notaChanukahpost)

Somehow, while I wasn’t paying attention…

The Kindle edition of my book is ready! Healing People, Not Patients is now available in e-book format on Amazon. If you or someone you know has gone paperless (or run out of shelf space, as I have) but wants to have a copy, now you can!

One Small Step

One Small Step

There’s a talmudic tradition that when a person takes their first steps in the morning, they should recite the blessing, “ha-meichin mitzadei gaver” – “who prepares a person’s steps.”[i]

Recently, I learned a new understanding of this prayer, and a new occasion on which to say it.  When one is uncertain, afraid, or overwhelmed, ha-meichin mitzadei gaver is a prayer to be shown where to place one’s feet next, to have a clear path appear.  In the traditional instance, the word gaver means “person,” but here it suggests to me gevurah, strength or fortitude.  “Blessed are you, God, who prepares a sure path, who makes my steps sturdy.”  I also think of the verb le-hitgaber, to overcome.  “Blessed are you, God, who shows me the way to overcome.”

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Twin Cities

New material will be coming shortly, but in the meantime please check my events page for the details of my trip to the Twin Cities in a couple weeks! Many thanks to my cousins Rabbi Jeffrey and Dr. Deborah Schein for their hospitality and to Liz Rappoport, SaraLynn Newberger, Susie Held, and Rabbi Alexander Davis for bringing this together!

Cutting Ties

Cutting Ties

I spent the morning of October 27, 2019 taking down my sukkah.

Not my sukkah, but this is what a sukkah looks like. From

Leviticus 23:42-3 tells us that God commands us to dwell seven days in the sukkah so that future generations will remember that God made the Israelites dwell in sukkot when God redeemed them from Egypt.  Rabbi Adin Steinsaltz comments that this period in Jewish history is like the childhood of the nation, quoting Jeremiah 2:2:

“I counted in your favor the devotion of your youth, your love as a bride; How you followed me in the wilderness in a land not sown.”

For Steinsaltz the period of the Exodus is marked by a youthful, innocent love between the people and God, unencumbered by mundane distractions and burdens of working land, paying debts, and maintaining possessions.  The Children of Israel have nothing to concern themselves with other than their relationship with God.

In such a time, it is possible to be totally present, to experience real, complete joy.  The kind of joy experienced by children.  If you have children, you have likely seen unadulterated joy – the child at Disney World, the child when you give them a balloon, the child when they bite into a piece of chocolate.  Or even, and this I think is what Steinsaltz is really referring to, the child when they run to greet a parent returning home from work, plastering themselves to the adult’s legs before the bags, coat, and keys have even been dropped.

It is for this reason that in a different passage about the holiday of Sukkot we are commanded, “V’samachta b’chagecha . . . v’hayyita ach sameach.”  “Rejoice on your holiday and be ach happy.” Ach is a strange word, which is why I’ve left it untranslated for a moment.  It could either mean, “entirely,” alluding to the precise kind of unbridled happiness I described above.  Or, it could mean something along the lines of “but” – in other words, “you should nevertheless be happy.”  Those future generations would no longer be in the devotion of their youth, their nuptial bliss.  They would have business deals, ill relatives, marauding cattle thieves, and a host of other annoyances and tragedies to deal with.  The verse is therefore saying to them, “Nevertheless, you should be completely happy.  Forget all of those other things; for seven days you must rejoice!  Get to it!”

Those seven days are over, as are the two additional days of joy and celebration that follow.  We are back to the grind.  And so it happened that on the morning of October 27th, the one year anniversary of the worst tragedy my neighborhood has ever seen, and the thirtieth anniversary of the tragic murder of my classmate Karen Hurwitz, I was physically dismantling the temporary dwelling of joy on my deck.

The basic design of my sukkah is PVC pipes, tarps, and bamboo mats held together with PVC joints and cable ties.  Dismantling it begins with taking a garden clipper to the cable ties one by one.  At certain points, there are often multiple overlapping layers, or extra ties securing a tarp both to the horizontal and to the vertical pipe, or attaching lights and decorations.

As I worked I noticed something that had never caught my attention in years past: when I would clip one tie, it often seemed I had done nothing at all.  The pieces would hang in mid-air undisturbed, testing my faith in gravity.  Only when I made two or three more snips, cutting all the ties would the tarp flap open, or the strand of lights drop agonizingly toward the deck, daring me to catch them before they shattered on the wood.  Likewise, when I got to the end and took a hammer to the frame to open the joints of the pipes, disconnecting just one elbow or tee left the skeletal walls still upright.  Only when I had separated an entire panel from the structure did it topple forward onto the boards like a fainting drunk.

