Health concerns for Yom Kippur, Ramadan
Although religion should promote good health, sometimes the two can clash. In such cases – for example, religious fasts – clergymen and doctors should intervene to ensure that patients are not harmed. The Jerusalem College of Technology, an Orthodox Jewish educational institution in the Givat Mordechai neighborhood, held an unusual daylong conference earlier this month on this meeting point of medicine and Jewish law. It was introduced by JCT president emeritus Prof. Noah Dana-Picard, who holds a chair in education, mathematics and Judaism at the college.
While the conference focused on fasting for Yom Kippur and the possible complications it could cause to people with certain medical conditions and was attended by over 100 male and female doctors and Orthodox rabbis, it began with an hour-long lecture on Ramadan fasting and the health condition of the Israeli-Arab sector by Dr. Bishara Bisharat, a Christian Arab and family doctor, former director of the EMMS Nazareth Hospital and currently chairman of the Society for Health Promotion of the Arab Community.
Bisharat, a graduate of the Hebrew University Medical Faculty who has worked as a physician at Kibbutz Ein Dor and development towns as well as Arab villages, was the first hospital director to supply only nutritious whole-wheat bread, rather than unhealthful white bread to all patients, staffers and visitors. This one change, in addition to promoting the drinking of water rather than cola and other sweet beverages, can have as great a beneficial effect as many drugs in the basket of medical technologies.
“The Health Ministry suggested that other hospitals switch from white bread to wholewheat, but few if any have done it because of the significantly higher cost,” he says.
He bemoaned the worrisome health condition of many Arabs – from high rates of smoking, obesity, diabetes, kidney failure and limb amputation. Arabs tend to copy the health behavior of their doctors, so if a doctor smokes, drinks cola and other sweet beverages, they think they can too.
“Smoking is serious problem in the Arab sector, with 35% and 32% of women addicted to tobacco.”
While the 1994 National Health Insurance Law significantly improved the medical condition of Arab citizens, their average lifespan lags four years behind that of Jews (largely because of lifestyle problems), compared to just two years when the reform was implemented. Before the national health insurance system went into effect in 1995, 25% of Israeli Arabs had no health insurance at all, he said.
In the last 35 years, the diabetes rate among Israeli Arabs has multiplied sevenfold, said Bisharat, who was chief medical officer in Clalit Health Services’ northern district. Infant mortality among Arabs has declined a lot, but it still remains too high; among Negev Beduin, the rate is five times that of Jewish infants in the center of the country, he continued. There are also many accidents and health problems due to consanguinity (marriage of first cousins) in the Arab sector. But much can be done to teach health promotion, he said. He criticized Arab MKs for “not showing any interest in Arab health. You won’t see them at the Knesset’s health lobby. I call on them to change this.”
Because of the high diabetes rate among Muslims, observing the month-long Ramadan fast poses health problems. “The fast was initiated by Muhammad,” he said, “but it is meant for healthy adults, not for the sick or for children or pregnant or lactating women. If you can’t fast for health reasons, it’s just as good to give charity instead.”
Some 40% of Muslims with insulin-dependent diabetes and 78% of diabetics who are not taking insulin fast during Ramadan. The diabetes rate among Arab adults following its sevenfold jump is an incredible 21%. The obesity rate in the sector is also very high, with obesity/diabetes diagnosed in 52% of the adult Arab population, compared to 31% in the Jewish population. As a result, kidneys fail. The need for dialysis grew threefold in the Arab population, compared to 10% among their Jewish counterparts.
Most Arabs who undergo dialysis have diabetes, said Bisharat. At Emek Medical Center in Afula, all patients whose feet have been amputated are Arabs suffering from diabetes. One must pay attention to one’s body.
A diabetologist at Hadera’s Hillel Yaffe Medical Center told him that the relatives of many Arab patients bring large amounts of colas and other sweet drinks when they visit.
Bisharat added that the JCT provided participants in the conference with an abundance of sweet cakes and burekas containing harmful trans fat, and that all but two big beverage bottles were sweet, with only two water or carbonated water.
“Israelis eat much too much sugar. We have to prevent diabetes in the Arab population, and this advice will help the Jewish population as well,” he said.
“I give lectures on health to Arab religious leaders. But unfortunately,” Bisharat explained, “there is low health literacy in the Arab population. It can be a problem for people with chronic illness to fast. They might stop taking their drugs with water so they are tempted not to take the pills during the fast. Muslims, like Jews on Yom Kippur, with chronic illness will thus be tempted to hide their condition from others and to fast.”
A major risk of diabetics fasting, especially if they are insulin-dependent, is hypoglycemia. Many with type-2 diabetes who are not injecting insulin can fast if they get guidelines from their doctor, but those on insulin should not fast, said Bisharat. If they insist nevertheless, they need to know what type of insulin and when in relation to the daily suhoor meal before the fast and the iftar meal after it, said Bisharat. RABBI YOSEF Zvi Rimon, the rabbi of JCT and head of its Beit Midrash, noted that “medicine develops all the time. Doctors may have said something 20 years ago, and rabbis gave halachic rulings on the basis of that, but maybe the information is obsolete. The principles of Jewish law are the same, but conclusions may be wrong because doctors made statements not based on medical evidence and research. One has to go deeper.”
