Are You SURE You're Bluish? (part 2)

In Jewish religious law, a person is Jewish if his mother is Jewish in Jewish law. That's not as confusing as it sounds. Either she was born to a Jewish mother, or she converted in accordance with Jewish law. In other words, Jewishness is genetic. (That, incidentally, is how one can be a Jewish atheist). In fact, the traditional way of assigning Jewish identity is racist: if a Jew says, of a non-Jew, that he has a Yiddishe kop (a Jewish head), that's a tribute to the Gentile's intelligence. If a non-Jew begins talking about "Jewish blood", Jews know it's time to bar the door and close the window shutters before the pogrom begins. But I digress.

There is another definition that requires some explanation but is important to understand in this story. A "bastard" in Jewish law (mamzer) is the child of an adulterous relationship, not born out of wedlock. There are very significant penalties for being a mamzer, one of which is not being allowed to marry anyone but another mamzer for 10 generations.

Back to the story.

Jewish rabbinical courts consist of three rabbis. Women, children and idiots are not allowed to be witnesses. When we applied for an Israeli marriage certificate, we of course submitted the marriage license signed by Rabbi Lipman in Washington DC. However, the Israeli rabbinate keeps lists of American rabbis they deem sufficiently Orthodox, and Rabbi Lipman wasn't an Orthodox rabbi. That in itself wasn't an insurmountable obstacle. Cohabitation can be one of the three ways a woman is "purchased in marriage" (the language is Mishnaic, not mine). But a Jewish marriage has to be between two Jews. Was I a Jew?

Bring your mother to Israel to testify to her Jewishness, the rabbis told me. No way, said I. My mother was undergoing chemotherapy and could not travel. OK, have her make a deposition before a rabbi we accept. I refused this too, because I knew my mother had a very bad conscience about marrying "out" and the last thing I wanted at this time was to increase her emotional problems. Finally, after much consultation, the rabbis decided my two aunts could make depositions, stating that they definitely knew my grandmother to be Jewish, and my mother was indeed their sister. (Trying to explain this to my aunts was a job in itself, since neither was observant. WTF? Of course Bubbie was Jewish! Nevertheless, it was done.)

Then the rabbis dropped the bombshell: how do we know that your first husband was indeed NOT Jewish? Perhaps he was secretly Jewish, and in that case, since you don't have proof of death, you are still married to him, not having received a Bill of Divorcement according to Jewish law! Bring HIS parents--if you can't find him--to Israel to testify that they are goyim!

This was patently impossible. Bernard had never told his parents, from whom he was estranged, that he'd even married me. The rabbis had cause for concern because in Europe there were children who had been saved from the Holocaust with faked baptismal papers, and his mother might have been one. But it was very important because I was now pregnant with my first child, and unless I could prove, to the court's satisfaction, that my first husband had not been Jewish (and therefore my first marriage was not Jewishly valid), I was pregnant with a mamzer, because the second marriage was invalid.

DH didn't understand the implications; he may be a "kosher" Jew, but he's Israeli, and not a Torah scholar. I collapsed in hysterical tears outside the courtroom. Another rabbi hurried over, thinking perhaps we were having a marital dispute, and when I managed to blurt out a bit of the story, he immediately told us to follow him to the offices of the Jerusalem Chief Rabbi. This rabbi was his secretary. I spent over two hours with Rav Zolti (z"l), and the upshot was he gave me a letter to take back to the court which said, in essence, "solve this now".

The rabbis did, in the following manner:

As stated above, a Jewish marriage is the union of two Jews (a man and a woman, incidentally) and must be dissolved according to Jewish law with a "get" or Bill of Divorcement. However, a marriage between a Jew and a non-Jew is not a valid marriage, and no Jewish divorce is required. So, (Talmudic sing-song with waving finger for emphasis is appropriate here) if we cannot prove that Bernard definitely wasn't Jewish, then, the rabbis reasoned, using the "no women, children, or idiots are legal witnesses" cop-out, we can definitely say that Antigonos isn't Jewish because her aunts' testimony is worthless!

So they sent me to be "converted".

It was less of a problem for me than for DH who, if he didn't rabidly hate the rabbinate before, he does now. I recognize the legal fiction, and the need for it, that the rabbis used. They were forced to work within Jewish law, and in its best tradition managed to find a way around what appeared a nearly-insoluble problem. DH just thought the whole thing was a farce. At the end of the day I merely was dunked in a ritual bath and given a piece of paper which I think I've lost over the years (along with my Israeli marriage certificate, which I haven't lost). The rabbis are happy. Now my daughter's getting married, and because I went through this soap opera she isn't having any problems with the rabbis at all. Her Jewishness isn't in doubt.

But every time the stranglehold of the religious authorities in the areas of conversion, marriage and divorce makes the headlines, I feel sympathetic. On the one hand, it is Halacha--literally, "the way in which one walks"--that has kept the Jewish people a coherent unit throughout more than two millennia, in spite of the most ferocious persecutions. On the other, it takes rabbis of real moral stature to be able to have the guts to adapt the Halacha to current conditions. It's just too easy to fall back on the generations of scholars who went before and not allow any innovations out of fear. Right now there are significant numbers of Russians who would formally convert if it wasn't made so difficult; they have Jewish partners and have chosen to leave the FSU and make their lives here, and there are many Ethiopians who consider themselves completely Jewish but whom the rabbis doubt and it is deeply insulting to them. Once again, a bill is in the Knesset for civil marriage, but that will only divide the religious and the secular even more. It is a very difficult problem.

How NOT to Have a Baby

Birdie's Mama doesn't like me.