The sukkah is an inherently unstable structure, so much so that during the grace after meals on the holiday we bless, “The Merciful One who will right for us the fallen sukkah of King David.”  I once received a text message from my wife 90 minutes before the holiday started imploring me to come home at once because the wind had literally folded the entire thing flat, like a broken-down cardboard box.  These pipe joints and cable ties are a flimsy defense against the heavy rains and high winds that often hit Pittsburgh in October (to say nothing of the snows in places like the Twin Cities or Toronto).  The bamboo roof is intentionally porous to the elements, so that the rules of the holiday actually have a built-in excuse to let you eat inside if there are raindrops visibly falling in your soup.

Yet taken together, all of those little connections keep it standing.  This year I lashed one side to the drainpipe, one to the planter box, and one to the basketball hoop for good measure, and it held.  And in that place, despite illness, a flood of work which threatened to drown me, and the looming commemoration of all that was evil in the world, when I was in there I was ach sameach – nevertheless completely happy.

So it was striking to see that my happy place did not fall apart with the loss of one or two of its connections – but with the removal of more and more of them, I was soon left with just its bones, and then with a disassembled array of parts drying in the sun.

It’s been a hard year, but one of the overarching themes of the anniversary commemoration was that we are strong as a community.  Rabbi Joseph Ozarowsky, whose book To Walk In God’s Ways was one of my first stops on the journey to Healing People, Not Patients, taught us that when Isaiah 40:1 says, “Comfort, comfort, my people,” what he means is “Comfort one another, and be comforted by one another.”  Individual connections were destroyed in the shooting, but in this neighborhood there existed so many connections, including hundreds I have only realized existed in the aftermath, that we could not be broken.  The sukkah did not fall down because there were so many ties holding it together.  In the wake of the shooting I was able to call my second son to the Torah as a Bar Mitzvah, and feel true joy in that moment, because those ties were enough to hold it all together.

I liken it to human balance.  There are three components to being able to keep yourself upright: vision, the balance organ known as the vestibule in your inner ear, and proprioception, which is the sense of knowing where your joints are positioned (for example, is your foot flat on the ground or are you standing on your toes?).  The body does not need all three of these to keep you balanced; any two will suffice. 

Years ago, a doctor named Romberg figured out that if you deprive a sighted person of their vision by having them close your eyes, you can then confirm that both of the other components are working.  To do Romberg’s test, a person must stand with their feet flush together.  As my own Rabbi, Seth Adelson, has recently taught me, this stance, the regel yeshara or “fused leg” of the angels, is the way we are supposed to stand when reciting especially holy texts, including the Kaddish for mourners.  In addition to mimicking the angels, it is also an inherently unstable stance – as is fitting when we are speaking words of holiness while mourning.  Yet according to Romberg, if both the vestibule and our proprioception are working, if the nerves are connected properly, we will not fall.

Romberg also forbids people to hold their arms out to the sides to aid in balance.  What to do if someone starts to fall?  That is the job of the healer: they must keep their hands just an inch or so away from the person’s shoulders.  The healer catches the person who can no longer hold themselves upright.

One of the most dangerous things I encounter in my healing work is people who do not have sufficient connections, where one snip, one loose joint is enough to bring their whole shelter crashing down.  Even a missed bus connection, on the way to a job interview or to a court hearing, can destroy everything.  When they experience trauma, like the death of a loved one or being assaulted by a domestic partner, there are no walls surrounding them to protect them from the aftermath.  A person with diabetes gets an infection, has a toe amputated, and stays a week in the hospital.  When the wound heals and the infection is cleared, who will they go home to?  How will they cope with mobility, grocery shopping, showering, and food prep if they are going home to an isolated, and empty, apartment?

You may have a picture in your mind of the type of person I mean; discard it.  We can all readily call to mind some of the factors that might leave a person vulnerable, lacking a sukkah to hide in on a bad day (see my earlier post “One Thing I Ask”); poverty and disadvantaged minority status are two of the most obvious.  Yet within those groups are some who are incredibly resilient to trauma, because other connections make up for those which they lack in the financial or social status categories. 

