Torah Talk Tazria-Metzora
TORAH TALK TAZRIA-METZORA
As our very successful Torah Talk series establishes its pattern, people seem to merge what they do either professionally or out of interest into the insights of the parsha or sometimes multiple portions. Tazria-Metzora describes activities of the Kohen assigned to a medical situation recognizable to any modern physician, whether Hagar the Horrible’s Dr. Zook or myself, even five years into retirement.
First a quick overview of the Text, which divides into five parts, each beginning with Vayadaber Hashem el Moshe or both Moshe v Aharon.
1. Restoration of female purity after childbirth: Moshe
2. Identification and classification of Tzara’at as a spiritual disorder. Moshe and Aharon
3. Restoration of a Metzora afflicted with Tzara’at to full participation in the community. Moshe alone
4. Future contamination and restoration of permanent dwellings after settlement of Israel. Both Moshe and Aharon, though later sages state that this circumstance never arose
5. Dealing with genital discharges. Both Moshe and Aharon
The two haftaroth, often pre-empted as they are this year for Rosh Hodesh, have more direct medical themes. In Tazria, an accomplished foreign warrior named Naaman gets assigned to Elisha who finds him objectionable but must still treat Naaman’s tzara’at. And for Metzora, four lepers isolated from the community and looked at by the machers as untrustworthy because of it, are still judged useful if not really worthy of social equality.
While Tzara’at has generally been accepted as a spiritual disorder, its presentation is a physical one, a condition, or really a series of conditions that goes through phases easily recognizable by experienced physicians. Some activity reflects better on medicine and Kohanim than others. They also have implications on how members of the public view those who they can see not only as sick but as tainted people because of the way they acquired their condition. This being long before HIPPA, a relatively recent American protection, who had the disease and who went to the Mishkan for their remedial Hatat or Asham was not shielded from scrutiny of the curious.
As anyone assigned to the ER or the inpatient unit in the City of Boston on March 18 well knows, sometimes you are sick because you created your own illness or in the case of the Metzora, deserve to be sick. Tzara’at at its core is a disease of personal misconduct, most commonly improper speech, though the section Avachim in Talmud expands this to perjury, envy, arrogance, and other personal shortcomings. So, on March 18 we see contemporary clinical outcomes of misconduct: lacerations with broken bottles, facial trauma with knuckle outlines, by dawn acute alcohol intoxications, and when the morning crew arrives, the patients come with delirium tremens, all enthusiastic National Pride derailed. But despite the misconduct, the Kohen and modern doctors keep their thoughts of self-infliction to themselves and maintain their professionalism as they go about objective observation and implementation of what they need to do to assess damage accurately, then reverse it.
Unlike Torah text, which stays constant, medical sensibilities often change. What constitutes self-inflicted conditions shifts, and in both directions. As a VA Hospitalist in the 1980s every day for eight years I was the physician of record for at least one man in some stage of lung cancer, from an abnormal Chest film needing biopsy to terminal care. World War 2 vets smoked too much, so from the lenses of a young doc twenty years after the surgeon general’s public disclosure, this was a self-inflicted condition. But maybe not. While these now 60-somethings fought in Asia and Europe, their smoking was not only accepted conduct but supported by the military and companies who deferred their own profits to maintain a unified military effort with soldiers less stressed by the dangers they faced, with no apparent long term harm.
And psychiatric illness changed considerably. In her best seller of thirty years ago, The Stone Diaries, its author Carol Shields describes her heroine’s encounter with disabling depression in the 1950’s. She suspends her elegant prose for that chapter, replacing it with correspondence of the most gossipy kind traded among acquaintances of the now hospitalized Daisy. As they wrote to each other, they assigned various forms of blame for the illness, either callous treatment of the ill victim or how their friend might have responded to life experiences in a way that created her depression. Another disease of somebody’s harmful behavior. By 1993, the novel’s publication date, we all knew about Prozac, with clinical depression shifting to a chemical disorder of behavioral manifestation rather than clinical retribution for prior actions.
We struggle with this today, both as physicians and public. At AKSE, we have vaccine mandates. Beyond AKSE considerable portions of the public rejected immunization, either as an expression of their personal autonomy or faith in their preferred leadership. As many became ill their providers maintained professionalism amid the knowledge that these deaths could have been avoided.
The Kohen had to deal with uncertainty, as do physicians today. What might this skin lesion be? What might this cough, dizziness, palpable mass, or CT finding be? In many of the presentations, the Kohen did not diagnose right away but bought a week’s time with provisional separation, then revisit, allowing the tzara’at to remit or to declare itself. We do the same, assessing a symptom’s course, doing a test, offering brief therapeutic trials of omeprazole or ibuprofen, then see what happens. We docs today are often accused of cookbook medicine, but despite sophisticated diagnostics, we still share the Kohen’s uncertainties at the initial encounter. In my era, the day began with Morning Report, yesterday’s admitting resident giving a summary of what he did about the people who came in, while the other residents and the Big Bagel, the senior guru, pounced on us for our lapses. The Kohen at least did not get second-guessed.
For every condition, the Kohen had a divinely mandated solution, something modern doctors often don’t. It would always work. Gather the birds and the materials, put one bird’s blood in a jar, add the thread and hyssop, sprinkle and all would be well. Then send the bill, in the form of a formal sacrifice, even reduce the bill to assure that treatment was not a hardship.
Alas, we don’t do as well. Not all our interventions are a sure thing. We have some sure things, levothyroxine for hypothyroidism, DPT for tetanus prevention. If something works there is only one treatment that everybody does. Then we have conditions with lots of options. How many diets are there for obesity and glucose control? How many different glucose lowering drugs can we now choose from? If there are a lot of options and prescribing anarchy in our medical community, expect none of the approaches to be especially good. Kohanim didn’t have that challenge. He did what he was told by Moshe, didn’t ask questions, and took credit for the favorable outcomes.
The failure to question authority when it should be questioned appears at the end of the Pasha Metzora and in the theme of the Tazria Haftarah. For both male and female discharges, there is no distinction between physiologic and pathologic. Discharge is a discharge, whether normal semen or VD in a man or normal cycling or endometrial cancer in a woman. The Kohen just did what he was told. At least Elisha, when he was tasked with treating the foreign VIP Naaman, took a let me think this through approach. Even if the command to treat dysfunctional uterine bleeding comes directly from God, or today from the person who wrote that chapter in the textbook, we’ve come to appreciate that what we are told to do is not always the very best we could be doing. We modern doctors undoubtedly had more failures than the Kohanim did, but it is recognition of those limitations and honest examination of what could be better, allowed us to schect so many Sacred Cows of medicine, from the towering Galen of another era to the abandonment of therapeutic staples of digoxin and theophylline in my own professional lifetime.
And a thought to take to kiddush or Seudah Shelishit. Doctors make an effort to have less of what we encounter, fewer infections, less heart disease, less risky personal behavior. Our parsha seems to reject this fundamental medical effort. Rather than act to create less ill-advised speech or other behavior leading to tzara’at, the parsha anticipates its expansion over time, affecting permanent structures that will eventually replace tents. And with ever more draconian and destructive interventions to reverse new damage. Why might prevention of the underlying problem not be part of the parsha’s stated mission?