On her blog she relates the story of her pregnancy, her labor, and the stillbirth that resulted. She doesn't like me because I told her that it was most probably her bad choices which caused the baby to die in utero. OK, I admit being harsh. But trying to exonerate her by commiserating uncritically with her is actually an act of collusion in the tragedy. More than that, I desperately want to jolt her into not endangering either herself or her next baby.

I don't think I'm doing too well. She's now into something called "Mayan Massage" which is just woo, and is already thinking about trying for VBAC even though she's not yet pregnant again.

So, for what it's worth, even though I doubt she will read this (why should she?), let me recap what I know, what I speculate, and what I fear. Perhaps it will be of benefit to someone.

Birdie's Mama chose, in her first pregnancy, to decline being tested for gestational diabetes. An adopted child herself without information about her biological mother, she nevertheless claimed she had no inherited tendency to diabetes. She wrote:

The test is more for women who run a high risk for having GD. I don't fall into
this category, however the concern lies in my being adopted and not knowing my
biological health history. For all I know, my biological parents could now have
diabetes. Nonetheless, even if I am tested there is not any real evidence that
shows treating GD can improve the outcome for mom & baby. So, I am going to
think about it over the weeknd....and make a decision early next week. Of course
the risk of not having the test is growing a larger baby, and in the end not
being able to have a vaginal delivery....that is not an option for me.

But gestational diabetes is not real diabetes at all, and it isn't an inherited trait. Gestational diabetes is a condition of pregnancy where the mother's blood sugar during pregnancy behaves in the same way that it does in true diabetics. However, almost always, it returns to normal within hours of birth. The risks of gestational diabetes are twofold: either the baby is unusually big, with the consequent problems of possibly being too big to go through the mother's pelvis, and also, after birth, having trouble maintaining his blood sugar levels, or the baby is unusually small because the placenta isn't working properly and the baby is being starved of oxygen and food. A baby whose blood sugar levels unexpectedly plummet can convulse, and there can be permanent brain damage as a result since during a convulsion, the supply of oxygen to the brain is interrupted.

Generally speaking, most gestational diabetics can be managed on a diet which keeps their blood sugar levels within normal limits. This has the additional effect of keeping the babies from growing excessively large, and thereby also reducing the chances of hypoglycemia after birth. Some gestational diabetics, however, require insulin (oral diabetic agents are not suitable during pregnancy). The diet has some carbohydrate (carbohydrates are metabolized in the same way as sugar) but it is very limited. Birdie's Mama is a vegetarian. While it is possible, on a vegetarian diet, to get sufficient protein when pregnant, it isn't easy, and the typical vegetarian diet is heavy with carbohydrates.

So I speculate: did Birdie's Mama have undiscovered gestational diabetes? The fact that the baby weighed over 9 lbs (4 kilo) at birth suggests it but does not prove it. If Birdie's Mama did have gestational diabetes, her diet was almost certainly higher in carbohydrates than it should have been, and therefore she exacerbated her own problem. Whoever told her that gestational diabetes poses no risk if untreated was wrong. The risks are real, and substantial. And one of them is intrauterine fetal death. But Birdie's Mama didn't want to even think about the possibility: "it isn't an option". I won't think about it, therefore it can't happen. Birth, after all, is normal; complications come from medical interventions. Trust your body.

Birdie's Mama published, throughout her pregnancy, photos of herself. There is a photo, taken at 31 weeks, which strongly suggests polyhydramnios. This is a situation where there is excessive production of amniotic fluid. The uterus looks "large for dates". I won't go into the various methods of estimating gestational age by height of the uterine fundus because nowadays most women have repeated ultrasounds during pregnancy, and this is more accurate (indeed the amount of amniotic fluid can also be measured this way). Polyhydramnios is a warning of many possible problems. If--IF--there was polyhydramnios, it was either missed or not even noticed by Birdie's Mama's health care providers. She also gained much more weight during her pregnancy than was advisable.

Apparently, as far as I can tell, Birdie's Mama's antenatal care was supervised by certified nurse midwives without reference to a doctor. In the blog it is noted that she was scheduled to see one at 32 weeks, but she does not say if she went to the appointment. She arranged for the birth itself to be attended by a doula and a midwife who was not a nurse. At times Birdie's Mama seems to confuse the two kinds of attendants, and she quotes, at one point, completely fictional statistics regarding the use of doulas in labor ("50% less C/S") When I checked the links to the both the doula's and the midwife's. website, neither site was operational.

Birdie's Mama also wanted a home birth, preferably a water birth.

our homebirth....is going to be peaceful and quiet (soft
meditative music)....relaxed, candlelit and romantic.

I have very strong reservations about home birth in the US. There are no national standards for midwives. In some states, they are illegal. In others, only certified nurse midwives are legal, and in still others, "licensed" midwives (meaning they have had some training but the type of course varies widely) are allowed, and lastly there are states where anyone who attends a woman in labor can call herself a midwife. Moreover, there are no nationally agreed criteria for who is suitable for home birth; no form whatsoever of emergency backup, no requirement that the parturient woman should be within a certain distance of a medical institution with the facilities to offer emergency care to mother and baby on a 24/7 basis.



Criteria in the UK have changed in the thirty years since I studied to be a midwife at Cambridge. Back then a woman having a first baby could not have a home birth, because it was not possible to know whether she could put a baby through her pelvis or not. Ultrasound has made that less of a risk, since both the size of the baby's head and the weight can be reasonably estimated and the diameters of the pelvic inlets and outlets can be measured. As Birdie's Mama came closer and closer to her due date, it is impossible to know from her blog whether she had ultrasounds to estimate fetal size at all. She passed her due date, and obviously was oblivious, as were her health care providers, of the risks of postmaturity (placental insufficiency which causes the baby to have no reserves for the stresses of labor)



In the event, engagement happened in the 38th week. Apart from that, there is little information in the blog about her status until a brief mention, in her 41st week, that she has lost her mucus plug and thinks she is beginning to go into labor. Even though she added details to her blog after the birth, all that is certain is that she had contractions for 24 hours. Whether these were real contractions, whether she had any cervical dilatation at all, what station the baby's head was at (whether it was actually descending through the pelvis), we don't know.