Family, close-knit neighborhoods, worship communities, professional associations, old army buddies and roommates are just a few of the places where people might find the ties they need to hold them together in a crisis.  The more of these they have, the more intricate the network, the harder it is for one cut to destroy the whole web.  Should these disappear, being in the cultural majority, educated and well-off may not be enough to provide the support someone needs.

Think for a moment about overcrowding.  We are used to thinking of this as a public health hazard.  Refugee camps are among the most overcrowded places in the world, and filled with infectious disease, potential violence, and safety hazards like fire.  Yet they are strangely protective against this danger we have been discussing.  For the elderly, the mentally ill, and the disabled, being in a crowded environment like that means never being alone.  Someone is always present to watch over them, keep them from harming themselves, and sit with them when they become confused, afraid or sleepless.

In America, that thick blanket has been pulled away.  Even in densely packed city neighborhoods, the walls between apartments and colder weather mean that those refugees now have to go out of their homes looking for connection, and the families that they live with must travel “far” from home, even if just a bus ride, to find work.  They are alone at home for hours at a time, not understanding how to go places, or what to do when they get there, or how to use the modern appliances (including gas stoves!) in their homes.  In isolation, they forget things, become afraid, and fall ill.  With time, their family members earn enough money to leave the city and move to a suburb, if only a few minutes’ drive away, and they are even more isolated.

This dependence on closeness is not obvious, especially to a Westerner so steeped in “America=Good; refugee camp=bad.”  In the previous post I referenced, I suggested asking every person I provide care to what their achat shaalti is – what is the one thing that they need most, or are most worried about, right then.  After thinking about the clipped connections, and the sea of used cable ties now covering my deck, I have a second question to ask: what is your sukkah made out of?  What are the connections that keep you safe, the resources you turn to in hard times, and the places you seek comfort?  For that matter, who do you share your unbridled joy with?

If the answer is, “I don’t know,” then the next question should be, “How can I help you build one?”

I have some cable ties I can lend you…

Here We Sit Again

It is late Friday afternoon. 364 days ago, blissfully unaware of the awful events that would take place the next morning, I went to welcome the Sabbath Queen with joyous music, resounding off the walls, floor and ceiling of the lobby of my synagogue. You can read the story of that night, and the day and month that followed, in my earlier post “Sitting In the Valley of Tears.”

That night, October 26th, 2018, I imagined that the words of Lecha Dodi could heal a soul broken by unimaginable horror, unable to reintegrate despite years of distance from the event. In the year since I have had occasion to wonder whether I myself don’t find them to be mocking me.

And so I share these words with you now. I am beginning to feel I can sing again, and someday soon they will have music. They hurt me to write, they are a chore to read and a burden to sing, but the song must be written and sung. May they serve you well, and may they help to strengthen the memories of my 11 friends and neighbors.

“You have sat long enough in the vale of tears;

God will have compassion on you.”

We have sat too long in the vale of tears.

God will have compassion on us.

Sadness is a valley, crying a wide rift

And the rift of our tears is still deep

The wound is open, the soul injured

Who can say now we have sat long enough?

In a moment of haste You hid Your face

And in that same moment everything changed

With eternal lovingkindness reveal Your mercyThen we will no longer sit in the vale of tears.     

רב לך שבת בעמק הבכא

והוא יחמול עלייך חמלה

רב לנו שבת בעמק הבכא

והוא יחמול עלינו חמלה

הצער הוא עמק, הבכי הוא בקעה

ובקעת דמעותינו עוד עמוקה

הפצע הוא פתוח, הנפש פגועה

ומי יגיד עכשיו שרב לשבת בה?

שצף קצף הסתרת פניך

ובאותו הרגע הכל כבר השתנה

בחסד עולם גלה רחמיך

ולא נשב יותר בעמק הבכא

One Thing I Ask

One Thing I Ask

If you could only ask me one question, what would it be?

It sounds like a party game, a conversation starter designed to get people talking at a speed dating event or a team-building exercise.  But sadly it’s the way most people’s encounters with their healers go these days.  For all practical purposes, there is a “one question per visit rule.”  Better make it a good one.

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The Same Joy

The Same Joy

Update: Video of the talk is now available online, beginning at 18:18 of the video. Watch the entire clip to see the evening’s other excellent speakers, Rabbi Shira Stern, speaking about “Finding our Resilience by Owning Our Grief,” and Professor James Young, speaking on the process of creating memorials for traumatic events.

