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!
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.”
If you are in the Land of Enchantment (New Mexico, not Disney) the last weekend of December, come join me for my next speaking (and singing!) engagement, December 27th and 28th in Albuquerque. Details on the events page.
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!
I spent the morning of October 27, 2019 taking down my sukkah.
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
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
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?”
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.
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.
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
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
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
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
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.
– age. One of the same age may be more
of a comfort that someone too young or old.
– joy. One of the same temperament, who enjoys
same things, can provide greater comfort than someone with whom we have nothing
– l’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.
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.”
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
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
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
Goyal, MK et al. Racial Disparities in Pain Management of Children With
Appendicitis in Emergency Departments. JAMA Pediatr.
Published online September 14, 2015.
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.
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
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
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
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
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.
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.