She writes that her midwives listened to the fetal heart every half hour or so. It's better than nothing. But a heartbeat can be within the normal 120-160 bpm range and the baby can still be very stressed. That is why intermittent fetal monitoring is done in the hospital; to see whether the baby's heartbeat is showing normal beat to beat variability. If it is absent, if the FH is always the same rate, this is not a good sign. By the time there are decelerations, the baby is now actively distressed. Moreover, it is often very hard to hear the baby's heart beat without electronic equipment (did the midwives have a doppler?) during contractions. If the baby's heartbeat is 80 between contractions, that is a very serious matter indeed.

Was it normal that I did not feel my baby m0ving at all during lab0r? The
morning that my lab0r had begun and then stalled I mentioned that I had not
really been feeling her move to one of our hom3b1rth m1dw1ves, as I did feel
a
little concerned about this, but she told me that this was normal. She
said that
when my body is c0ntr@cting that the baby "bears down" and does
not really
move.

What incredible balderdash! Of course babies move during labor. Sometimes less than before, but they do move. Birdie's Mama was right to question. She also began to wonder whether the "excruciating pain" she felt was right. Any woman who has had a baby can tell her that it is no picnic. So much for the romantic side of labor. Labor is not only hard work, it hurts.



The "midwives" put her on her side. There is no mention of oxygen in the blog. They then called the backup midwife (by implication a CNM) rather than alert the hospital that they were bringing Birdie's Mama in with probable severe fetal distress and to prepare for all emergencies. The hospital, in any case, was a small community one without an obstetrician in the house all the time, and possibly no neonatal intensive care facilities. The "three minute" trip, because of weather conditions, took longer (it always does; and getting dressed, etc. eats up the time as well. This is one of the reasons that countries with organized backup facilities for home births work on a concept of bringing the "hospital to the home" rather than the other way round). The nurses at this hospital were obviously unprepared for this type of occurence.



What Birdie's Mama describes as chaos, and as a situation where no one knew what to do is not entirely fair. (I can't think why she was told to go into knee-chest position). Writing after the event, there is an element of wanting to assign blame as a way of relieving guilt (she becomes much more critical of the hospital later on) Not being a medical person, she didn't fully understand what was going on. But there were delays that would not have happened had she been laboring in a well-equipped and staffed hospital. Further, she seems to have had some kind of seizure on the operating table, but I suspect it was a panic attack--certainly not surprising.



In short, her baby was born dead. There was some question whether the baby's heartbeat was actually heard in the hospital, or whether what the nurses heard was the maternal pulse. How long the baby had been in distress is unknown. One has to wonder whether the "midwives" actually heard the fetal heart before deciding that Birdie's Mama should go to the hospital. It's quite possible that what they heard was the maternal pulse. The placenta looked "normal" (no reason why it shouldn't actually) and nowhere is it noted that an autopsy was performed before the baby was cremated when dead three days.



I think Birdie's Mama's antenatal care was not adequate. She was obsessed with the effects of "toxic" substances on her fetus and eating only "organic" vegetarian foods, but certainly the choice of birth attendants was not sensible; these were not medical professionals. The question of whether a home birth should have been attempted is controversial. I'm not convinced that she was a low-risk patient who should have had even a trial of labor at home.



For the past few months she has been wallowing in grief. It is always tragic to lose a baby. It's my opinion that she needs professional counseling (and her husband probably does too). As grief gives way to anger, the next stage of grieving, her anger is increasingly directed outward at the hospital. Understandable, but not really correct, given the circumstances. Her most recent posts discuss the possibility of trying for a VBAC in her next pregnancy. She thinks this is possible because of the type of Caesarean Section she had. Wrong. It depends on a number of factors. VBACs, when the reason for the C/S was fetal distress are possible; if the reason was failure to progress in labor/cephalopelvic disproportion (baby too big to pass through the pelvis) it is not, whether fetal distress was a factor or not. Since babies tend to be some ounces bigger in each subsequent pregnancy, this may be a major consideration.



Right now she has become enamoured of something called "Mayan Massage". I haven't got a clue what this is, but since her uterus long ago reentered the pelvic cavity and cannot be massaged at all abdominally, I can't think what organs other than the intestines are being massaged and what effect this has on adhesions (present, if at all, within several weeks of the operation) or on the position of the uterus or its ability to house a pregnancy. It is a total waste of time, and money, although a massage is an enjoyable way of spending time, I'll grant you that.



In short, next time round Birdie's Mama should get competent, professional medical care during her pregnancy, and accept it. She should choose a hospital not because it's homelike or comfy, but because it contains all the facilities needed for all events connected with birth, uncomplicated or complicated. The idea that hospitals just want to make people suffer as much as possible is absurd. Unlike minimally-trained homebirth "midwives" who bleat on and on about having beautiful and "spiritual" experiences, hospital staff have only one top priority: the safe delivery of mother and baby. That is, after all, the whole point of giving birth.

I wish Birdie's Mama consolation for her loss, and the wisdom to make better choices next time--and I'm sure there will be a "next time".

Are You SURE You're Bluish? (part 1)

Prepare to be very confused. The title above comes from "Yellow Submarine", the Beatles' animated feature where they confront the Blue Meanies, and at one point the Blue Meany leader asks them querulously "Are you sure you're Bluish? You don't look Bluish..."