Remarks from a “FEDTalk” given at the annual meeting of the Jewish Federation of Greater Pittsburgh, September 5, 2019.

It was the morning of March 17th.  48 hours earlier, a co-worker had alerted me to the horrible terror attack in Christchurch, New Zealand.  I had been in a fog ever since.  The young Syrian man across from me stared at the floor and told me, “I watched the video online – he wasn’t showing any emotion.  He was shooting people like it was a video game.”

Less than five months out from our own communal tragedy, I thought I had begun to heal myself.  Christchurch ripped open the wounds – his memories of the catastrophic disintegration of his home country into civil war, and mine of the loss of dear friends, colleagues, and co-workers, and of my illusion of being secure in our wonderful Jewish community. 

It was a conversation particular to the Squirrel Hill Health Center.  While we are not a “Jewish health center,” SHHC grew out of the Jewish Healthcare Foundation, is a Federation beneficiary, and in many ways is a living legacy to Montefiore Hospital’s tradition of serving all of the underserved communities of Pittsburgh.  Those underserved include refugees and immigrants whose language, culture or religion serves as a barrier to care in many places.  SHHC was also where our late, beloved friend Richard Gottfried worked until the day before he was killed while davening with his community at New Light. 

I suppose I’ve known for years that a conversation like this would happen one day.  Last fall, just a month before the 18th of Cheshvan upended all our worlds, I reached a major career milestone.  My book, Healing People, Not Patients, was finally published thanks to generous support from the Jewish Healthcare Foundation.  The premise of the book is simple: people who heal for a living are in a relationship or, as Rabbi Harold Schulweis suggested, a covenant with people seeking healing.  Thinking of those seekers first and foremost as people, created in God’s image, demands a completely different approach to healthcare than our current model that often reduces a person’s identity to their diagnosis or even their room number.

The most crucial skill in this covenant is the ability to listen attentively to another person’s story, and to ask them questions out of genuine interest in knowing more.  My friend Martin often admonishes me not to ask questions I don’t want to know the answer to.  Well, in the aftermath of a tragedy, I don’t want to know the answers.  I’m not sure I can handle the answers anymore.  Yet those answers are the key to helping the other person heal.  What was I supposed to do?

My young Syrian friend is not the only person I care for to have experienced trauma.  “Trauma-informed care” is one of the newest buzz-words in healthcare, and especially in mental health.  But Dr. Megan Gerber, author of the first textbook on trauma-informed care for primary care docs like me, distills this buzzword into a stark realization: depending on where you are, a history of trauma can be nearly ubiquitous.  Consider the SHHC team to be fully informed.

What isn’t ubiquitous is what grows out of that history.  Gerber makes the point that people who have been traumatized may be angry and frightened, jumping at a touch or snapping at every perceived verbal micro-aggression, even when the intent of that touch is to soothe or that speech is to counsel.  Others bury the trauma almost as soon as it occurs. 

Trauma can lead to chronic pain and disability: a back bent into the shape of the lowercase letter “r” which bows even further on the yahrzeit of a lover.  At the other end of the spectrum, health workers whose patient dies in mid-shift return to work within minutes.  I debriefed after my first experience of a patient’s death in the stairwell of the VA hospital only because the intern supervising me took two minutes to stop and check on me as we ran past each other in opposite directions. 

Jewish tradition prescribes a middle path.  We find triumph in tragedy, and remember tragedy in moments of triumph.  The chevra kadisha, of which our community is blessed to have two that work in cooperation and respect, does a tahara using texts comparing the deceased to a bride, or to the Kohen Gadol.  The mashiach is going to be born on Tisha B’Av.  The broken glass at a wedding tempers our joy with a memory of Tisha B’Av.  And at one point in history, that wedding was likely arranged on the afternoon of Yom Kippur, when the life of each Jewish soul is hanging in the balance. 

Saturday, November 3, 2018, the 25th of Cheshvan, when 1500 people crowded the sanctuary at Beth Shalom to mourn and daven together, we ended Kiddush by celebrating the sheva brachot of our Rabbi, Jeremy Markiz, and his wife Elana Neschkes.  They married on the 19th of Cheshvan in Los Angeles, and bound by the mitzvoth to rejoice that entire week, even in the wake of unspeakable tragedy.  If it is possible to be both broken and restored in the same moment it happened to me as I struggled to sing for the bride, “Kol sasson v’kol simcha, kol chatan v’kol kalah.”