The rabbi produced a pamphlet with guidelines for patients on Yom Kippur fasting.
“It there is doubt, one must consult with a rabbi. If it is impossible and there is a real doubt [about whether the fast will cause harm], one should not fast and not endanger life, even if there is no immediate danger but only one that is distant. A patient must not risk his or her health and fast in contravention of doctor’s orders.”
The rabbi added that if one’s doctor and rabbi say the patient can fast, except to drink small amounts of water every nine (or even six) minutes, the permitted amount of water is easy to measure. Fill your mouth with as much water as you can and then spit it out into a cup. Half of that amount can be drunk every nine minutes by chronic patients who need to hydrate themselves. The average amount is 38 milliliters and should be less than 44 milliliters. If necessary, to provide sick people with more energy, they can drink a sweet beverage or soup in intervals, Rimon continued. If a patient has to eat at intervals as well, the food should be able to fit inside an Israeli-style matchbox.
A patient is allowed to take a shower on Yom Kippur to refresh himself (it is forbidden to healthy people) if he needs it to fast, and is advisable over eating and drinking if the doctor permits. It is preferable to stay home, pray and fast, if permitted by a doctor or rabbi, rather than go to synagogue and forgo the fast.
Pregnant and lactating women who are healthy usually are bound to fast (unless the new mother cannot produce enough milk for the baby), but pregnant women should consult with authorities on whether going without food and drink would harm them or the fetus.
Chronically ill patients who must take pills during the fast are advised to take them without water, but if this is impossible, they should do so in a different way, such as adding a bit of salt or something bitter, the rabbi suggested. DR. EPHRAIM Jaul, director of complex geriatric nursing at Jerusalem’s Herzog Hospital, said that ironically, there were many recommendations for vaccination for babies and children up to the age of 18, but only one recommended vaccination (against pneumonia) for those over 65.
“Old age is the most heterogeneous condition, but it is treated as homogeneous.” He urged pensioners to walk fast to improve their heart, brain and gastrointestinal systems, as well as to do mental exercises. CALLING A person “old” should not be determined by his chronological age but more exactly by his biological age, said Prof. Tzvi Dwolatzky, an expert in geriatrics and internal medicine at Haifa’s Rambam Medical Center.
“It used to be that kidney-failure patients were not sent to dialysis after the age of 75. Today, one can be 85 or more and still undergo it. The decision is made according to the biological age of the patient,” he said, showing a photo of an 89-year-old woman who piloted a plane, and of Jeanne Louise Calment, a French woman who lived to the age of 122 and of a Holocaust survivor and Israeli named Yisrael Kristal, who died recently at the age of 113.
Whether an elderly person should eat or drink on Yom Kippur, said Dwolatzky, depends on whether he is healthy or fragile (living at the edge of his abilities and could fall at a slow walking speed).
“From my experience, most old people fast better than young persons.” DEHYDRATION FROM fasting is a significant risk in elderly patients, noted Dr. Ephraim Rimon of the Hartzfeld Geriatric Hospital in Gedera, who is also the older brother of Rabbi Rimon.
“One should drink three liters of water during the 24 hours before a fast, but it’s hard for the elderly to drink so much. If a patient is dehydrated, the risk of a heart attack or stroke is higher. An elderly person who wants to fast and drink at intervals may forget to drink water and them harm himself.”
He told the story of Rabbi Chaim Sonnenfeld of the Eda Haredit who learned of a blind woman who was fasting and endangered her health.
“He came to her and blew the shofar during the fast and told her it was night and the fast was all over. But every case is different.” DR. RABBI Mordechai Halperin, head of Jerusalem’s Schlesinger Institute for Medical-Halachic Research, added that a patient with irregular heartbeats can even die if he fasts.
“If we make an error in our guidelines, we are spilling blood. If a person is sick and at risk, he doesn’t need to drink at intervals. He should eat. If based on medical evidence, a person could be harmed by the fast, he must eat.” THE ONLY part of the body that needs carbohydrates is the brain, said Prof. David Zangen, a senior endocrinologist at Hadassah University Medical Center.
“When you haven’t eaten for hours and the blood sugar level is low, the liver will release sugar from the liver to reach the brain rather than to remain in storage. If there isn’t enough, a patient can fall and be seriously hurt.”
Working with observant adolescents with type-1 diabetes, Zangen asked if they intended to fast on Yom Kippur. Thirty-nine of 190 said they would fast no matter what the doctor said.
“They want to be like all the others, but it could be dangerous. Those who nevertheless insist on fasting are advised to check their blood sugar every 2.5 hours and to start eating if they have nausea, vomiting or hyperglycemia. A diabetic should always consult their personal physician, as he or she knows the medical condition well.”
The joint conclusion of the Muslim doctor, the rabbis and the Jewish physicians was that if life and health are at risk by fasting, choose life.
MAURYCY GOTTLIEB’s 1878 painting ‘Jews Praying in the Synagogue on Yom Kippur.’
DR. BISHARA BISHARAT
RABBI YOSEF ZVI RIMON