Shades of an old Jewish joke. But this isn't funny: see "Glad tidings for the lepers" in today's Haaretz.


And I think it's time to tell my own story.


First, some background. My mother was born to a Jewish family that left Russia in 1905 for the Lower East Side. She alone of her three siblings was born in the US. In her 20s, which was during the "Roaring Twenties", like many other young Jewish women, tried hard to obliterate all traces of her heritage. She was a "flapper"; she anglicised her name, did not date Jewish boys. When the Depression hit, she kept her job with the Veterans' Administration by moving to Washington, where she met my father.


Dad came from the Black Hills of Dakota--Sioux Indian country. Two of his grandfathers had fought against one another at Gettysburg, and the family, on his father's side, could trace its American roots to before the War of Independence. He was something of an oddball for his time and place, however: he voted Democratic, considered himself an agnostic, hated everything to do with horses and cowboys, affected an Edwardian look about 2 decades too late. His plans to become an engineer were sidetracked by the Depression, and in the mid-1930s found himself also forced to move from the Chicago branch office of the Weather Bureau to Washington, DC.

My mother, who thought Zelda Fitzgerald was simply the bee's knees, the height of exoticism, thought my Dad looked a lot like F.Scott Fitzgerald, and they fell in love. They were married in a civil ceremony, although it became obvious pretty quickly that Dad knew quite a bit more than Mom did about Judaism, he had no desire to convert. In fact, my mother's family accepted him much more warmly, in that day and age when intermarriage was a major crime, than was usual.


In due course, I arrived, but I was not told I was Jewish until I was 7. I then had 4, very disorienting, years of cheder. Shortly after refusing to go to Hebrew school (the afterschool variety) any more, Leon Uris published "Exodus" and, Halleluyah! I could be Jewish without being religious.


Fast forward to my 20s. Now a registered nurse, I met a young Frenchman on holiday, and we decided to get married. He was as irreligious as my father, but nominally was Catholic. The marriage (civil) lasted 4 months before being annulled (civilly). He had married mainly to convince himself that he wasn't homosexual, and had discovered that indeed he was. I later heard, via a third party, that he had committed suicide. I don't know if that was true or not, and never bothered to investigate.


When I opened a file at the aliyah center prior to making aliyah, I told all the above story to the shaliach. He thought he was doing me a favor by noting my marital status as "widow" because it gave me a double aliyah grant. At the time, I didn't know that. I don't remember supplying any evidence of my Jewishness, by the way. The shaliach took my word for it.


Fast forward again, to 1979. My mother was terminally ill; I had met the sabra who would become DH, and we went to the US for the wedding. The ketubah, an artistic one, was actually written here, to be signed and filled in as necessary in the States. I went to the only Orthodox mikvah in the DC area, but the wedding itself was going to be performed by a Reform rabbi, who was not only a very close friend of mine, but my parents' main support (Dad had never converted, but Mom dragged him to services every Friday night) during her illness. Rabbi Lipman had a lot of experience with Israeli bureaucracy and the Israeli rabbanut, and made sure the ceremony was halachically correct.


When we got back to Israel, DH said he wanted to get an isshur nisuin--a certificate from the Israeli rabbanut--that acknowledged our marriage. And that's when the fun began. The rabbis wanted me to prove (1) my Jewishness, and (2) the Jewishness, or lack of it, of my former spouse.


(to be continued)

Homesteading

It's such an evocative word. Westward Ho! and Ward Bond (although most of today's immigrants to Israel were born after Bond died). Little House on the Prairie and all that. Building one's own home in The New (Altneu?) Land--the Holy Land. Gee whillikers, gosh darn, what could be more noble than that?


Thirty years ago, when I made aliyah, it was quite true that Israel lacked many American luxuries. Electrical appliances--those which were available, in pre-microwave and pre-VCR eras--were so highly taxed as to be almost beyond the reach of Israelis, with the exception of small refrigerators (not self-defrosting) and rather basic, and also small cooking stoves. Lots of women still did laundry by hand, although the washing machine (also small by American standards) was somewhere between "luxury" and "necessity". My sister-in-law, who lived on a moshav built to house Jews from Middle Eastern countries in the 1950s still only had one tap, for cold water, in her kitchen. Dryers and dishwashers were still regarded as luxuries. TV was black and white and there were only three channels anyway: Israel, Jordan in English, and Jordan in Arabic. All the channels closed down early enough in the evening to ensure you got a good night's sleep. To have one's own car--a "private"--was definitely a luxury.

So immigrants, clutching their precious "rights", prepared to abandon America for Israel as if they were going on a kind of Mayflower in reverse, bringing everything they could possibly want for the next 50 years with them. Lifts were packed, for example, with disposable diapers (unknown in Israel) and jars of instant coffee (expensive and although locally available, not very coffee-like to the American palate). Soft toilet paper was also a favorite. In the 1980s it seemed water filters were an indispensable item (tap water is safe to drink in Israel).

Appliances were bought en masse from export shops on the Lower East Side. The "rights" allowed you to import one of each kind of item from your country of origin without Customs duty or purchase tax (usually 110% for electrical items). The only way you could NOT pay tax on a German-made washing machine was to import it from a 220 volt electrical appliance shop in the US. Having "rights" for tax exemption had another consequence: it made you buy locally more than you needed, since you only got "one". I am lumbered today with a 2 X 3 meter carpet I can't begin to shift because it's so heavy, but had I bought two smaller carpets back then, I'd have had to pay tax on one.


And the Americans came with everything, from stashes of vitamin tablets to a five-year supply of sponge mop refills. Not just what they had owned in the Old Country, but everything they could possibly imagine needing in future. Questions on the Tachlis email list, which I joined in 1997, often were about items veteran Israelis had never even heard of, nor felt the lack of. Diaper Genie bags? GPS units? Pressure cookers?