Remember that stark realization about the ubiquity of trauma?  Megan Gerber reminds us healers of an even more stark truth: many if not most of us have also been traumatized.  We not only need to be broken and restored in the same moment – we need to be broken and restore others in the same moment.  Gerber might well paraphrase my friend Martin and say, “Don’t asked questions if you’re not fully prepared to deal with the answers you get.”  But we had to be prepared; we had to continue. 

The weeks and months that followed the shooting were a pendulum swinging between attending to the pain and suffering of those we had always cared for, and tending to our own wounds.  There was Rich’s funeral, the cookie trays and lunches, the Bhutanese community vigil, the outreach from JFCS.  Despite their own vulnerabilities, their limited English, their own emotional exhaustion, the seekers were now healing the healers.  Their example inspired what I am going to share with you now.

Fans of medical Latin may have heard the term furor therapeuticus, a term the great teachers of medicine often apply to their students who simply cannot stand to leave a problem un-fixed, often to the great detriment of the person with that problem.  The golden age of medicine that dawned in the sixties and continues to this day filled many of us with the belief that every disease could be cured, every hurt healed, and even death made optional.  We learned to say, “No one needs to be in pain.”

As we become trauma-informed we are learning to say, like Rosey Grier, “It’s all right to cry.”  Healers like me who have never really learned properly to shut up now recognize that it’s also all right not to have an answer to the crying.  We just need to name it, and be present with it, and share the tears. 

Pittsburgh Jews are now trauma-informed whether we like it or not, aware of both the ubiquity of trauma experienced by others, and of our own inability to escape trauma ourselves.  It seems preposterous that after 2,000 years we should need to be reminded of the ubiquity of trauma, but individual memory is short. It’s hard for one person to remember what it’s like to be a “stranger” when we are no longer feeling so “strange.” Now, our own immediate experience parallels that of those we support, and of those we try to heal.

Erica Brown, who came to comfort our community on the shloshim, and who will return here later this month for the Fall Forum, takes exception to the five-stage Elisabeth Kubler-Ross paradigm of grief.  In her book Happier Endings, Brown contends that there are really only three stages: denial and resignation, which encompass all five of Kubler-Ross’s original stages, and inspiration, in which a new life is formed, absent that which was lost, yet incorporating it into something greater which did not exist before the loss.

The inspiration stage is digging into that parallel experience to help others.  Before the shooting I would sometimes ask myself, “What can I learn from my patients who have survived war trauma and are thriving that could help others who are not?”  Now I am looking at myself, asking how we might help each other. 

Answers are already emerging: by returning support to our Muslim neighbors who rushed to our aid in October.  By sending letters to the survivors of the more recent tragedies in Poway, Dayton, Gilroy, El Pason, and now Odessa-Midland.  By tapping the resource of our Holocaust survivor community to support our Hillel JUC students, or to partner with SHHC to help Bhutanese refugees process their own tragic losses.

This is variation of the phenomenon known as “concordance:” people build more trust and experience greater healing with a healer who is similar to them in gender or ethnicity.  In the Talmud, Nedarim 39b, Rav Aha bar Hanina speaks of a different kind of concordance, necessary for effective healing when visiting a sick person – to be “ben gilo.”  One translation is that this means to be of the same astrological sign, but as always, there are other ways to read this. 

Gil – age.  One of the same age may be more of a comfort that someone too young or old. 

Gil – joy.  One of the same temperament, who enjoys same things, can provide greater comfort than someone with whom we have nothing in common. 

Gill’galot, to reveal.  If we are vulnerable, broken, and willing to share that vulnerability with the others, we connect in a way that armored stoicism and charmed innocence do not allow. 

Glu’im – exposed.  The media encampment last fall left us exposed, but in that exposed vulnerability is our strength, our newfound ability to be there for each other. 

L’galot – to discover, strength we did not know we had. 

Gilinu, we discovered this year what we already knew.

We are surrounded by bnei gileinu, our friends and neighbors with whom we have a special, Pittsburgh concordance. 

Bo’u ngaleh, let us show the rest of the city and the world what we have to share with them.

