Fast de­ci­sion

Health con­cerns for Yom Kip­pur, Ra­madan

Jerusalem Post - - FRONT PAGE - Judy Siegel-Itzkovich re­ports

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.

(Wiki­me­dia Com­mons)

MAURYCY GOTTLIEB’s 1878 paint­ing ‘Jews Pray­ing in the Syn­a­gogue on Yom Kip­pur.’

(Wiki­me­dia Com­mons)

(Judy Siegel-Itzkovich)

DR. BISHARA BISHARAT

(Judy Siegel-Itzkovich)

RABBI YOSEF ZVI RI­MON

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