In the past decade prices have plummeted on nearly all electrical appliances, and at the same time the shops all began to carry wider and wider varieties of brands, from excruciatingly expensive to el cheapo Far Eastern junk. My first PC cost me close to $2000; I replaced it a few months ago for a much better one for about $700. My first TV was also well over $1000 for a small, 14" B&W one; you can now get a 37" LCD one (HD ready; there's no HD in Israel yet) for about the same price and the average price for a 29" standard TV is around $500. DVD players can be bought for less than $100; my first (Betamax) VCR was about $2000.



It's ALL here, folks! You may not get the tax discount, but it hardly matters, when you add the shipping costs to the "cheaper" item you bought in the States, from a narrow range and without any certainty of local service.


Israel isn't the end of the world. It really annoys the heck out of me that olim are still being duped into shipping massive amounts of stuff in the belief that they are going to some benighted desert like sub-Saharan Africa and the "natives" sit around outside thatched huts, rubbing two sticks together to make fire. And it annoys me even more that, now that Nefesh b'Nefesh is giving money to olim, businesses are actually starting up to relieve them of it, by making claims that the services they provide will actually save the oleh money and/or distress. 90% of it is so unnecessary.


The latest cause for oleh panic was the reduction in the discount given to olim buying a new car. Life in the US (except maybe in central Manhattan) without a car is unimaginable. Here, it is a very mixed blessing. The cost of gasoline, insurance, and maintenance is extremely high. Local incomes, however, are relatively low, in most cases. A car is a convenience, no doubt of it, but once the grace period for income tax reductions, etc. ends, and the oleh is living on an Israeli income, a car can become a huge burden. Try telling this to an oleh; he won't believe it until it actually happens. So, to counter the payment of purchase tax on a car, olim now are increasingly attempting to actually ship their cars from America! Besides a huge amount of bureaucracy and regulations to cope with, it costs about $8000 to do so. But of course, those homesteaders in the Old West moved west with their wagons and livestock, so I suppose I shouldn't be surprised that today's olim want to bring their MPVs and vans with them...

M*O*H*A*M*M*A*D K*A*P*L*A*N ?

Some of you may remember the wonderful books by Leo Rosten, "The Education of H*Y*M*A*N K*A*P*L*A*N" and "The Return of H*Y*M*A*N K*A*P*L*A*N", set in a 1930s night school, an "Americanization school" in New York City, which not only taught immigrants to the US English, but prepared them for citizenship. Hyman Kaplan, from some unidentified Eastern European country, who always wrote his name in colored pencils and with stars between the letters, drove the WASP teacher, Mr Parkhill (Mr. "Pockheel") to the brink of despair. Rosten created other characters with equal distinction, such as Madame Olga Trasha, a Russian who could imbue the word "hello" with tragic overtones, but it is Kaplan we remember. His sheer exuberance, his logical but very odd English, his great love of America, his unique literary style (when asked to submit an autobiographical sketch, he began with "First, I was born." Even Mr. Parkhill couldn't find a way to criticize that, although he wanted to).

Most of us with parents who were first generation immigrants remembered how they worked long hours every day, and then went to night school, if at all possible, to "become Americans". My mother, the last child and the only one born in the US, after her family left Russia in 1905, was the "Amerikanska" and it was so important to leave the shtetl behind that no one ever spoke to her in any language but English, even though my grandmother's English was very poor. And she herself rebelled against her birth name of Luba and Anglicized it to "Lenore" when she was in her 20s. It was only with the rise in "Black Power" in the 1960s that ethnicity became "chic" in the US.

Something similar seemed to be happening in the UK. When I lived in Cambridge in 1975, the British comedian Dick Emory had a very popular sketch on his weekly program in which, dressed as a bucktoothed, elderly Indian gentleman in Nehru cap and jacket, he would give his grandson heavily-accented advice, every sentence beginning "We British..."

But the similarities with the two immigrant experiences end quickly. The US, at the beginning of the 20th century, took in vast numbers of immigrants from all over the world, and had lots of space for them. Even while trying to become "American", just about everyone had roots not many generations back somewhere else. Britain had a very homogenous culture and not a lot of room. In fact, one of the raisons d'etre for the Empire had been its solution for masses of young Britons looking for work they'd never find in the home island. Emory's Indian gentleman wasn't applauded for wanting to identify as British; he was laughed at. And color mattered, in the UK, too. (It did in the US, Asians and blacks, getting the worst of it, so that the "white races" like the Irish and Jews fared better). But whereas the average American had at least some sympathy for the "greenhorn", the British were patronizing, secure in their Britishness. At least until after the Second World War, when the wogs and darkies decided they'd rather be independent .

Both Christianity and Islam are proselytizing religions. Judaism stopped being one so long ago we are almost anti-conversion. Our Sages tell us to honor the convert, but we have a certain degree of ambivalence. Jews tend to find the confrontation between Christians and Moslems a bit ironic and a bit funny: "a plague on both your houses", is the way we see it, although, from a strictly theologic viewpoint, the Islamic Allah and the Jewish Yahweh are closer to One Another than the (to Jews, totally incomprehensible) concept of the Trinity. A religious Jew can step inside a mosque; he cannot enter a church, because of the images.

Christianity eventually spread by the sword, but not at first. It was a religion of the downtrodden, the powerless, and it percolated upwards, after initial persecution, from the lower classes, preaching a doctrine of passivity and respect for authority. "Turn the other cheek", "render unto Caesar", etc. It was also a very syncretic religion, incorporating aspects of just about every pagan cult it encountered (Jews tend to think this may be due to the central tenets of Christianity, which bear distinct resemblance to certain pagan myths). Islam, however, did not have the same experience. It began in armed conquest and never found much value in being the underdog. "Christian" values of humility and self-abnegation never struck a chord in the Islamic soul. The very fact that its armies walked over most of the civilized world for a couple of centuries was the vindication of its "truth". Islam never developed anything resembling Christian monastic life, either, with its emphasis on non-violence.