Facial Recognition

I catch a half-smile, a hesitant wave, and a curt nod, and I realize I am supposed to recognize this person.  I return the gestures, but my memory refuses to be jogged.  Finally, they approach me close enough for conversation, and say, “Dr. Weinkle, how are you?”  After caring for a few thousand people in the course of my career, I cannot hold all the names and faces in my head any longer.  “I’m so sorry,” I reply, “please remind me of your name.”

The double-edged sword of “recognizing faces”

If only I had chosen to be a judge.  According to the Torah, they’re not supposed to recognize faces – it says so right in Deuteronomy 16:19, when Moses is explaining the meaning of “judge the people with righteous judgment.”  Among other things, he says, “thou shalt not respect persons,” meaning not to show favor to a rich person because of their status, or to a poor person out of pity.  Equal treatment under the law is the meaning of righteous judgment.  But the Hebrew phrase that he uses to say this is lo takir panim – literally, “don’t recognize faces.”

But healers aren’t supposed to be blind like justice, are we?  We’re not meant to be impartial – we are meant to be completely partisan advocates for our own patients.  Haven’t I written a whole book, and dozens of blog entries, about how I want my colleagues to feel a certain amount of love for the people we care for, to really care instead of just “providing care?”

Knowing the face, being familiar with the person, is the essence of individualized, person-centered care.  You can’t be a “healer who listens” without understanding the uniqueness, “recognizing the face,” of the person you’re listening to.  By extension, you can’t know which person needs hand-holding and which one humor, which one deliberation and which one decisiveness, unless you know their “face,” the way they prefer to interact with the world.

But when you have a busy practice, how many faces can you “know?”  Can I be fully present for every single one of them, know all their preferences and tailor all my treatments to their needs?  Does every one of them get my equal passion?  Or are there a few faces that inevitably end up getting more attention?

Put another way, like that encounter on the street, there may be a limit to the faces I can recognize at one time.  So which faces am I going to end up seeing?

Over 11 years of my career I’ve seen myself default in a whole variety of directions.  Sometimes I “see the faces” of the people who happen to be in the office that day, to the detriment of those calling in from home.  Other days I dive into the first appointment of the day with 1000% commitment, only be insurmountably behind schedule by 4 pm, unable to see the faces of the last two or three people on the day’s schedule.  Still others, I am so consumed by the faces whom I can’t get out of my head at night, from the constant worry about their well-being, that the simple needs of the faces who just need a moment of my time are never seen.  And yes, sometimes I recognize the faces of the squeaky wheels and spend my time putting grease on them while the patient patients continue to languish.

My children might tell you that this arrangement is OK, because they’ve often heard me tell them, “Fair doesn’t mean equal.”  Not everybody gets the same amount of something, and that can be OK – but only if everyone gets the appropriate amount for them. 

“Recognizing faces” can have consequences beyond just how we allot our time, though.  Recognizing certain faces, and failing to recognize others, directly impacts the care that we provide.  We’ve all seen a child in pain; most of us who have our own children can even tell when they are really in pain and when they are simply shocked and betrayed that one of their siblings has whacked them with the broom.  Yet somehow when black children come into the emergency room with appendicitis, we find their pain harder to recognize than that of white children.[i]

Recognition often becomes easier when the face is one that looks like our own, a phenomenon called concordance.  There’s evidence that concordance can significantly improve care, reducing alcohol consumption in the aftermath of a traumatic injury, or leading to more rapid follow up of abnormal cancer screenings in populations where the patients and physicians are from the same background, where looking in the healers face feels a little more like looking in the mirror.[ii]  Recognizing faces can save lives, too.

Still other times the recognition can go too far.  We may be loath to admit it, but all of us have at some point cared for a person who was a “VIP patient,” whether a close friend, a famous person, or someone with an “in” at our place of employment that made them feel entitled to more expensive, more rapid, or more cutting-edge care than the other patients.  If we’re going to talk about recognition, let’s recognize what’s going on when we do a test we know doesn’t need to be ordered, acquiesce to a demand for an antibiotic or an opioid that isn’t called for, or change our practice that we do the same way, every time, “just this once” because we give too much recognition to one particular face. 

Orchot Tzadikim (a text from the musar, or ethical, tradition of Judaism) relates how learned people can shame the very holy texts they are studying when they do not act accordingly.  The example given is of when one studies the line, “You shall not be prejudiced in favor of the mighty,” but then does show favor to a wealthy person in court.  When we study the evidence and learn best practices, then toss them out the window when caring for a VIP patient, we bring shame on medicine as well.