I don't believe that the Crusades were basically a religious movement, but due to other factors, political and economic and that the defense of the Holy Places was really an excuse (in the way that "restoring democracy" to Iraq is--heaven forfend that someone mention oil). The Eastern Christians were always uneasy with the idea of Warriors for Christ, and it can be argued that many of the Crusader leaders and soldiers were hardly Christian. But in spite of the ultimate failure of the Crusades leading to the Reformation and the Renaissance and the flowering of Europe, the failure of Islam, to extend its hegemony beyond the Balkans, had an opposite effect: causing a reappraisal which turned it inwards. The Islamic world became Fortress Islam: no dissent, no ambiguities. "Myself and my brother against the world; myself against my brother". The essential constellation of Islam is the extended family, the clan, the tribe--not the nation.

Those Moslems, whether from Pakistan or Saudi Arabia, who emigrated to the UK, are the heirs of that denial of intellectual freedom, that indoctrination that Islam Is Best. Beyond certain material benefits, they don't see what Westerners see; they find the personal freedoms we cherish to be threatening, even if at first they try to adopt them. They don't want to be like Hyman Kaplan and his fellow students--instead, they want to convince Mr. Parkhill to become like them. Assuming they're willing to go to night school at all.

Dr. Death, PLC (public liability company, in a real sense)

When Sister Luke, in "The Nun's Story", tells her Mother Superior that she can no longer keep her vows, the Reverend Mother Emanuel says "You entered the convent to be a nun. Your love of God must be greater than your love of medicine". To which, because her love of God isn't as great as her love of being a nurse, Sister Luke has no real response.

Now we've got a bunch of doctors whose love of God--however odd that love, or that God, may be--is definitely greater than their love of medicine, and everyone seems shocked by the arrests made in the last few days of the Moslem doctors who tried to set off several car bombs in the UK.

Several generations ago, among immigrant families, largely Jewish, in the US, having a son become a doctor was just about the most precious dream out there (yes, women too, but to a much lower degree--the young lady should marry a doctor). Even today, among Asian immigrants it is a big thing. Why? For the mitzvah aspect? Or for the status aspect? To be a doctor shows that you've got intelligence--or that, at any rate, you've got enough smarts to master the curriculum (the obverse being the assumption that if you are in a skilled trade you aren't really very smart at all), that you are due respect because you have the power to save life in an almost magical way (and to the uneducated, it really is magical), and that, in the West, at least, you make a good income, and having that MD (and maybe some more initials after your name as well) give you a passport into the institutions of the rich and often the famous. The opinions of doctors carry more weight, even when discoursing on subjects remote from medicine, than the average joe. Don't ask me why. I know some doctors who are excellent physicians but absolutely clueless otherwise. Some of them are in the US Congress, for example.

None of this has anything to do with vocation, or with being a good, decent, moral human being. One has only to look at various medical publications that offer reams of advice on managing one's practice for maximum efficiency and profit to see that being a doctor is a business to a certain degree, sometimes big business, and for some doctors, it may be far more a business than a way to serve suffering humanity.

So why should those UK doctor-wannabe-terrorists be any different? Add to the mix the fact that they probably are vulnerable to a kind of subtle racism (Is Dr. Mahmoud really as good as Dr. Jones?) because they come from the "third world" and who knows what kind of education they got back in the boondocks/jungle/desert? "Can't you give me an appointment with a doctor who speaks English?" (Even when the doctor in question may speak better English than the patient). They are tolerated, rather than accepted, whereas, back in their original countries (or countries from which their families came) they would be looked up to as gods (if not on a level with Allah, peace and blessings be upon Him). How easy to turn the paranoia and feelings of inferiority into a desire to annihilate those who are really the inferiors if one only interprets the Koran in a certain way.

It's been noted that a large number of suicide bombers in our intifadas came from relatively well-educated middle class Palestinian backgrounds and they should have "known better" than to fall for the extremist propaganda. But that is exactly what makes them vulnerable: they don't know who they are. They can't identify with the peasants, they've left them behind, but they don't belong with the Western cultures they long to adopt. So, with the zeal of converts, they construct an ideal world which isn't tainted with "foreign" values (but which never really existed--A Thousand Nights and a Night is as realistic as A Fiddler on The Roof) and decide they must "re-establish" something that never was.

One hopes that, on the wards at least, these doctors had a better grasp of reality. They are really rather pathetic.

Where AM I?

Last week we all went to Herzliya, to a restaurant called Papagaio. This may not seem like a big deal to you, but not only were we en famille, both daughters and their fiances, and DH, but I very rarely leave Jerusalem. I just never seem to have the time to go anywhere, which is ridiculous, in a country as small as ours.

Besides, I intensely dislike the humidity of the coast, and if I were to go to the Tel Aviv-Gush Dan region, I'd go in December. But who am I to refuse a free meal? (Nurses, it should be noted, never refuse free meals.)

We drove through the chaos at the exit from Jerusalem that is the building site of a very modernistic Calatrava bridge that the city needs like a lok in kop, just as the sun was setting behind the Judean Hills, and everything seemed normal (the road's been improved a bit, I confess) until we got to the Shaar HaGai interchange, where the mountains suddenly change to flat land. What had been fields seemed mostly now to be road construction sites, with unfinished tunnels and flyovers and bridges and the landscape totally ruined in just about every direction. I had hardly taken this in, as we passed the exits to Ben Gurion, when one of the red double decker trains rushed by, and I had the feeling I had been transported suddenly to Queens, or the Jersey approaches to Manhattan. Tony Soprano would feel right at home. The entire approach to Tel Aviv now looks dreary and run down, with large billboards, often almost entirely in English, advertising Sony or Chevrolet. The roads are full of shiny, large cars, and in between hi-rise buildings like the round Azrieli Tower there are strip malls with Office Depots and McDonalds.