There’s no easy way out of this conundrum.  When I wrote in Healing People, Not Patients about creating my worry list, I wondered how I could ethically, fairly decide who I was sufficiently worried about to put them on the list.  I initially wrote that chapter three years ago; I’m still struggling with the question.  How do you create the oxymoron of “universally individualized care?”  How do you do the “right thing, for the right patient, at the right time, in the right way,” to quote the patient safety mantra, without inevitably having your individual relationship with the patient push someone else out of the way, or cause you to behave differently for that patient than you would?

While you think that over, I’m going to go grease some squeaky wheels.

[i] Goyal, MK et al. Racial Disparities in Pain Management of Children With

Appendicitis in Emergency Departments. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.1915

Published online September 14, 2015.

[ii] Poma, PA.  Race/Ethnicity Concordance Between Patients and Physicians.  Journal of the National Medical Association, 2017-03-01, Volume 109, Issue 1, Pages 6-8.  Poma cites numerous other studies in his review; the two referenced here are by Field and Caetano and by Charlot, Santana, Chen et al.

Surviving Sinai:

Surviving Sinai:

Modern day Exodus stories, and what happens when they are “over”

I speak in metaphor a lot. One of my favorite ones is using the Exodus from Egypt as a metaphor for healing from illness. The idea is that illness is a narrow place which does not permit a person to be truly free. Only by way of a long, difficult journey does a person leave the land of illness and its constraints and arrive in a new, hoped for place of wellness and plenty.

Two weeks ago I had to code switch. I met several people who had literally left Egypt and relived the journey of the ancient Israelites, looking for a place that was wide enough to allow them to breathe freely. Lest you think I’m putting my own gloss on someone else’s story, I mean to say that these individuals crossed through the Sinai desert. They made the crossing on foot and under attack from all sides, from a modern day Amalek of torturers, rapists and extortionists.  Their destination was the modern Israel.

One of them, a young Darfuri man named Usumain, took the analogy a step further.  He recalled being in Egypt, having already rejected Libya and Chad as suitable places to remain after fleeing for his life from the conflict in Darfur.  One night he was watching television and saw a program on Al Jazeera that told of the history of the Jews, including the Exodus from Egypt, and up through the genocide of the Holocaust.

“That’s me,” Usumain said to himself.  “I am running from genocide, and I am in Egypt.  But there’s no way I can wait forty years, I must go to Israel now.”

That was eleven years ago, when he was fourteen years old.  I met a 25-year-old Usumain in Tel Aviv this month, strolled with him through the streets and had lunch with him.  During those couple of hours, one thing became clear: there is a mirror image to my metaphor.

I’ve been relying on the Exodus metaphor as a road map to healing since the day my mentor, Rabbi Larry Heimer, introduced me to the idea.  Rabbi Yitz Greenberg’s chapter, “Judaism as an Exodus Religion,” is one of the founding documents of my personal philosophy of medicine.  This encounter with Usumain turned that concept on its head – the Exodus from Egypt can also be an experience from which one needs to heal.

Ancient or modern, a person who embarks on that journey faces thirst, starvation (see Numbers 20 for just one of the numerous Biblical examples of both), dangerous enemies (Numbers 22:2 and onward for the story of Balak, King of Moab, and the sorcerer Bil’am who was sent to curse the Israelites, or the stories of Og of Bashan, Sihon of Emor, and the people of Amalek attacking the weakened stragglers in the Israelite caravan) and despair.  Families separate; Usumain’s mother and sisters remained in Chad, while his brother sought asylum in the US.  Among the ancients, some Israelites preferred the known devil of slavery in Egypt to the unknown of a God taking them out into the wilderness.  Some die in the wilderness – Miriam, Aaron, Moses, the entire generation of adults who came out of slavery, and in Usumain’s group of 12 refugees alone, 3 fellow travelers shot dead by the Egyptian army trying to cross into Israel.

Arriving in the “Promised Land” does not bring the journey to a close.  One doesn’t just get to drop anchor beneath a vine and fig tree and live in peace and unafraid, as the prophet said.  One arrives at a destination where they don’t speak the language, where they are unwelcome, and where poverty and starvation are still a potential outcome.  Another Exodus, to another possible promised land, may be just around the corner.  Ironically, I met Usumain in South Tel Aviv, near a neighborhood called Neve Sha’anan, “the tranquil dwelling place.”  I couldn’t help but think instead that for Usumain, the commonly used Hebrew phrase, “ein sha’ananim b’Tzion” – there is no tranquility in Zion – is more applicable.

Tranquility is hard to come by elsewhere in the world as well.  Metaphorical Sinai crossings in other parts of the world also end in sexual assault, death from asphyxia and heatstroke in a truck-turned-oven in the Sonoran desert, or in a cage in the supposed “land of the free.”  Usumain chose Israel as his destination in part because he didn’t want to end up drowning on a raft in the Mediterranean, like so many African refugees before and after him.

Cynics in wealthy countries from Central Europe to the US have suggested that the migrants should have sought asylum in the first country they came to, as if this would somehow solve the problem (perhaps it would – it would save the wealthy nations from having to acknowledge how fortunate we are).  A laughable notion: should Sudanese refugees seek asylum in Chad, one of the two or three poorest nations on Earth?  Should the Congolese refugees that left in 1994 expect a homecoming in Rwanda, a country that had literally months before been torn apart by a genocide?  Refugees fleeing Somalia in the 1990s and 2000s ended up in refugee camps in Yemen – I wonder how their asylum cases would be going right about now? 

Usumain’s story ends well; he is one of a very few to gain official refugee status from among the Sinai survivors.  Thousands of others are still in limbo.  But even when the political drama reaches a conclusion, there is an internal drama of nightmares, anxiety, depression and flashbacks that continues.  It is not unique to the Sinai refugees, be they men from Darfur or women from Eritrea, but it is a further reminder that an exodus is both a journey to healing and a journey from which one must heal.

I left lunch with Usumain and soon found myself having coffee with Aeden, one of the Eritrean women I just mentioned, at the Kuchinate Gallery[i] a short distance from Neve Sha’anan.  Kuchinate is the Tagrinya word for “crocheting,” and that is what happens at the gallery.  Women like Aeden support themselves and their children by producing baskets in a traditional style, which the gallery buys from them no-strings-attached and sells to keep the doors open, the lights on, and food on the table for the kids in the afternoons. 

But Kuchinate, I learned, is about more than livelihood.  It is its own form of healing.  In a culture where unloading your troubles on a stranger with an impassive face is a laughable idea, the gallery brings together women who become fast friends and can confide in each other about the horrors they have experienced.  Both the work, and the comraderie that it creates, are their own form of therapy that may be more relevant than all the CBT in the world.  Among the Nepali-speaking refugees I care for, there has long been an idea that “a friend is a psychologist;”[ii] Kuchinate allowed me to watch this saying in action in another culture from another continent.

There’s also a lot of self-healing going on at Kuchinate.  The gallery’s director, Dr. Diddy Mymin Kahn, joined with an Eritrean nun that everyone calls Sister Aziza to produce a book, A Guide to Recovery for Survivors of Torture,[iii] written in English and Tigrinya with culturally relevant drawings and blank pages for notes, that walks a survivor through the process of healing moment-by-moment, helping them to feel safe, conquer basic fears like agoraphobia, and combat anger, depression and despair.

There are 60 million people in the world today estimated to be in the midst of writing their own Exodus narrative.  It is a public health crisis on the same order of magnitude as HIV/AIDS, malaria or tuberculosis.  Both the social services and the mental health services in almost every one of the “promised lands” these Sinai-crossers are striving toward, not to mention the places many of them languish in the meantime, are underfunded and overwhelmed.  It will be because of individual resilience, and because of the embrace of intimate friends like Kuchinate, that they will someday be able to complete their journeys and recover from their travels.  Day to day, I strive to provide that embrace in my work.  I invite you to join me.


[ii] Liana Chase and Ram P. Sapkota.  ‘‘In our community, a friend is a psychologist’’: An ethnographic study of informal care in two Bhutanese refugee communities.  Transcultural Psychiatry 2017, Vol. 54(3) 400–422.

[iii] Dr. Diddy Mymin Kahn and Sr. Azezet Habtezghi Kidane, tr. Mebrhatu Baraki and Kebedom Mengistu, ill. Karen Brockman.  A Guide to Recovery for Survivors of Torture.  Tel Aviv: UNHCR, 2016.