The restaurant itself is at the marina, just outside a shopping mall that could have been anywhere in the American Southwest, with its "Mexican Mediterranean" theme. For a fixed price you get an endless amount of 11 varieties of beef which has been grilled on rotating spits "in the Brazilian manner". Except that I ate too much meat and not enough roast potatoes, so that I awoke hypoglycemic and sweating at 4 a.m., it was a pleasant experience--I might think about going again in about 5 years or so.

But I felt so sad, seeing the Israel I made aliyah to disappear under the Trans-Israel Highway and skyscrapers and malls a la East Coast USA. Time was, as you drove from Jerusalem to the coast, Shaar HaGai was an intersection, where (after waiting for an age and with your pulse racing that you could get your car in gear and cross the dual carriageway before some other car came, like a bat out of hell, across your path) you turned left to go to Bet Shemesh. This "intercity highway" was actually two lanes in each direction at this point. As it went around the Taggart fort, dating from the British Mandate, now the headquarters of the Tank Brigade (with a tank up on a high platform, looking very odd indeed) and the Trappist monastery at Latrun, the road narrowed to one lane in each direction. It crossed a ravine by way of a single lane wooden bridge, causing traffic buildups in each direction, then rose out of the ditch by a series of hairpin curves, to enter an area of moshavim, mostly subsisting by selling produce and flowers at roadside stalls.

There was no such thing as an "express" Tel Aviv-Jerusalem bus when I arrived in the 70s. There were several varieties of "local" depending on whether the bus stopped at every stop or every second or third stop, or merely when flagged down or a passenger (who then would often trudge a kilometer or more to his yishuv) indicated he wanted to alight. There was no airconditioning--the buses resembled the yellow and black school buses one sees in rural American areas (except these looked a lot more banged up and dirty) and the back third was empty for baggage, goats, chickens, or Yemenites, who felt more comfortable squatting on the floor, apparently, than sitting on the fiberglass (hard to vandalize) seats.

The road was lined with eucalyptus trees, bark peeling, leaves always--even in the winter when it rained--looking dry and tired. Every so often there'd be a black and white sign, like an arrow, pointing to a clump of houses in the midst of fields that, depending on the season, were either plowed earth, green with growing grain or sunflowers, or yellow as harvest approached. "Gezer" was about halfway between Jerusalem and Tel Aviv, and it was always something of a shock to realize that the modern kibbutz was barely a stone's throw from Solomon's chariot city. A lot of the place names, such as Mikveh Israel, had distinct resonances to any student of Zionist history, not to mention ancient history.

The closer to Tel Aviv and the coast one got, the more the fields gave way to orchards. The Nesher cement factory intersection was where one really felt the approach of the city. And the old central bus station in Tel Aviv! A world in itself. I think I'm the only person around who actually misses the old Central Bus Station in Jerusalem. It was, so, well, Israeli. It was so grimy and uncomfortable, open to the elements, with convoluted railings and splintery benches designed to keep the passengers from mobbing the driver when the bus (finally) opened its doors. But prior to the everyone-has-his-own-car era, the Egged bus co-op was a real leveler of society and you met everyone (and not infrequently their pets and/or farm animals) on the bus. Thank heaven Tverya's bus station still hasn't been "modernised".

I don't mind good highways, and fancy restaurants and malls. But so much of the flavor of Israel is going, soon they'll have to build theme parks to remind us what the earlier decades of the country were like ("Experience life in a ma'abara! Work in the fields by day and dance around medurot at night like a chalutz at the Tzena-World! Group discounts for students and pensioners")

Why I'm a Nurse

MonkeyGirl says it so much better than I ever could:

http://highlytrainedmonkey.blogspot.com/2007/06/just-nurse.html

A New Look

The time has come for a "new look" to the site, hope you all like it. I have been most culpably remiss in posting--why did I think that having a second computer would make it easier to find time to blog, now that I don't have to do the Uriah Heep thing with my daughters, begging for a few uninterrupted minutes on "their" computer?

I am opening a second blog--as yet there are no posts on it--which will be rather more "personal" and try to keep this one for my main interests of midwifery, medicine, politics, and Israel. It will be called "It Ain't Over 'til The Fat Lady Sings". When I begin posting there, I'll let you know.

NHS BlogDoctor

"But you will not convince the nurse-specialists of this; they still
churn out their vacuous botty-wipe when they would be better occupied wiping
bottoms. "

Thus writes "Dr. Crippen" of the NHSDoctor blog. He is a British GP who is deeply, deeply unhappy with the state of the NHS. His attitude seems to be that the NHS would be in fine form if doctors were paid the kind of salaries that US private physicians made, and if it were managed by the CEOs of major industry.


This does seem somewhat contradictory to the original aim of the NHS, which was to provide every British citizen with a high level of free health care, but I can see the allure of it. My own experience of the NHS, in, admittedly, a somewhat ideal situation and over 30 years ago, gave me a lot to think about.


ANY national health service, introduced at a time when the country was bankrupt [as the UK was after two ruinous World Wars, a Depression, and the loss of its Empire] is going to have hard going living up to its promises. Especially at a time when it still had food rationing, for heaven's sake. Moreover, there wasn't then--and there isn't now--any way to adequately budget such an all-encompassing health service for the simple reason that inevitably it will uncover vast amounts of hidden health problems. You don't go to a doctor when you're feeling a bit off-color if it's going to cost you an arm and a leg. But if it's free, you run to him with every ache and pain (real or imaginary) and some turn out to be serious, unsuspected illness. Further, there's no way of knowing what advances there will be in medical science. Heavens, when I was a child, there were hardly any antibiotics besides penicillin, and when I was a newly-graduated obstetric nurse, neither ultrasound nor fetal monitors had yet been invented.


And lastly, the NHS was brought into being by politicians. And every change of government--and sometimes even more often than that--added "reform" which is politician-speak for another layer of bureaucracy. And bureaucracy = inefficiency nearly 100% of the time.


But my year in Cambridge was vastly instructive. The level of care a pregnant woman/newly-delivered British mother and her baby got was immensely better than her American cousin who did everything privately and at great expense (let's not even compare our British patient to those millions of American women who have no antenatal care at all because they haven't got insurance or ready cash). Even in the mid-70s there was moaning and teeth-gnashing by the consultants about the "14 signatures" needed to order a new scalpel, but I couldn't help feeling that some of this was overreaction when I made home visits (home visits!!) to every woman after discharge from the postpartum ward to check her and her baby. American women have no such service at all.


But that's not what I really wanted to address when I began this. "Dr. Crippen" doesn't like nurses who don't stay in "their place". He doesn't like nurse practitioners, calling them "nurse quacktitioners". He obviously feels very threatened by them and wants to maintain his medical superiority at all costs. I noticed this back in the 70s in Cambridge. Doctors did not breathe the same air as us on a social level. Nurses were expected to associate with hospital auxiliary staff, such as ambulance drivers. Our lounge in the hospital had a black and white TV and several tabloids and the Daily Telegraph while the doctors' lounge had a color TV and The Times. (As a Yank who didn't know any better, and since the doctors' lounge was in the part of the nurses' residence in which I lived, I blithely used the doctors' lounge all the time and none of the doctors--the British are so polite--quite had the nerve to ask me to leave it) This was rather odd, because the relationship between the obstetricians and the midwives was actually quite good, on a professional level. The Central Midwives Board's code of practice made us the complement of the doctors, not subordinate to them. As long as our patients were within certain parameters, we were not even obliged to notify a doctor of their existence. But once those parameters were crossed, and we called a doctor, he knew that it was not a trivial call.


What "Dr. Crippen" is actually protesting is not that nurses are too stupid to work in conjunction with, instead of for doctors. What he is protesting is the level of their education, which, for all I know, may be inadequate nowadays. If this is true, then get the nurses' education upgraded! But don't be paranoid about nurses being used as "doctors on the cheap". Nurse practitioners can be an immense asset.

I currently work in the Israeli version of an HMO. Every day I get women who come into my room seeking amplifications and explanations that their doctors either didn't think necessary to give or which they didn't understand. It is part of my job to make sure these women do understand, as well as to screen those patients prior to seeing the doctor. Sometimes they don't need to. Sometimes they need to see the doctor immediately and must jump the queue. The doctors rely on me to be sufficiently able to discern this. That's what I mean by "complement".


I could do more. There really isn't any reason to make a woman wait an hour to get a prescription for prenatal vitamins, but in Israel nurses cannot write any prescriptions at all. As a midwife, in hospital I can do a vaginal exam to determine if a woman is in labor, but I can't do that in a sick fund clinic, although we tell women that they should come to us rather than go directly to the labor unit if they suspect they are in labor, in order to prevent unnecessary trips to the hospital (which charges the sick fund). So when a woman arrives, in obvious labor, I have to have her wait until a doctor is free (and to the great annoyance of the other women, who have to wait even longer to get into the doctor).


When I was a student nurse, I remember being told by a nurse nearly ready to retire of her excitement when, in 1938, a doctor had actually allowed her to take a blood pressure. Now of course, even nurses' aides do it. As doctors get new toys, they generally find that--amazing!--the nurse who was too stupid or uneducated to use the old ones has suddenly had a brain transplant and can cope with the technology. I think it took about 3 years before we were allowed to do anything more than wrestle the tank-sized first models of fetal monitors into patients' rooms. Placing the sensors on the woman's abdomen was obviously beyond our capabilities (although dragging the heavy machine around wasn't) until ultrasound arrived and then the doctors had something new to entrance them and fetal monitoring became a time-consuming burden best left to their "inferiors".


Because I spent some time in medical school, I understand the difference in the mental disciplines of doctors and nurses. Our goal is the same: to return the patient to health; our methods are different. It is truly sad when one group feels threatened by the other, and the other is made to feel inferior to the "superiority" of the medicos. I'm not a "diluted doctor" nor do I want a string of initials after my name for the snob appeal in order to feel less "exploited". I think doctors--some of them, at any rate--actually resent that it is good nursing care which can actually be the determining factor in a patient's recovery. (And let me state that the quality of British nursing care which I saw in Cambridge was truly excellent). So yes, "Dr. Crippen", wiping bottoms is important. But it's not the only thing. When my mother was dying, good nursing care was all that eased her suffering, once the doctors had thrown up their hands. But the kind of care she received could not have been done by stupid, uneducated, indifferent health care workers. It was done by highly intelligent, well-educated nurses, who saw aspects of her situation the doctors never noticed. Without the care and the observations of the nurses, doctors wouldn't have almost any data on which to base their plans of treatments. Lab results and tests only tell you so much.


As part of his blog, "Dr. Crippen" includes a weekly diary of some of the patients he sees. Nearly every week he describes at least one patient who could have been assisted by a nurse, at least partially, and would have helped him spend more time with the sicker ones. He finds this almost frightening, and I really can't understand it. I'm not there to replace him, heaven forbid.